Exam 2 ATI Quiz Questions

A nurse is providing an educational session on cognitive development at a community event. Which of the following statements by the nurse are consistent with Piaget's theory of cognitive development? (Select all that apply.) - "Individuals acquire knowledge, intellect, and cognition over time." - "Intelligence is a natural ability that develops as a child grows and adapts to their environment." - "Children construct knowledge that evolves and changes over time." - "Children construct knowledge in new ways at critical points during development." - "Adolescents achieve formal operational thought by 16 years of age."

"Individuals acquire knowledge, intellect, and cognition over time." "Intelligence is a natural ability that develops as a child grows and adapts to their environment." "Children construct knowledge that evolves and changes over time." "Children construct knowledge in new ways at critical points during development."

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include? - "Insert the earpieces at a downward angle toward you nose." - "Use the diaphragm to listen to low-pitched sounds." - "Drape the stethoscope over your neck when not in use." - "Clean the stethoscope by immersing it in soapy water."

"Insert the earpieces at a downward angle toward you nose."

A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make? - "You can wear artificial fingernails if they are kept short." - "Leaving rings on your fingers when performing surgical hand asepsis." - "Keep your fingernails less than half an inch in length." - "Remove nail polish on your fingernails if it is chipped."

"Remove nail polish on your fingernails if it is chipped."

A nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough. The client states they identify as transgender. Which of the following questions should the nurse ask? - "How does your family feel about your gender identity?" - "What pronouns do you use?" - "When did you start identifying as transgender?" - "Are you planning to ever have surgery to change your sex assigned at birth?"

"What pronouns do you use?"

A nurse is discussing a client's tobacco usage during a health history interview. Which of the following questions should the nurse ask to maintain nurse-client rapport? - "You are worried about the amount that you smoke, right?" - "Did you know that smoking can lead to a decreased lung recoil, which results in hyperinflation and dyspnea?" - "Would you like any information on smoking cessation?" - "Why do you think that you are smoking so much?"

"Would you like any information on smoking cessation?"

A nurse is preparing to administer purified protein derivative 5 tuberculin units (TU) intradermal to a client. Available is 5 TU/ 0.1 ml. How many ml should the nurse administer? (Round to nearest tenth)

0.1 mL

A nurse is preparing to administer vasopressin 5 units IM to a client. Available is vasopressin 20 units/ml. How many ml should the nurse administer? (Round to nearest hundredth)

0.25 mL

A nurse is preparing to administer enoxaparin 30 mg subcutaneous to a client. Available is enoxaparin 60 mg/0.6 ml. How many ml should the nurse administer? (Round to nearest tenth)

0.3 mL

A nurse is preparing to administer morphine 4 mg IV bolus every 3 hr PRN pain. Available is morphine injection 10 mg/ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

0.4 mL

A nurse is preparing to administer epoetin alfa 50 units/kg subcutaneous to a preschooler who weighs 40 lb. Available is epoetin alfa 2,000 units/mL. How many mL should the nurse administer? (Round to nearest hundredth)

0.45 mL

A nurse is preparing to administer calcitonin 100 units subcutaneous to a client. Available is calcitonin 200 units/ml. How many ml should the nurse administer? (Round to nearest tenth)

0.5 mL

A nurse is preparing to administer digoxin 0.125 mg IV bolus stat. Available is digoxin injection 0.25 mg/ml. How many ml should the nurse administer? (Round to nearest tenth)

0.5 mL

A nurse is preparing to administer diphenhydramine 25 mg IV bolus stat. Available is diphenhydramine injection 50 mg/ml. How many ml should the nurse administer? (Round to nearest tenth)

0.5 mL

A nurse is preparing to administer lorazepam 2 mg IV bolus 20 min prior to surgery. Available is lorazepam injection 4 mg/ml. How many ml should the nurse administer? (Round to nearest tenth)

0.5 mL

A nurse is preparing to administer morphine 5 mg subcutaneous to a client. Available is morphine 10 mg/ml. How many ml should the nurse administer? (Round to nearest tenth)

0.5 mL

A nurse is preparing to administer cephalexin 0.25 g PO every 6 hr. Available is cephalexin 500 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest tenth.)

0.5 tablet

A nurse is preparing to administer methadone 2.5 mg PO every 8 hr. Available is methadone 5 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest tenth)

0.5 tablet

A nurse is preparing to administer methylprednisolone 4 mg PO daily. Available is methylprednisolone 8 mg tablets. How many tablets should the nurse administer daily? (Round to nearest tenth)

0.5 tablet

A nurse is preparing to administer famotidine 20 mg PO every 12 hr. Available is famotidine 40 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest tenth)

0.5 tablets

A nurse is preparing to administer trazodone 25 mg PO at bedtime. Available is trazadone 50 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest tenth)

0.5 tablets

A nurse is preparing a medication and calculates the dosage as 0.547 mL. Rounding this amount to the nearest hundredth, the nurse should administer how many mL?

0.55 mL

A nurse is preparing to administer diazepam 3 mg IV bolus every 3 hr PRN anxiety. Available is diazepam injection 5 mg/ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

0.6 mL

A nurse is preparing to administer haloperidol 3 mg IM for agitation. Available is haloperidol 5 mg/ml for injection. How many ml should the nurse administer? (Round to nearest tenth)

0.6 mL

A nurse is preparing to administer ziprasidone 12.5 mg IM to an adolescent. The nurse reconstitutes a vial of ziprasidone to yield a final concentration of 20 mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

0.6 mL

A nurse is transcribing medication prescriptions for a group of clients. Which of the following is the appropriate way for the nurse to record medications that require the use of a decimal point? - .4 mL - 0.6 mL - 8.0 mL - 125.0 mL

0.6 mL

A nurse is preparing to administer ceftriaxone 250 mg IM. The nurse reconstitutes a vial of ceftriaxone to yield a final concentration of 350 mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

0.7 mL

A nurse is preparing to administer heparin 15,000 units subcutaneous every 12 hr. Available is heparin injection 20,000 units/ml. How many ml should the nurse administer per dose? (Round to nearest hundredth)

0.75 mL

A nurse is preparing to administer meperidine 75 mg subcutaneous every 4 hr PRN pain. Available is meperidine injection 100 mg/ml. How many ml should the nurse administer per dose? (Round to nearest hundredth)

0.75 mL

A nurse is preparing a medication and calculates the dosage as 0.893 mL. Rounding this amount to the nearest hundredth, the nurse should administer how many mL?

0.89 mL

A nurse is preparing to administer regular insulin 15 units and isophane 40 units subcutaneous at 6:30 a.m. At which of the following times should the nurse administer the medication? - 0430 - 1630 - 0630 - 1430

0630

A nurse is preparing to administer a time-crucial medication to a client at 0800. Which of the following times are appropriate for the nurse to administer the medication? (Select all that apply) - 0700 - 0745 - 0830 - 0845 - 0900

0745 0830

A nurse is preparing to administer digoxin 0.125 mg PO at 9:00 a.m. At which of the following times should the nurse administer the medication? - 1500 - 0900 - 1700 - 2100

0900

A nurse is preparing to administer codeine oral solution 30 mg PO to a client. The amount available is codeine 10 mg/5 mL. How many Tbsp should the nurse administer? (Round to nearest whole number.)

1 Tbsp

A nurse is preparing to administer digoxin 0.25 mg IV bolus. Available is digoxin injection 0.25 mg/ml. How many ml should the nurse administer per dose? (Round to nearest whole number)

1 mL

A nurse is preparing to administer sucralfate 1 g PO twice daily to a client. Available is sucralfate 1,000 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest whole number.)

1 tablet

A nurse is preparing to administer meperidine 100 mg IM stat. Available is meperidine injection 75 mg/ml. How many ml should the nurse administer? (Round to nearest tenth)

1.3 mL

A nurse is preparing to administer tobramycin 2.5 mg/kg IM to a preschooler who weighs 20 kg. Available is tobramycin injection 40 mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

1.3 mL

A nurse is preparing a medication and calculates the dosage as 1.42 mL. Rounding this amount to the nearest tenth, the nurse should administer how many mL?

1.4 mL

A nurse is preparing to administer ceftriaxone 0.5 g IM. The nurse reconstitutes a vial of ceftriaxone to yield a final concentration of 350 mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

1.4 mL

A nurse is preparing to administer diazepam 7 mg IV bolus every 4 hr PRN muscle spasm. Available is diazepam injection 5 mg/ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

1.4 mL

A nurse is preparing to administer methylprednisolone acetate 120 mg IM daily. Available is methylprednisolone acetate injection 80 mg/ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

1.5 mL

A nurse is preparing to administer methylprednisolone acetate 60 mg IM every week. Available is methylprednisolone acetate injection 40 mg/ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

1.5 mL

A nurse is preparing to administer nafcillin 375 mg IM to a school-age child. Available is nafcillin powder for injection 2g vial. The nurse reconstitutes the powder to yield a final concentration of nafcillin 250mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

1.5 mL

A nurse is preparing to administer doxepin 75 mg PO at bedtime. Available is doxepin 50 mg tablets. How many tablets should the nurse administer? (Round to nearest tenth)

1.5 tablets

A nurse is preparing to administer furosemide 60 mg PO daily. Available is furosemide 40 mg tablets. How many tablets should the nurse administer daily? (Round to nearest tenth)

1.5 tablets

A nurse is preparing to administer chlorpromazine 40 mg IM to a client. Available is chlorpromazine 25 mg/ml. How many ml should the nurse administer? (Round to nearest tenth)

1.6 mL

A nurse is preparing to administer pentamidine 175 mg IM. The nurse reconstitutes a vial of pentamidine to yield a final concentration of 100 mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

1.8 mL

A nurse is preparing albuterol 4 mg PO every 6 hr. Available is albuterol syrup 2 mg/5 mL. How many mL should the nurse administer per dose? (Round to nearest whole number)

10 mL

A nurse is preparing to administer acetaminophen 325 mg PO every 6 hr. Available is acetaminophen oral suspension 160 mg/5 mL. How many mL should the nurse administer per dose? (Round to nearest whole number)

10 mL

A nurse is preparing to administer amoxicillin/clavulanate 250 mg PO to a client. Refer to the medication label below. How many mL should the nurse administer? (Round to nearest whole number)- 125mg/5ml

10 mL

A nurse is preparing to administer ceftazidime 40 mg/kg IV bolus every 8 hr to a toddler who weighs 22 lb. Available is ceftazidime injection 40 mg/mL. How many mL should the nurse administer per dose? (Round to nearest whole number)

10 mL

A nurse is preparing to administer cephalexin 500 mg PO every 6 hr. Available is cephalexin suspension 250 mg/5 mL. How many mL should the nurse administer per dose? (Round to nearest whole number.)

10 mL

A nurse is preparing to administer diphenhydramine 25 mg PO to a client. The amount available is diphenhydramine elixir 12.5 mg/5 mL. How many mL should the nurse administer? (Round to nearest whole number)

10 mL

A nurse is preparing to administer erythromycin ethylsuccinate 800 mg PO every 12 hr. Available is erythromycin ethylsuccinate suspension 400 mg/5 mL. How many mL should the nurse administer per dose? (Round to nearest whole number.)

10 mL

A nurse is preparing to administer cefaclor 400 mg PO. The nurse reconstitutes a container of cefaclor powder to yield a final concentration of 187mg/5mL. How many mL should the nurse administer? (Round to nearest tenth)

10.7 mL

A nurse is preparing to administer cefazolin 1.5 g IV bolus to a client who has fluid restrictions. The nurse reconstitutes a vial of cefazolin to yield a final concentration of 138mg/mL. How many mL should the nurse administer? (Round to nearest tenth)

10.9 mL

A nurse is preparing to administer phenytoin 15 mg/kg/day PO divided in three equal doses to a client who weighs 120 lb. Available is phenytoin suspension 125 mg/5ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

10.9 mL

A nurse is preparing to administer potassium chloride 15 mEq PO every 12 hr. Available is potassium chloride liquid 20 mEq/15 mL. How many mL should the nurse administer per dose? (Round to nearest whole number)

11 mL

A nurse is preparing to administer potassium gluconate 3 mEq/kg/day PO divided in equal doses every 6 hr to a preschooler who weighs 42 lb. Available is potassium gluconate liquid 20 mEq/15ml. How many ml should the nurse administer per dose? (Round to nearest whole number)

11 mL

A nurse is caring for an infant who weighs 11 lb 4 oz. What is the infant's weight in lb? Round to nearest hundredth)

11.25 lb

A nurse is preparing to administer famotidine 0.5 mg/kg PO to a child who weighs 50 lb. How many mg should the nurse administer per dose? (Round to nearest tenth)

11.4 mg

A nurse is preparing to administer amikacin IM to a client who weighs 176 lb. The medication reference states that the safe dosage range is 7.5 to 15 mg/kg/day divided every 12 to 24 hr. What is the maximum safe dose the nurse should expect to administer per day? (Round to nearest whole number)

1200 mg

A nurse is preparing to administer clindamycin 0.2 g PO. The nurse reconstitutes a container of clindamycin powder to yield a final concentration of 75 mg/ 5 mL. How many mL should the nurse administer? (Round to nearest tenth)

13.3 mL

A nurse is preparing to administer potassium chloride 5 mEq/kg/day PO divided in equal doses every 6 hr to a child who weighs 64 lb. Available is potassium chloride liquid 40 mEq/15 mL. How many mL should the nurse administer per dose? (Round to nearest tenth)

13.6 mL

A nurse is preparing to administer phenytoin 5 mg/kg/day PO divided equally every 12 hr for an infant who weighs 12 lb 4 oz. How many mg should the nurse administer per dose? (Round to nearest tenth)

13.9 mg

A nurse is preparing to administer cefdinir to a child who weighs 44 lb. The medication reference recommends administering 7 mg/kg PO every 12 hr. How many mg should the nurse plan to administer per dose? (Round to nearest whole number)

140 mg

A nurse is preparing to administer ethosuximide 750 mg PO daily. Available is ethosuximide syrup 250 mg/tsp. How many mL should the nurse administer? (Round to nearest whole number)

15 mL

A nurse is preparing to administer furosemide 40 mg PO in 0.5 oz of orange juice. How many mL of orange juice should the nurse administer? (Round to nearest whole number.)

15 mL

A nurse is preparing to administer lamivudine 150 mg PO every 12 hr. Available is lamivudine oral solution 10 mg/mL. How many mL should the nurse administer per dose? (Round to nearest whole number)

15 mL

A nurse is preparing to administer gentamicin to a client who weighs 165 lb. The medication reference recommends administering 2 mg/kg IM every 8 hr. How many mg should the nurse plan to administer per dose? (Round to nearest whole number)

150 mg

A nurse is preparing to administer acyclovir 5 mg/kg IV bolus every 8 hr to a client who weighs 75 lb. How many mg should the nurse administer per dose? (Round to nearest tenth)

170.5 mg

A nurse is preparing to administer codeine 30 mg PO every 4 hr. PRN for pain. The client last received the medication at 1 p.m. The earliest the nurse should administer the next dose is at which of the following times? - 1400 - 1500 - 1600 - 1700

1700

A nurse is preparing to administer potassium chloride powder 20 mEq PO in 6 oz. of water. How many mL of water should the nurse administer? (Round to nearest whole number.)

180 mL

A nurse is preparing to administer gabapentin 1,800 mg per day divided into three equal doses. The amount available is gabapentin 300 mg capsules. How many capsules should the nurse administer per dose? (Round to nearest whole number)

2 capsules

A nurse is preparing to administer lithium 600 mg PO every 8 hr. Available is lithium carbonate 300 mg capsules. How many capsules should the nurse administer? (Round to nearest whole number)

2 capsules

A nurse is preparing to administer levothyroxine 200 mcg IV bolus. The nurse reconstitutes a vial of levothyroxine to yield a final concentration of 100 mcg/mL. How many mL should the nurse administer? (Round to nearest whole number)

2 mL

A nurse is preparing to administer methylprednisolone acetate 40 mg IM daily. Available is methylprednisolone acetate injection 20 mg/ml. How many ml should the nurse administer per dose? (Round to nearest whole number)

2 mL

A nurse is preparing to administer nafcillin 0.5 g IM. The nurse reconstitutes a vial of nafcillin to yield a final concentration of 250mg/mL. How many mL should the nurse administer? (Round to nearest whole number)

2 mL

A nurse is preparing to administer penicillin G benzathine 1,200,000 units IM. Available is penicillin G benzathine injection 600,000 units/ml. How many ml should the nurse administer per dose? (Round to nearest whole number)

2 mL

A nurse is preparing to administer phenytoin 100 mg IV bolus every 8 hr. Available is phenytoin injection 50 mg/ml. How many ml should the nurse administer per dose? (Round to nearest whole number)

2 mL

A nurse is preparing to administer digoxin 250 mcg PO daily. Available is digoxin 0.125 mg tablets. How many tablets should the nurse administer? (Round to nearest whole number.)

2 tablets

A nurse is preparing to administer doxycycline 100 mg PO every 12 hr. Available is doxycycline 50 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest whole number)

2 tablets

A nurse is preparing to administer quinapril 40 mg PO daily. Available is quinapril 20 mg tablets. How many tablets should the nurse administer daily? (Round to nearest whole number)

2 tablets

A nurse is preparing to administer triazolam 0.25 mg PO. Available is triazolam 0.125 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest whole number)

2 tablets

A nurse is preparing to administer zolpidem 10 mg PO at bedtime. Available is zolpidem 5 mg tablets. How many tablets should the nurse administer per dose? (Round to nearest whole number)

2 tablets

A nurse is preparing to administer amoxicillin 500 mg PO every 8 hr. Available is amoxicillin oral suspension 250 mg/5 mL. How many tsp should the nurse administer per dose? (Round to nearest whole number)

2 tsp

A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr. Available is diphenhydramine syrup 12.5 mg/5 mL. How many tsp should the nurse administer per dose? (Round answer to nearest whole number.)

2 tsp

A nurse is preparing to administer dextrose 5% in water 2 L to infuse over 6 hr. The nurse should administer how many mL? (Round to nearest whole number.)

2,000 mL

A nurse is preparing to administer oxacillin 375 mg IM. The nurse reconstitutes a vial of oxacillin to yield a final concentration of 250mg/1.5mL. How many mL should the nurse administer? (Round to nearest tenth)

2.3 mL

A nurse is preparing to administer 0.9% sodium chloride 2,500 mL to infuse over 12 hr. The nurse should administer how many L? (Round to nearest whole number.)

2.5 L

A nurse is preparing to administer levothyroxine 0.25 mg IV bolus stat. Available is levothyroxine injection 100 mcg/ml. How many ml should the nurse administer? (Round to nearest tenth)

2.5 mL

A nurse is converting an infant's weight from lb to kg. If the infant weighs 6 lb 2 oz, what is the infant's weight in kg? (Round to nearest tenth)

2.8 kg

A nurse is preparing to administer potassium gluconate 2 mEq/kg/day PO divided equally every 12 hr to a child who weighs 50 lb. How many mEq should the nurse administer per dose? (Round to nearest tenth)

22.7 mEq

A nurse is preparing to administer magnesium gluconate 270 mg PO. Available is magnesium gluconate liquid 54 mg/5 mL. How many mL should the nurse administer? (Round to nearest whole number)

25 mL

A nurse is preparing to administer ampicillin 0.75 g IM every 6 hr to a client. The nurse reconstitutes a vial of ampicillin to yield a final concentration of 250 mg/mL. How many mL should the nurse administer? (Round to nearest whole number)

3 mL

A nurse is preparing to administer furosemide 30 mg IV bolus stat. Available is furosemide injection 10 mg/ml. How many ml should the nurse administer? (Round to nearest whole number)

3 mL

A nurse is preparing to administer levothyroxine 0.3 mg IV bolus. The nurse reconstitutes a vial of levothyroxine to yield a final concentration of 100 mcg/mL. How many mL should the nurse administer? (Round to nearest whole number)

3 mL

A nurse is preparing to administer levothyroxine 0.075 mg PO to a client. Available is levothyroxine 25 mcg tablets. How many tablets should the nurse administer? (Round to nearest whole number.)

3 tablets

A nurse is preparing to administer amoxicillin 25 mg/kg/day PO divided in equal doses every 8 hr to a preschooler who weighs 43 lb. Available is amoxicillin suspension 250 mg/5 mL. How many mL should the nurse administer per dose? (Round to nearest tenth)

3.3 mL

A nurse is preparing to administer amoxicillin 30 mg/kg/day PO divided in equal doses every 12 hr to an infant who weighs 5.5 kg. Available is amoxicillin suspension 125 mg/5 ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

3.3 mL

A nurse is preparing to administer cefaclor 40 mg/kg/day PO divided in equal doses every 8 hr to a child who weighs 48 lb. Available is cefaclor suspension 375 mg/5 mL. How many mL should the nurse administer per dose? (Round to nearest tenth)

3.9 mL

A nurse is preparing to administer clindamycin 450 mg PO. The nurse reconstitutes a container of clindamycin powder to yield a final concentration of 75mg/5mL. How many mL should the nurse administer? (Round to nearest whole number)

30 mL

A nurse is preparing to administer rifampin 0.6 g PO daily. Available is rifampin 150 mg capsules. How many capsules should the nurse administer? (Round to nearest whole number)

4 capsules

A nurse is preparing to administer hydrocortisone 200mg intermittent IV bolus. Available is hydrocortisone powder for injection 1 g vial. The nurse reconstitutes the powder to yield a concentration of 50mg/mL. How many mL should the nurse administer? (Round to nearest whole number)

4 mL

A nurse is preparing to administer hydromorphone 4 mg PO every 4 hr PRN for pain. Available is hydromorphone oral liquid 1 mg/1 mL. How many mL should the nurse administer per dose? (Round to nearest whole number)

4 mL

A nurse is preparing to administer amlodipine 10 mg PO once per day to a client. The amount available is amlodipine 2.5 mg/tablet. How many tablets should the nurse administer? (Round to nearest whole number)

4 tablets

A nurse is preparing to administer 650 mg of acetaminophen syrup to a client. The amount available is acetaminophen syrup 160 mg/5 mL. How many tsp should the nurse administer per dose?

4 tsp

A nurse is preparing to administer amoxicillin 325 mg PO. The nurse reconstitutes a container of amoxicillin powder to yield an oral suspension with a final concentration of 400mg/5mL. How many mL should the nurse administer? (Round to nearest tenth)

4.1 mL

A nurse is preparing to administer erythromycin ethylsuccinate 50 mg/kg/day PO divided in equal doses every 6 hr to a toddler who weighs 32 lb. Available is erythromycin ethylsuccinate suspension 200mg/5ml. How many ml should the nurse administer per dose? (Round to nearest tenth)

4.5 mL

A nurse is converting an infant's weight from lb to kg. If the infant weighs 10 lb 4 oz, what is the infant's weight in kg? (Round to nearest tenth)

4.7 kg

A nurse is preparing to administer midazolam IM to a client who is preoperative and weighs 132 lb. The medication reference states the safe dosage range is 0.07 to 0.08 mg/kg. What is the maximum safe dose the nurse should expect to administer? (Round to nearest tenth)

4.8 mg

A nurse is preparing to administer cefazolin 500 mg IV bolus. The nurse reconstitutes a vial of cefazolin to yield a final concentration of 100 mg/mL. How many mL should the nurse administer? (Round to nearest whole number)

5 mL

A nurse is preparing to administer fluconazole 200 mg PO. The nurse reconstitutes a container of fluconazole powder for oral suspension to yield a final concentration of 40 mg/mL. How many mL should the nurse administer? (Round to nearest whole number)

5 mL

A nurse is preparing to administer oxacillin 500 mg IV bolus. The nurse reconstitutes a vial of oxacillin to yield a final concentration of 100mg/mL. How many mL should the nurse administer? (Round to nearest whole number)

5 mL

A nurse is preparing to administer ampicillin 1.5 g IV bolus. The nurse reconstitutes a vial of ampicillin to yield a final concentration of 30 mg/mL. How many mL should the nurse administer? (Round to nearest whole number)

50 mL

A nurse is preparing to administer cefotaxime 1 g IV bolus every 12 hr. Available is cefotaxime injection 1 g/50 ml. How many ml should the nurse administer per dose? (Round to nearest whole number)

50 mL

A nurse is preparing to administer epinephrine hydrochloride 0.5 mg subcutaneous stat. How many mcg should the nurse administer? (Round to nearest whole number.)

500 mcg

A nurse is preparing to administer haloperidol 5 mg IM at 1715. At which of the following times should the nurse administer the medication? - 7:15 a.m. - 5:15 a.m. - 7:15 p.m. - 5:15 p.m.

5:15 p.m.

A nurse is preparing to administer ampicillin 50 mg/kg/day PO divided in equal doses every 8 hr to a child who weighs 39.6 lb. Available is ampicillin oral suspension 250 mg/5 mL. How many mL should the nurse administer per dose? (Round to nearest whole number)

6 mL

A nurse is preparing a medication and calculates the dosage as 6.25 mL. Rounding this amount to the nearest tenth, the nurse should administer how many mL?

6.3 mL

A nurse is preparing to administer daptomycin 360 mg IV bolus. The nurse reconstitutes a vial of daptomycin to yield a final concentration of 0.5 g/ 10mL. how many mL should the nurse administer? (Round to nearest tenth)

7.2 mL

A nurse is preparing to administer 375 mg of cephalexin PO. The nurse reconstitutes a container of cephalexin powder to yield a final concentration of 0.25 g/ 5 mL. How many mL should the nurse administer? (Round to nearest tenth)

7.5 mL

A nurse is converting a toddler's weight from lb to kg. If the toddler weighs 17 lb 9 0z, what is the toddler's weight in kg? (Round to nearest whole number)

8 kg

A nurse is preparing to administer fluoxetine 35 mg PO daily. Available is fluoxetine solution 20 mg/5 mL. How many mL should the nurse administer daily? (Round to nearest tenth)

8.8 mL

A nurse is preparing to administer valproic acid 45 mg/kg/day PO divided in equal doses every 8 hr to a child who weighs 66 lb. Available is valproic acid syrup 250 mg/5 mL. How my mL should the nurse administer per dose? (Round to nearest whole number)

9 mL

A nurse is converting a toddler's weight from lb to kg. If the toddler weighs 20 lb 8 oz, what is the toddler's weight in kg? (Round to nearest tenth)

9.3 kg

A nurse is preparing to administer amoxicillin 775 mg PO. The nurse reconstitutes a container of amoxicillin powder to yield a final concentration of 400mg/5ml. How many mL should the nurse administer? (Round to nearest tenth)

9.7 mL

A nurse is preparing to administer nystatin 400,000 units PO. Available is nystatin powder 500,000 units/ 0.125 tsp. The nurse reconstitutes a container of nystatin to yield a final concentration of 500,000units/ 120 mL. How many mL should the nurse administer? (Round to nearest whole number)

96 mL

A nurse is inspecting the thorax of an infant. Which of the following findings should the nurse expect? - Primarily thoracic movement during inspiration - A barrel-shaped chest in which the anterior-posterior are equal - Asymmetrical movement of the chest during respirations - A chest circumference that is twice the measurement of the head circumference

A barrel-shaped chest in which the anterior-posterior are equal

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? - A continuous sensation of vibration felt over the second and third intercostal spaces - A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum - A brief thump felt over the fourth or fifth intercostal space near the left midclavicular line - A whooshing or swishing sound over the second intercostal space along the left sternal border

A brief thump felt over the fourth or fifth intercostal space near the left midclavicular line

A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (Select all that apply) - A client's visitor falls in the hallway - A nurse forgets their computer password - A client develops an unexpected reaction to a medication - A client's dentures are lost - An antibiotic was administered to a client 30 min after the scheduled time

A client's visitor falls in the hallway A client develops an unexpected reaction to a medication A client's dentures are lost

A nurse is reviewing a client's prescriptions. The nurse should contact the provider to clarify which of the following prescriptions? - Ampicillin 100 mg/kg/day by mouth in 4 equally divided doses - Phenytoin 300 mg by mouth every 12 hours - Metronidazole 500 mg IV bolus every 6 hr - Acetaminophen 325 mg every 6 hr PRN for headache

Acetaminophen 325 mg every 6 hr PRN for headache

A charge nurse is reviewing the types of prescriptions with a newly licensed nurse. Which of the following prescriptions should the nurse include as an example of a standing prescription? - Oxycodone 5 mg by mouth every 4 hr as needed for pain - Furosemide 20 mg IV stat - Acetaminophen 650 mg by mouth every 6 hr for temperature greater than 38.4°C (101.2°F) - Diazepam 10 mg IV 30 min prior to procedure

Acetaminophen 650 mg by mouth every 6 hr for temperature greater than 38.4°C (101.2°F)

A nurse discovers a small fire in a client's room. After removing the client to safety. Which of the following actions should the nurse take next? - Extinguish the fire - Close the windows in the client's room - Close the client's door - Activate the fire alarm

Activate the fire alarm

A nurse is caring for a client who reports severe back pain at 1400. The client's prescriptions include oxycodone extended - release 20 mg PO every 12 hr (last dose received at 600) and oxycodone immediate - release 5 mg PO every 4 hr PRN (last dose received at 2300 the day before). Which of the following actions should the nurse take? - Contact the provider to request an order for a different pain medication - Administer oxycodone immediate-release 5 mg PO at 1600 - Administer oxycodone immediate-release 5 mg PO now - Contact the provider to request an increase in the oxycodone extended-release dose

Administer oxycodone immediate-release 5 mg PO now

A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves? - After donning a gown and before collecting vital signs on the client. - After removing food items off the client's tray and before removing soiled linens from the client's bed. - After helping the client stand up and before helping them brush their teeth. - After changing a dressing on the client and before documenting findings on a computer.

After changing a dressing on the client and before documenting findings on a computer.

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission? - Airborne - Droplet - Direct contact - Indirect contact

Airborne

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask? - Protective isolation - Contact - Droplet - Airborne

Airborne

A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39°C (102°F). Which of the following other vital signs should the nurse expect? - An elevated pulse rate - A decreased blood pressure - An elevated blood pressure - A decreased pulse rate

An elevated pulse rate

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include? - Use a brush to scrub the surface of the hands. - Rinse antiseptic solution from the hands before it dries. - Apply chlorhexidine and ethanol to the hands. - Leave jewelry on the hands when cleansing them.

Apply chlorhexidine and ethanol to the hands.

A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. What action should the nurse take? - Assess the client's blood glucose level - Ask the client for additional information regarding the management of their diabetes - Encourage the client to join a diabetic support group - Provide education for the client on the management of diabetes

Ask the client for additional information regarding the management of their diabetes

A nurse is performing an abdominal examination on a preschooler. Which of the following actions should the nurse take during the assessment? - Instruct the child to take a deep breath and hold it while the nurse palpates - Ask the client to "help" with the exam by placing their hand on top of the nurse's hand - Begin by palpating any identified tender areas - Position the child with legs and arms extended

Ask the client to "help" with the exam by placing their hand on top of the nurse's hand

A nurse is preparing to administer a medication to a newly admitted client. The nurse should identify which of the following actions as a part of the assessment phase of the nursing process? - Asking the client about a history of medication allergies - Instructing the client about the medication's adverse effects - Determining whether the medication should be administered with or without meals - Monitoring the client's response to the medication

Asking the client about a history of medication allergies

A nurse discovers a medication error in which the client received twice the prescribed amount of medication. Which of the following actions should the nurse take first? - Notify the provider - Complete an incident report - Assess the client - Report the error to the nurse manager

Assess the client

A nurse manager is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse manager take first? - Complete an incident report - Notify the provider about the medication error - Assess the client for adverse effects - Report the error to the risk manager

Assess the client for adverse effects

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first? - Assessment - Analysis - Evaluation - Planning

Assessment

A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take? - Palpate client-identified areas of discomfort first - Begin auscultation in the left upper quadrant - Auscultate bowel sounds prior to palpating - Count the number of bowel sounds auscultated over 1 min.

Auscultate bowel sounds prior to palpating

A nurse has performed preoperative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind. I do not want to have this surgery." Which of the following ethical principles is the client using? - Nonmaleficence - Autonomy - Justice - Fidelity

Autonomy

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger? - Burn - Frostbite - Bacteria - Radiation

Bacteria

A nurse is preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? - Gait - Hearing - Vision - Balance

Balance

A nurse is preparing to administer glipizide 5 mg PO ac. At which of the following times should the nurse administer the medication? - After meals - Before meals - As needed - At bedtime

Before meals

A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is a hospital-acquired injury? (Select all that apply) - Blood transfusion incompatibility - Wrong site surgery - Ineffective insulin usage - Dysphagia following a stroke - Dehydration due to diarrhea

Blood transfusion incompatibility Wrong site surgery Ineffective insulin usage

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests? - C-reactive protein - Troponin - Creatine kinase - Lactic acid

C-reactive protein

A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAI's). Which of the following infections should the nurse include? (Select all that apply) - Influenza infection - Catheter-associated urinary tract infection - Mycobacterium tuberculosis infection - Central line-associated bloodstream infection - Surgical site infection

Catheter-associated urinary tract infection Central line-associated bloodstream infection Surgical site infection

A nurse is planning an educational session about human growth and development for a group of clients who are pregnant. Which of the following universal principles should the nurse include in the discussion? (Select all that apply.) - Cephalocaudal principle - Equifinality principle - Simple to Complex - Continuous process - Individualized rates

Cephalocaudal principle Simple to complex Continuous process Individualized rates

A nurse is assessing a client's vital signs. While counting the number of respirations, which of the following assessments should the nurse simultaneously perform? - Characteristics of the respirations - Symmetrical expansion of the chest walls - Shape and alignment of the rib cage - Intensity of tactile fremitus

Characteristics of the respirations

A nurse is administrating medications to four clients. The nurse should identify which of the following nursing actions as a part of the evaluation phase of the nursing process? - Collecting information about a client's pain level administration of a narcotic - Taking the blood pressure of a client before administering an antihypertensive medication - Lowering the level of a client's bed before administering a benzodiazepine medication - Instructing a client to rinse their mouth following administration of an inhalation corticosteroid

Collecting information about a client's pain level administration of a narcotic

A nurse working in a medical-surgical unit is preparing to administer medications to a client. The nurse plans to use two forms of identification to verify that she has the right client. Which of the following actions can the nurse take to identify the client? (Select all that apply) - Compare the name on the client's wristband with the name in the medication administration record (MAR) - Ask the client to state his date of birth - Check the room number in the medication administration record (MAR) with the room number of the client - Ask the client to state his name - Use the bar code scanner to identify the client

Compare the name on the client's wristband with the name in the medication administration record (MAR) Ask the client to state his date of birth Ask the client to state his name Use the bar code scan to identify the client

A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions? - Protective - Contact - Droplet - Airborne

Contact

A nurse is planning to admit a client who has respiratory syncytial virus. Which of the following precautions should the nurse plan to implement? - Protective - Contact - Standard - Airborne

Contact

A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection? - Incubation - Convalescence - Acute infection - Prodromal

Convalescence

A nurse is preparing about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for fire to occur? (Select all that apply) - Carbon dioxide - Nitrogen - Cooking oil - Oxygen - Heat

Cooking oil Oxygen Heat

A nurse is preparing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings? - Crackles - Stridor - Wheezes - Friction rub

Crackles

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? - Document accurate data - Develop a plan of care - Validate previous data - Evaluate outcomes of care

Develop a plan of care

A nurse is inspecting the anterior chest of a client. Which of the following findings should the nurse report to the provider? - Distended veins in one breast - Costal margin of 85° - Point of maximal impulse (PMI) located to the left of the midclavicular line at the 5° intercostal space - Symmetrical chest expansion during the inspiratory phase

Distended veins in one breast

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? - Close the examination room door but do not pull the curtain in the examination room. - Remain in the client's room while the client is getting undressed. - Ask the client if they would like to empty their bladder and bowel before the physical examination begins. - Do not expose any more of the client's body than required at a time.

Do not expose any more of the client's body than required at a time

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses? - Posterior tibial - Popliteal - Dorsalis pedis - Femoral

Dorsalis pedis

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? - Direct contact - Droplet - Airborne - Indirect contact

Droplet

A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes? - Droplet - Indirect contact - Airborne - Direct contact

Droplet

A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance? (Select all that apply) - During an interview about the client's health history - When introducing themselves to the client - Once the focused assessments have been completed - While collecting the client's vital signs - During the discussion of planning for follow-up care

During an interview about the client's health history When introducing themselves to the client While collecting the client's vital signs

A nurse is inspecting the skin of a toddler. Which of the following findings should the nurse report to the provider? - Prescence of fine hair on the lower arms and legs - Telangiectatic nevi on the back of the neck - Mongolian spot across the buttocks - Ecchymotic area on the abdomen

Ecchymotic area on the abdomen

A nurse is preparing an educational session about school-age children to a group of caregivers. Which of the following characteristics should the nurse include in the teaching? (Select all that apply.) - Attributes feelings and motives to objects - Egocentrism decreases - Begins to understand reversibility - Understands events can be interpreted in different ways - Deductive reasoning develops

Egocentrism decreases Begins to understand reversibility Understands events can be interpreted in different ways

A nurse is assessing a client's respiration. Which of the following actions should the nurse take? - Have the client lie flat in bed with their head on a pillow - Elevate the head of the client's bed 45° to 60° - Encourage the client to breathe shallowly - Ask the client to take several deep breaths prior to the assessment

Elevate the head of the client's bed 45° to 60°

A nurse is preparing to perform a physical examination on a 10-year-old child. Which of the following interventions should the nurse plan to implement? - Allow the child to touch and play with the equipment - Play games while performing the physical examination - Explain how the equipment works using correct medical terminology - Discuss the benefits of performing the examination with the child

Explain how the equipment works using correct medical terminology

A nurse is caring for a 10-year-old child who is newly diagnosed with diabetes mellitus. Which of the following actions by the child should the nurse recognize as characteristic of Erikson's stage of industry versus inferiority? - Becomes frustrated when their caregiver fills out the child's menu - Apologizes to their caregiver for wanting to manage their insulin administration independently - States frustration that diabetes mellitus will make them different from everyone else - Expresses confidence in their ability to self-administer insulin

Expresses confidence in their ability to self-administer insulin

A nurse is assessing an adolescent who reports feeling "very depressed." The nurse should recognize that which of the following are signs of increased risk for suicide? (Select all that apply.) - Expressing feelings of gloom and helplessness - Expressing loss of interest in activities once considered important - Making threats of self-harm - Having access to weapons - Purchasing valued possessions

Expressing feelings of gloom and helplessness Expressing loss of interest in activities once considered important Making threats of self-harm Having access to weapons

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply) - Fall history - Medical diagnosis - Use of assistive devices - Mental status - Do-not-resuscitate status

Fall history Medical diagnosis Use of assistive devices Mental status

A nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? - Legitimate absenteeism - Strict adherence to facility policies - Consistent adequate work performance - Frequent reports of not being treated fairly

Frequent reports of not being treated fairly

A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first? - Mask - Gloves - Goggles - Face shield

Gloves

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of personal protective equipment should the nurse wear while performing this task? (Select all that apply) - N95 Mask - Gloves - Surgical cap - Gown - Goggles

Gloves Gown Goggles

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include? - Gowns can be reused on the same client. - Masks should be removed after leaving a client's room. - Gloves should be removed from the inside out. - Eyeglasses can be used in place of goggles.

Gloves should be removed from the inside out.

A nurse should use which of the following units when measuring weight? - Gram - Liter - Meter - Milliliter

Gram

A nurse on a medical unit is assisting with the orientation of a newly licensed nurse. The nurse should remind the newly licensed nurse to have a second nurse review the dosage of which of the following medications prior to administration? - Heparin - Acetaminophen - Acetylcysteine - Hydroxychloroquine

Heparin

A nurse is providing prenatal education to a client who is in the first trimester of pregnancy. Which of the following teratogens should the nurse instruct the client to avoid during pregnancy due to the risk to fetal development? (Select all that apply.) - Chamomile tea - Hyperthermia - Uncontrolled glucose levels - Rubella - Smoking

Hyperthermia Uncontrolled glucose levels Rubella Smoking

A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? (Select all that apply) - If the client is experiencing abuse or human trafficking - Client's ability to perform activities associated with daily living - The reason that the client is seeking health care - The client's use of substances - The environment in which the client resides

If the client is experiencing abuse or human trafficking Client's ability to perform activities associated with daily living The client's use of substances The environment in which the client resides

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing? - Implementation - Evaluation - Analysis - Planning

Implementation

A nurse is conducting a health history interview. Which of the following type of information is the nurse gathering when using the acronym "OLD CARTS"? - Information about the client's presenting problem - Information about the client's spirituality - Information about the client's obstetrical history - Information about the client's family history

Information about the client's presenting problem

A nurse is preparing to administer insulin subcutaneously to a client. The nurse should document the administration of the medication immediately after which of the following actions? - Taking the insulin from the automated dispensing machine - Injecting the insulin - Checking the client's blood glucose level - Checking the correct dosage of the insulin

Injecting the insulin

A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take? - Rotate the probe if any resistance is met as the thermometer is inserted - Insert the probe to aim at the client's pelvic area - Dip the probe about 0.58 cm (2 in) into a tube of lubricant - Insert the probe about 2.5 cm (1 in) into the client's anus

Insert the probe about 2.5 cm (1 in) into the client's anus

A nurse is assessing a client's upper extremities. Which of the following actions should the nurse take? (Select all that apply) - Inspect the condition of each fingernail - Apply a pulse oximeter to a finger - Compare the amplitude of the radial pulses bilaterally - Evaluate the blood pressure in an upper extremity - Palpate the shoulder, elbow, wrist, and finger joints

Inspect the condition of each fingernail Compare the amplitude of the radial pulses bilaterally Palpate the shoulder, elbow, wrist, and finger joints

A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment? - Palpate the strength of the brachial pulse - Observe the client's gait as they walk across a room - Use a sharp pin to assess sensation on the sole of the client's foot - Inspect the pattern of hair distribution

Inspect the pattern of hair distribution

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment? - Palpation - Percussion - Auscultation - Inspection

Inspection

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? - Auscultation - Inspection - Percussion - Palpation

Inspection

A nurse is providing discharge teaching to parents of a preschooler who was admitted due to a severe asthma exacerbation. Which of the following instructions should the nurse include? (Select all that apply.) - Instruct on the use of a metered-dose inhaler (MDI). - Have family members smoke tobacco products outside of the house. - Make changes in the home environment to reduce dust mites. - Share the plan for managing an asthma attack with the child's preschool teachers. - Decrease fluid intake to prevent an exacerbation of asthma.

Instruct on the use of a metered-dose inhaler (MDI). Have family members smoke tobacco products outside of the house. Make changes in the home environment to reduce dust mites. Share the plan for managing an asthma attack with the child's preschool teachers.

A nurse is assessing a client's neck. Which of the following actions should the nurse ask the client to perform during this assessment? (Select all that apply) - Instruct the client to swallow - Apply downward pressure and ask the client to shrug their shoulders - Tell the client to open their mouth and say "ahhh" - Test the client's ability to protrude their tongue - Request the client to move their head forward and backward and then side to side

Instruct the client to swallow Apply downward pressure and ask the client to shrug their shoulders Request the client to move their head forward and backward and then side to side

A nurse is collecting information about a client's spirituality using the FICA Spiritual History Tool. Based on this tool, which of the following information should the nurse gather? (Select all that apply) - Is there a spiritual or religious group that the client identifies as having an importance in their life? - Are there any spiritual or religious practices that should be included when planning the client's care? - What is the address of the client's identified religious or spiritual gathering place? - Does the client identify spiritual or religious beliefs that are of importance to them? - What impact do the client's spiritual or religious beliefs have on their health care decision making?

Is there a spiritual or religious group that the client identifies as having an importance in their life? Are there any spiritual or religious practices that should be included when planning the client's care? Does the client identify spiritual or religious beliefs that are of importance to them? What impact do the client's spiritual or religious beliefs have on their health care decision making?

A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? - It corresponds to the client's systolic pressure - It is the second diastolic pressure to record - It is the loudest of the Korotkoff sounds - It might not follow with a fifth Korotkoff sound

It might not follow with a fifth Korotkoff sound

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? - Lordosis - Kyphosis - Ankylosis - Scoliosis

Kyphosis

A nurse is preparing to reconstitute and administer a powdered medication in a multidose vial. Which of the following actions should the nurse plan to take? - Use a filtered needle to administer the medication - Briskly shake the medication vial after adding the diluent - Label the vial with the date and time before administering the medication - Swab the rubber seal on the vial with triclosan prior to adding the diluent

Label the vial with the date and time before administering the medication

A nurse is performing a cardiac assessment on a preschooler. The nurse should plan to auscultate the apical pulse at which of the following precordial landmarks? - Along the sternal border at the third intercostal space - At the second intercostal space, to the right of the sternum - Left of the midclavicular line at the fourth intercostal space - At the fifth intercostal space, left of the midclavicular line

Left of the midclavicular line at the fourth intercostal space

A nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health? - Limited access to prepared snacks, such as chips - A park available within walking distance from the client's residence - Limited access to a pharmacy - A neighborhood population that has a high rate of obesity and smoking

Limited access to a pharmacy

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (Select all that apply) - Locks the brakes on the client's bed - Checks the maximum weight of the life before using it - Places the client on the edge of the sling - Uses the lift without assistance from another team member - Performs a safety check before lifting the client

Locks the brakes on the client's bed Checks the maximum weight of the life before using it Performs a safety check before lifting the client

A nurse is preparing to care for a group of clients in an acute care setting. Which of the following should the nurse plan to assess for every client? (Select all that apply) - Lung sounds - Bowel sounds - Measurement of abdominal girth - Pedal pulses - Mental status

Lung sounds Bowel sounds Pedal pulses Mental status

A nurse is performing a preadmission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse? - Asking the client to clarify a statement - Asking the client open-ended questions - Maintaining an arm's length between self and client - Stating name and providing credentials upon entering the client's room

Maintaining an arm's length between self and client

A home health nurse is planning care for an older adult client who has hypertension and is living alone. Which of the following health promotion topics should the nurse include in the client's plan of care? (Select all that apply.) - Maintaining functional capacity - Encouraging the use of free-weight exercises - Participating in social functions - Installing grab bars in the shower - Preparing for age-related diminished cognition

Maintaining functional capacity Encouraging the use of free-weight exercises Participating in social functions Installing grab bars in the shower

A nurse is teaching a class about error-prone abbreviation in medication prescriptions. The nurse should include that which of the following prescriptions has acceptable abbreviation? - Metoclopramide 10 mg IM Q6H PRN nausea - Desipramine 100 mg PO QD - Enoxaparin 30 mg sub q 2 hr before surgery - MSO4 10 mg IM Q3H PRN pain

Metoclopramide 10 mg IM Q6H PRN nausea

A nurse is reviewing a client's prescriptions. The nurse should contact the provider to clarify which of the following prescriptions? - Phenytoin 100 mg PO every 8 hr - Morphine 2.5 mg IV bolus PRN for incisional pain - Regular insulin 7 units subcutaneous 30 min before breakfast and dinner - Lisinopril 20 mg PO every 12 hr. Hold for systolic BP less than 110 min mm Hg

Morphine 2.5 mg IV bolus PRN for incisional pain

A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? - Near-miss event - Client safety event - Adverse event - Sentinel event

Near-miss event

A nurse in an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client? (Select all that apply) - Nutritional status - Hygiene - Lung expansion - Posture - Range of motion

Nutritional status Hygiene Posture

A nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take? - Position the client in prone position - Observe for the use of accessory muscles during inspiration - Begin auscultating at the level of C4 - Reposition the stethoscope downward at 4-inch (10 cm) intervals

Observe for the use of accessory muscles during inspiration

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take? - Instruct the client to breathe in and to exhale out as they normally do - Count the client's respirations for 15 seconds then multiply by 4 - Determine if the client has a history of any chronic respiratory problems - Observe the client's chest movements while appearing to assess their pulse

Observe the client's chest movements while appearing to assess their pulse

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration? - Observe the degree of chest-wall movement during inspiration and expiration - Count how many breathing cycles are observed per minute - Notice whether or not expiration takes longer than inspiration - Measure the precise amount of air the client takes in and breathes out

Observe the degree of chest-wall movement during inspiration and expiration

A nurse is caring for a client who received lisinopril 30 minutes ago and is now reporting dizziness and headache. Which of the following actions should the nurse take first? - Obtain the client's vital signs - Notify the prescriber - Document the client's response in the medical record - Tell the client to change positions slowly

Obtain the client's vital signs

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? - Open the first flap on the sterile package away from their body. - Place objects on the sterile field at least 1.3 cm (0.5 in) from the edge. - Unwrap both sides of the sterile package at the same time. - Set up the sterile field next to a wall in the client's room.

Open the first flap on the sterile package away from their body.

A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question? - Leading question - Closed-ended question - Direct question - Open-ended question

Open-ended question

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope? - Over the right midclavicular line - Over the angle of Louis - Over the fifth intercostal space at the left midclavicular line - Over the suprasternal notch

Over the fifth intercostal space at the left midclavicular line

A nurse is performing an assessment of the head for a client who reports ear pain. Which of the following actions should the nurse take? - Palpate the temporomandibular joint for pain - Palpate the mastoid area for pain - Inspect the nasal mucosa for redness - Inspect the conjunctival sac for erythema

Palpate the mastoid area for pain

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? - Use the soft end of a cotton swab over the client's abdomen - Auscultate the tender areas of the client's abdomen through clothing - Palpate the tender areas of the client's abdomen last - Use deep palpation when assessing the client's abdomen

Palpate the tender areas of the client's abdomen last

A nurse is collecting information about a client's family history. The nurse should plan to collect information about the health of which of the following client relatives? (Select all that apply) - Parents - Siblings - Aunts and uncles - Cousins - Grandparents

Parents Siblings Grandparents

A nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather? (Select all that apply) - Blood glucose meter - Penlight - Stethoscope - Sphygmomanometer - Sterile gloves

Penlight Stethoscope Sphygmomanometer

A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? - Wipe down the client's bedside table with an antiseptic wipe - Conduct informal audits of medical records to identify the number of healthcare-associated infections - Perform hand hygiene - Instruct the client on ways to reduce the risk for infection

Perform hand hygiene

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take? - Wear an N95 respirator when caring for the client. - Place the client in a private room. - Place a mask on the client when they leave their room. - Place the client in a negative airflow room.

Place the client in a private room.

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (Select all that apply) - Place the client on round-the-clock surveillance - Remove objects from the room that the client could use to harm themselves - Search items brought into the client's room by visitors - Refrain from asking the client if they intend to harm themselves - Screen the client for suicidal ideation

Place the client on round-the-clock surveillance Remove objects from the room that the client could use to harm themselves Search items brought into the client's room by visitors Screen the client for suicidal ideation

A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take? - Place the probe in the posterior lingual pocket lateral to the midline - Rest the probe on the lower lingual frenulum - Place the probe centrally on top of the client's tongue - Rest the probe under the tongue just beyond the client's teeth

Place the probe in the posterior lingual pocket lateral to the midline

A nurse is preparing to obtain a temperature on an 18-month-old toddler during a well child examination. Which of the following actions should the nurse take? - Pull the pinna up and back before placing the tympanic thermometer in the ear canal - Insert the lubricated tip of a rectal electronic thermometer 2.5 cm (1 inch) into the toddler's rectum - Place the tip of the oral electronic thermometer under the toddler's tongue in a posterior sublingual pocket - Place the thermometer tip in the center of the toddler's axilla against their skin

Place the thermometer tip in the center of the toddler's axilla against their skin

A nurse is assessing the reflexes of a 6-month-old infant. Which of the following reflex findings should the nurse expect? - Positive extrusion reflex - Negative plantar grasp reflex - Positive Babinski reflex - Negative sucking reflex

Positive Babinski reflex

A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse speak to gather while investigating substance abuse? (Select all that apply) - Prescription medications taken for recreational purposes - Adverse reactions to medications and environmental substances - Determination of when the client last had an alcoholic drink - Frequency of consumption of over-the-counter (OTC) medications - Highest level of schooling completed

Prescription medications taken for recreational purposes Determination of when the client last had an alcoholic drink

A nurse is planning a health class at a local middle school about puberty during adolescence. Which of the following pieces of information should the nurse include in the discussion? (Select all that apply.) - Primary sex organs mature during puberty. - Puberty begins with a growth spurt in height and weight. - Onset of puberty is influenced by genetics, environmental factors, and gender. - Secondary sex characteristics emerge during puberty. - Maturation during puberty occurs at the same rate for everyone

Primary sex organs mature during puberty. Puberty begins with a growth spurt in height and weight. Onset of puberty is influenced by genetics, environment factors, and gender. Secondary sex characteristics emerge during puberty.

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing? - Incubation - Convalescence - Acute illness - Prodromal

Prodromal

A nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview? - Document client data - Provide an opportunity for the client to ask questions - Explain the reason for the interview - Greet client with an introduction

Provide an opportunity for the client to ask questions

A nurse is preparing to administer an oral medication. Which of the following actions should the nurse take? (Select all that apply) - Provide client education about the medication - Check the expiration date of the medication - Verify the dosage of the medication - Call the client by name to confirm their identity - Ask the client if they have any allergies

Provide client education about the medication Check the expiration date of the medication Verify the dosage of the medication Ask the client if they have any allergies

A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading? - Attach the disposable probe cover - Assess the external ear for redness - Pull the pinna back and upward gently - Replace the thermometer in its charger

Pull the pinna back and upward gently

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting? - Auscultatory gap - Pulse pressure - Orthostatic hypotension - Pulse deficit

Pulse pressure

A school nurse asks a first grader about rules at school. The child responds, "We need to wash our hands before lunch, be respectful to the teacher, and pay attention in class. If we don't, we'll get into big trouble." The nurse should recognize that the child is in which of the following of Kohlberg's stages of moral development? - Punishment and Obedience - Good boy-Nice Girl - Social Contract - Law and Order

Punishment and Obedience

A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document? - Borborygmi - Rebound tenderness - Tympany - Abdominal guarding

Rebound tenderness

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? - Record the time and length of the seizure - Restrain the client's extremities - Place the client in the prone position - Monitor the client's hemoglobin level

Record the time and length of the seizure

A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this actions? (Select all that apply) - Depth of pedal pitting edema - Regularity of the pulse - Prescence of a murmur - Prescence of a bruit - Strength of the pulse

Regularity of the pulse Strength of the pulse

A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? - Tie the restraints to the siderails on the client's bed - Remove the restraints with each vital sign check - Use a square knot to secure the restraints - Make sure one finger can fit under the restraints

Remove the restraints with each vital sign check

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include? - Empty sharps containers when they become full. - Report needlestick injuries to the nursing supervisor. - Engage the safety device on a needle after documenting the medication administration. - Recap needles after medication administration.

Report needlestick injuries to the nursing supervisor.

A nurse is providing teaching regarding medication administration to a group of newly licensed nurses. Which of the following is a legal responsibility of a nurse? - Prescribing the correct dosage - Modifying the medication regimen - Reporting the medication errors - Delegating administration to assistive personnel

Reporting medication errors

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process? - Enlist the aid of the client's school-age child to interpret for the nurse and the client - Ask the client's best friend to interpret for the nurse and client - Use jokes and laughter to make the client feel more at ease - Request assistance from an interpreter during the assessment

Request assistance from an interpreter during the assessment

A nurse is caring for a client who is to receive topiramate XR 100 mg PO daily. The client tells the nurse that the capsule is too hard to swallow. Which of the following actions should the nurse take? - Crush the contents of the capsule to administer in a small amount of pudding - Request extended-release sprinkles from the pharmacy - Ask the charge nurse to clarify the prescription with the provider - Withhold the medication until the time for the next dose

Request extended-release sprinkles from the pharmacy

A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent? - Reservoir - Susceptible host - Portal of entry - Portal of exit

Reservoir

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? - Oral temperature 37.8°C (100°F) - Respirations 30/min - BP 148/88 mmHg - Radial pulse rate 45 beats/30 seconds

Respirations 30/min

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first? - Right upper quadrant - Left upper quadrant - Right lower quadrant - Left lower quadrant

Right lower quadrant

A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take? - Rinse the client's skin with water - Remove the client's clothing by pulling it over their head - Dispose of the client's clothing in a single biohazard bag - Prepare to administer potassium inside to the client

Rinse the client's skin with water

A nurse is obtaining the blood pressure of a school-age child. Which of the following actions should the nurse take? - Position the arm at the level of the umbilicus while the child is sitting in a chair - Release the cuff pressure at a rate of 4 to 5 mm Hg per second - Ensure the cuff bladder encircles 50% of the extremity - Select a cuff width that covers 40% of the upper arm

Select a cuff width that covers 40% of the upper arm

A nurse is planning to conduct a health history interview with a client. Which of the following actions should the nurse plan to take? (Select all that apply) - Select a position that is approximately 2 to 4 feet from the client during the interview - Ensure face-to-face contact is at eye level - Conduct the interview in an open area such as the reception area or hallway - Review the client's medical record at the conclusion of the interview - Gather supplies to take notes

Select a position that is approximately 2 to 4 feet from the client during the interview Ensure face-to-face contact is at eye level Gather supplies to take notes

A nurse is caring for a client who is carrying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client? - Tell the client that everything will be just fine - Change the subject while the client is discussing their feelings - Show interest in the client's feelings by acknowledging that they are upset - Tell the client that it is wrong to be crying over this situation

Show interest in the client's feelings by acknowledging that they are upset

A nurse is transcribing a provider's prescription for a client. The prescription reads morphine 2 mg IV bolus at 1400. The nurse should recognize this as which of the following types of medication orders? - Routine order - Stat order - PRN order - Single order

Single order

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation - Unexpected sounds made by tapping on the client's skin - Skin temperature, moisture, or unexpected findings - Heart sounds, lung sounds, and bowel sounds - The client's cleanliness and grooming

Skin temperature, moisture, or unexpected findings

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use? - Alcohol-based sanitizer - Soap and water - Iodine solution - Chlorhexidine solution

Soap and water

A nurse is collecting a health history from a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? - Speak directly to the client throughout the interview - Use a family member to interpret for the client - Ask the interpreter to summarize a group of questions for the client - Rely on using medical terminology when gathering information

Speak directly to the client throughout the interview

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment? - Tongue depressor - Penlight - Reflex hammer - Stethoscope

Stethoscope

A nurse is documenting their assessment and documents that the client states, "I have a dry cough every morning when I wake up." Which of the following types of data is the nurse documenting? - Subjective - Social determination of health - Objective - Olfactory

Subjective

A nurse is teaching a newly licensed nurse about crushing medications. The nurse should explain that which of the following medications can be crushed? - Extended-release oxycodone - Sublingual nitroglycerine - Enteric-coated aspirin - Sucralfate tablets

Sucralfate tablets

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection? - Reservoir - Susceptible host - Portal of entry - Portal of exit

Susceptible host

A nurse is performing a throat culture on a client. Which of the following actions should the nurse take? - Swab the back of the client's pharyngeal wall. - Place the swab in a clean container after obtaining the culture. - Insert the swab in the culture medium within 1 hr of obtaining the sample. - Don sterile gloves to obtain the culture from the client.

Swab the back of the client's pharyngeal wall.

A nurse is assessing a client following administration of an antibiotic. The nurse should identify that which of the following findings is a manifestation of an anaphylactic reaction to the medication? - Swollen lips - Hypertension - Low heart rate - Constipation

Swollen lips

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply) - Doppler - Tape measure - Tongue depressor - Penlight - Electrocardiogram monitor

Tape measure Tongue depressor Penlight

A nurse is performing an annual physical examination on an adolescent. Which of the following should the nurse include in the general survey? - The adolescent's deep tendon reflexes 2+ bilaterally - The adolescent is able to read small print at a distance of 14 inches - The adolescent demonstrates fine motor coordination - The adolescent makes good eye contact

The adolescent makes good eye contact

A nurse is performing a general client survey and finds that the client has a BMI of 23. Which of the following should the nurse document? - The client has no nutritional issues or deficits - The client is at high risk for obesity-related health problems - The client will need a referral to a dietitian - The client has a BMI within the expected reference range

The client has a BMI within the expected reference range

A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? (Select all that apply) - The client who has a BMI of 35 - The client has had nausea for 2 days - The client is reporting a "stuffy" nose - The client has been fasting for blood tests - The client is taking digoxin for an irregular heart rate - The client had a mastectomy 2 years ago

The client who has a BMI of 35 The client is reporting a "stuffy" nose The client is taking digoxin for an irregular heart rate The client had a mastectomy 2 years ago

The nurse is completing documentation in a client's medical record. Which of the following entries display proper documentation by the nurse? - The client is feeling better - The client's abdomen is soft and nondistended - The client's status is unchanged - The client appears in pain

The client's abdomen is soft and nondistended

A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (Select all that apply) - The client's full name - The client's date of birth - The client's telephone number - The client's diagnosis - The client's room number

The client's full name The client's date of birth The client's telephone number

A nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? - The client's admitting diagnosis - The client's medical history - The client's laboratory test results - The client's response to treatment

The client's laboratory test results

A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? (Select all that apply) - The date the medication was mixed - The client's age - The client's room number - The dose of the mixed medications - The time the medication was mixed

The date the medication was mixed The dose of the mixed medications The time the medication was mixed

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include? - The door to the AIIR should remain closed. - Clients who are on contact precautions require AIIR. - An AIIR has at least 4 air exchanges each hr. - A mask is not needed to care for clients who are in an AIIR.

The door to the AIIR should remain closed.

A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicate an understanding of home safety? - An extension cord is secured under a rug - The edges of stairs are marked with brightly colored tape - A toaster is plugged in when not in use - The water heater is set to 55°C (131°F)

The edges of stairs are marked with brightly colored tape

A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? - The nurse plugs in a sequential compression device with wet hands - The nurse holds onto the plug to unplug a client's electronic blood pressure machine - The nurse rolls the client's bed over an electrical cord - The nurse uses an extension cord to plug in a client's smart infusion pump

The nurse holds onto the plug to unplug a client's electronic blood pressure machine

A nurse is conducting a health history interview with a client. Which of the following is true of a directive interview technique? - This technique consists of mostly closed-ended questions - This technique enables the client to control the pace of the interview - This technique is used to gather general information about a client's condition - This technique is effective for determining a client's emotional responses

This technique consists of mostly closed-ended questions

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle? - Try to use alternatives before inserting indwelling urinary catheters. - Use clean technique for insertion of indwelling urinary catheters. - Check clients every 2 days to evaluate the need for indwelling urinary catheters. - Disconnect the system to obtain urine samples from indwelling urinary catheters.

Try to use alternatives before inserting indwelling urinary catheters.

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? - Washes their hands for 10 sec. - Turns off the faucet with a towel. - Uses hot water to wash their hands. - Holds their hands above their elbows while rinising off the soap.

Turns off the faucet with a towel

A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately? - Obtain the reading in the early morning - Use a cuff of the appropriate size for the client - Assist the client to the bathroom to void - Apply the cuff loosely around the client's arm

Use a cuff of the appropriate size for the client

A nurse is planning to implement the Transforming Care at the Bedside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan? - Require nurses to spend 50% of their time at the bedside of the clients - Perform change-of-shift report at the nurses' station - Complete client rounds every 4 hours - Use a standardized communication tool

Use a standardized communication tool

A nurse is planning to complete a physical assessment of a client. Which of the following actions should the nurse plan to take? - Maintain client modesty by auscultating over the client's clothing - Include the nurse's interpretation when recording objective information - Perform the assessment in the same order every time - Use quotation marks when documenting client statements

Use quotation marks when documenting client statements

A nurse is preparing to administer digoxin 225 mcg for a pediatric client who has a heart rate above 90/min. Which of the following actions should the nurse take to ensure administration of the right dose? (Select all that apply) - Validate that the dosage is within the safe range - Confirm the medication amount is appropriate for the child - Verify that the medication is not expired - Check the client's heart rate prior to administration - Document the administration in the medication administration record

Validate that the dosage is within the safe range Confirm the medication amount is appropriate for the child

A nurse is preparing to administer a high-alert pain medication to a client. Which of the following actions should the nurse perform during the planning stage of medication administration? - Assess the effectiveness of the pain medication - Verify the dosage calculation with another nurse - Teach the client about the action of the medication - Ask the client to state their name and birthdate

Verify the dosage calculation with another nurse

A charge nurse is teaching a newly licensed nurse about medication reconciliation. Which of the following information should the charge nurse include in the teaching? - Perform medication reconciliation daily during a client's hospitalization - Only newly prescribed medications need to be reviewed during a medication reconciliation - Vitamins, supplements, and over-the-counter (OTC) medications should be included in a medication reconciliation - The goal of medication reconciliation is to minimize the financial impact of prescription medications to the client

Vitamins, supplements, and over-the-counter (OTC) medications should be included in a medication reconciliation

A nurse is planning discharge teaching for a client who is newly diagnosed with type 2 diabetes mellitus. Which of the following topics should the nurse include in the teaching? (Select all that apply.) - Weight management - Low-protein diet - Glucose testing - Daily exercise - Foot care

Weight management Glucose testing Daily exercise Foot care

A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? - When the atria contracts vigorously - As the ventricular walls contract - When the semilunar valves close - As the mitral valve snaps open

When the semilunar valves close

A nurse is preparing to administer medication to a client who has a prescription for decussate sodium 50 mg capsule PO twice daily. The client refuses to take the medication because of nausea. Which of the following actions should the nurse take? - Administer a docusate sodium capsule rectally - Withhold the medication - Administer 100 mg docusate sodium with the next scheduled administration - Encourage the client to take the medication as the provider prescribed

Withhold the medication

During a wellness visit for a 4-year-old preschooler, a parent explains that their child enjoys playing games on a computer and asks the nurse about an acceptable amount of screen time for their child. Which of the following responses should the nurse make? - "If the child is learning, there are no screen time limits." - "An acceptable amount of screen time is 1 hour per day." - "If the child is content, there is no protocol for screen time." - "Acceptable screen time is 4 hours per day."

"An acceptable amount of screen time is 1 hour per day."

A nurse is caring for a client who states that his provider told him he is at risk for anaphylaxis following administration of amoxicillin and that he does not understand what this means. Which of the following is an appropriate response by the nurse? - "Anaphylaxis is a predictable and often unavoidable secondary effect that can occur at a usual therapeutic dose." - "Anaphylaxis will cause you to experience withdrawal symptoms when you discontinue taking the medication." - "Anaphylaxis is an unusual response that can occur due to an inherited predisposition." - "Anaphylaxis is a severe hypersensitivity or allergic reaction that is life-threatening."

"Anaphylaxis is a severe hypersensitivity or allergic reaction that is life-threatening."

A nurse is caring for a client during a prenatal visit. The client states, "Now that I'm pregnant, I drink wine with dinner. I've given up hard alcohol." Which of the following responses should the nurse make? - "Avoiding alcohol, even wine, is advised during pregnancy since it can cause harm to your baby." - "Since you've stopped drinking hard liquor, your baby will be fine." - "You can drink two glasses of wine each day and not cause harm to your body." - "You should consume with food to minimize its effects on your baby."

"Avoiding alcohol, even wine, is advised during pregnancy since it can cause harm to your baby."

A nurse is performing a screening for scoliosis on a school-age child. Which of the following instructions should the nurse provide? - "Bend your knees and touch your toes." - "Stand facing me with your hands on your hips." - "Bend forward with your knees straight and your arms dangling." - "Lie on your stomach with your arms extended over your head."

"Bend forward with your knees straight and your arms dangling."

A nurse is discussing climacteric changes that occur during middle adulthood with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the concept? (Select all that apply.) - "Both males and females experience a change of life referred to as climacteric." - "Climacteric in females is referred to as menopause." - "Climacteric in males means they are no longer able to fertilize a female egg." - "Climacteric changes in males occur gradually, over a number of years." - "Climacteric in females can manifest as heart palpitations."

"Both males and females experience a change of life referred to as climacteric." "Climacteric in females is referred to as menopause." "Climacteric changes in males occur gradually, over a number of years." "Climacteric in females can manifest as heart palpitations."

A nurse is evaluating a client for an alteration in orientation. Which of the following questions should the nurse ask the client? - "Can you tell me your birthday?" - "Can you tell me what you had for lunch yesterday?" - "Can you tell what month it is?" - "Can you repeat the four words that I asked you to remember?"

"Can you tell what month it is?"

A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation? - "I had a rash from poison ivy on my arms last week, but it's gone now." - "I wear a hearing aid." - "I had a negative tuberculosis screening test last month." - "I have a cough."

"I have a cough"

A nurse is caring for adolescents in a school-based health clinic. Which of the following client statements should the nurse recognize as an indication that the client is experiencing Erikson's stage of identity versus role confusion? - "I'm coaching a little league team." - "I think I might be gay." - "I can't seem to do anything right for my parents." - "Why would someone want to help me? What's in it for them?"

"I think I might be gay."