Final Fundamentals

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see whether the catheter is patent. B. Reassure the client that it is not possible for them to urinate. C. Recatheterize the bladder with a larger‑gauge catheter. D. Collect a urine specimen for analysis

A

A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? A. "Get up and change positions slowly." B. "Avoid eating aged cheese and smoked meat." C. "Report any usual bruising or bleeding to the doctor immediately." D."Eat the same amount of foods that contain vitamin K every day.

A

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall‑risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession

A

A nurse is caring for a client who has a prescription for a 24‑hr urine collection. Which of the following actions should the nurse take? A. Discard the first voiding. B. Keep the urine in a single container at room temperature. C. Dispose of the last voiding. D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

A

A nurse is reviewing the medical record of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply.) A. Diuretics B. Corticosteroids C. Oral anticoagulants D. Opioid analgesics E. Antipsychotics

A,B,E

A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply.) A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication.

A,B,E

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.) A. Hct 55% B. Blood osmolarity 260 mOsm/kg C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035 E. Blood creatinine 0.6 mg/dL

A,C,D

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply.) A. "Have your working hours changed recently?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing."

A,C,D,E

nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation

A,C,D,E

A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? (Select all that apply.) A. Urinary incontinence B. malaise C. Acute confusion D. Fever E. Agitation

A,C,E

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply.) A. REM sleep provides cognitive restoration. B. REM sleep lasts about 90 min. C. It is difficult to awaken a person in REM sleep. D. Sleepwalking occurs during REM sleep E. Vivid dreams are common during REM sleep

A,C,E

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear

A,D

a client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. the nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (select all that apply.) A. Cover the area with saline‑soaked sterile dressings. B. apply an abdominal binder snugly around the abdomen. C. use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. offer the client a warm beverage (herbal tea)

A,D

a nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (select all that apply.) a. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. d. Have the client sit on a gel cushion when in a chair. e. Reposition the client at least every 3 hr while in bed.

A,D

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "They said they hurt after walking about 10 minutes." C. The client's pain rating is 3 on a scale of 0 to 10. D. The client's skin is pink, warm, and dry. E. The assistive personnel reports that the client walked with a limp

A,D,E

A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization

A,D,E

nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime. B. Offer the client warm milk and crackers at 2100. C. Allow the client to take a bath in the evening. D. Ask the provider for a sleeping medication.

C

nurse is caring for a client who requires a low‑residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C

nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. Starting an Iv infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage

C

nurse reviewing a client's health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescription? A. Single B. Stat C. Routine D. Now

C

a nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) a. Instruct the client not to perform the Valsalva maneuver. b. apply elastic stockings. C. Review laboratory values for total protein level. d. Place pillows under the client's knees and lower extremities. E. assist the client to change positions often.

B,E

A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

BMI = weight (kg) ÷ height (m2). Step 1: Client's weight (kg) and height (m) = 80 kg and 1.6 m Step 2: 1.6×1.6 = 2.56 m2 Step 3: 80 ÷ 2.56 =31.25 A BMI greater than 30 identifies obesity.

A nurse on a medical‑surgical unit has received change‑of‑shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Updating the plan of care for a client who is postoperative B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure injury

C

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro‑organisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

C

a nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? a. Decreased subcutaneous fat b. Muscle atrophy C. Pressure injury d. Fecal impaction

C

charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin‑resistant Staphylococcus aureus (mRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? A."I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B."mRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C."I will protect others from exposure when I transport the client outside the room." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile

C

nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? A. Puncture another finger to obtain a capillary specimen. B. Test the urine with a urine reagent strip. C. Wrap the hand in a warm, moist cloth. D. Perform a venipuncture to obtain a venous sample

C

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated."

A

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. "I will review the past medical history on the client's record to get more information." C. "I will carry out the new prescriptions from the provider." D. "I will ask the client if their nausea has resolved."

A

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A. Infuse hypotonic Iv fluids. B. Implement a fluid restriction. C. Increase sodium intake. D. Administer sodium polystyrene sulfonate.

A

A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? A. Implement airborne precautions. B. Obtain a sputum culture. C. Administer antituberculosis medications. D. Recommend a screening test for family members.

A

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? A. "Flush the tube before and after each medication." B. "mix your medications with your enteral feeding." C. "Push tablets through the tube slowly." D. "mix all the crushed medications prior to dissolving them in water."

A

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A

A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take? A. Offer to assist the client who needs the bedpan. B. Administer the injection the other nurse prepared. C. Prepare another syringe and administer the injection. D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.

A

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing the pain.

A

a nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr

A

charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A

nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A

nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

A

nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A

nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open it. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth.

A

nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client

A

nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism

A

nurse on a medical‑surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an toxic dose of sodium bicarbonate antacid

A

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery.

A,B

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest. C. Administer oral pain medication. D. Obtain a Dobhoff tube for insertion. E. Have a petroleum‑based lubricant available.

A,B

nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone

A,B

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. many older men and women need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates

A,B,C

A nurse is caring for a client in a long‑term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents

A,B,C

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer cannula surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

A,B,C

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.) A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 5 cm (2 in). E. Hang the enema container 61 cm (24 in) above the client's anus

A,B,C

a nurse is collecting data from a client who is 5 days postoperative following abdominal surgery.the surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply.) a. Increase in incisional pain B. Fever and chills C. Reddened wound edges d. Increase in serosanguineous drainage e. Decrease in thirst

A,B,C

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common‑source outbreaks

A,B,C,E

a nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane

A,B,D

A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.) A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take an afternoon nap. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime

A,B,D,E

nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension

A,B,D,E

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

A,B,E

A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply.) A. "I will observe for adverse effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a medication if I believe it is unsafe."

A,B,E

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. Inspect the feet daily. B. Use moisturizing lotion on the feet. C. Wash the feet with warm water and let them air dry. D. Use over‑the‑counter products to treat abrasions. E. Wear cotton socks

A,B,E

nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come and speak with you?" B. "you will feel better soon. you have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "you know, it is quite normal to feel anger toward your loved one at this time." E. "Tell me more about how you are feeling."

A,D,E

nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Apply suction for 10 to 15 seconds

A,D,E

nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the information which of the following alterations for wound healing by secondary intention (select all that apply.) A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

A,E

nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents should the nurse include as examples of the direct mode of transmission? (Select all that apply.) A. Blood spurting from an arterial wound splashes into a nurse's eye. B.A nurse has a needlestick injury. C.A mosquito bites a hiker in the woods. D.A nurse finds a hole in their glove while handling a soiled dressing. E.A person fails to wash their hands after using the bathroom and touches a client

A,E

nurse is reviewing a client's prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply.) A. A once‑daily multivitamin B. Eye drops prescribed every 3 hr C. An antibiotic prescribed every 8 hr D.A blood pressure pill prescribed twice daily E.A subcutaneous injection prescribed once weekly

A,E

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.

B

A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia? A. Linear clusters of vesicles on the right shoulder B. Purulent drainage from both eyes C. Decreased white blood cell count D. Report of continued pain following resolution of the rash

D

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone

D

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids. B. Instruct the client to tuck their chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals

B

A nurse is instructing a client who has narcolepsy about measures that might help with self‑management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day."

B

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule. B. Check the client's weight each morning. C. Notify the provider of a urine output greater than 30 mL/hr. D. Encourage independent ambulation four times a day.

B

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Macaroni and cheese B. One medium apple with skin C. One cup of plain yogurt D. Roast chicken and white rice

B

A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine toxicity C. Decreased risk of adverse effects of cimetidine D. Increased therapeutic effects of imipramine

B

A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands? A. "I will straighten my ear canal by pulling my ear down and back." B."I will gently apply pressure with my finger to the front part of my ear after putting in the drops." C."I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal."

B

A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered nurse (RN) C. Practical nurse (PN) D. Assistive personnel (AP)

B

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A."I will place the client on their side." B."I will go to the nurses' station for assistance." C."I will note the time that the seizure begins." D."I will prepare to insert an airway."

B

A nurse on a medical‑surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites

B

A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A."A second nurse enters the prescription into the client's medical record." B."Another nurse should listen to the phone call." C."The provider can clarify the prescription when they sign the health record." D."I should omit the 'read back' if this is a one‑time prescription."

B

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold their breath briefly and bear down. B. Clamp the enema tubing. C. Remind the client that cramping is common at this time. D. Raise the level of the enema fluid container.

B

a nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? a."this device will keep me from getting sores on my skin." b. "this device will keep the blood pumping through my leg." C. "With this device on, my leg muscles won't get weak." d. "this device is going to keep my joints in good shape."

B

nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds. B. Stop the feeding. C. Obtain a chest x‑ray. D. Initiate oxygen therapy.

B

nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

B

nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? A. Use a 22‑gauge needle. B. Select a site on the client's abdomen. C. Use the Z‑track technique to displace the skin on the injection site. D. Observe for bleb formation to confirm proper placement

B

nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented

B

nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them

B

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral edema

B,C,D

a nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply.) a. Extremes in age B. Chronic illness C. Low hemoglobin d. Malnutrition e. Poor wound care

B,C,D

nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field

B,C,D

nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates wearing slippers over antiembolic stockings. C.The client uses a front‑wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning.

B,C,D

nurse is preparing to initiate a bladder‑retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine

B,C,D

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

B,C,D,E

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (Select all that apply.) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at increased risk for complications from food poisoning. C. Clients who are at high risk should eat or drink only pasteurized dairy products. D.Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately can prevent food poisoning.

B,C,E

A nurse is preparing an in‑service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances

B,C,E

nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply.) A. Orthostatic hypotension B. Tremors C. Acute dystonia D. Decreased level of consciousness E. Restlessness

B,C,E

nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions

B,C,E

nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C.A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

B,C,E

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.) A. Limit total daily fluid intake. B. Decrease or avoid caffeine. C. Take calcium supplements. D. Avoid drinking alcohol. E. Use the Credé maneuver.

B,D

nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

B,D

A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply.) A. Speak at a higher volume to the client. B. Make sure only one person speaks at a time. C. Avoid discouraging the client by indicating that they cannot be understood. D. Allow plenty of time for the client to respond. E. Use brief sentences with simple words

B,D,E

A nurse is collecting data from a client who has hypercalcemia as a result of long‑term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting

B,D,E

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

B,D,E

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Tuberculosis

D

A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A. Creating a plan of care for a client who is recovering following a stroke B.Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered‑dose inhaler

C

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? A. Alert the American Nurses Association. B. Fill out an incident report. C. Report the observations to the nurse manager on the unit. D. Leave the nurse alone to sleep

C

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A."I'd rather have my brother make decisionsfor me, but I know it has to be my wife." B."I know they won't go ahead with the surgery unless I prepare these forms." C."I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C

A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse's priority? A. Teaching the client about the purpose of the medication B. Giving the medication at the administration time the provider prescribed C. Identifying the client's medication allergies D. Documenting the client's anxiety level

C

A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment. B. Encourage visitors to distract the client. C. Provide a private room, and limit stimulation. D. Speak at a higher volume to the client

C

A nurse is caring for a client who has stage Iv lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kübler‑Ross model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance

C

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self‑care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen muscles and promote healing. B. The client needs privacy at times for self‑reflecting and organizing life. C. The client's sense of loss can be lessened through retaining control of some areas of life. D. Performing ADLs is a requirement prior to discharge from an acute care facility.

C

A nurse is caring for a client who is 1 day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO

C

A nurse is caring for a client who is receiving morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping."

C

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure their pain. D. Use open‑ended questions to identify the client's pain sensations

C

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

C

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure injury risk

C,D,E

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) A. Remove the dentures from the body. B. Make sure the body is lying completely flat. C. Apply fresh linens and place a clean gown on the body. D. Remove all equipment from the bedside. E. Dim the lights in the room.

C,D,E

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall‑risk assessment.

C,D,E

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings (Select all that apply.) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor

C,D,E

A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

C,D,E

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C,D,E

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations

C,D,E

nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C,D,E

nurse is teaching self‑monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Perform SMBG once daily at bedtime. B. Wipe the hand with an alcohol swab. C.Hold the hand in a dependent position prior to the puncture. D. Place the puncturing device perpendicular to the site. E. Prick the outer edge of the fingertip for the blood sample

C,D,E

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing. C.A red color change indicates a positive test. D. The specimen cannot be contaminated with urine.

D

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room.

D

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged from carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.

D

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."

D

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago

D

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

D

A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "Avoid green, leafy vegetables while taking this medication." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "Report diarrhea while taking this medication."

D

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned up so I can hear better." D. "I take the batteries out of my hearing aids when I take them off at night."

D

nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding? A. "I will set my water heater at 130° F." B. "Once my baby can sit up, they should be safe in the bathtub." C."I will place my baby on their stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib.

D

nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D

nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A."I can open the time‑release capsule with the beads in it and sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding." C."I can crush the enteric coated pill, if needed." D."I will eat two crackers with the pain pills."

D

nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? A.Smear the blood onto the strip. B. Squeeze the blood onto the strip. C. Touch the puncture to stimulate bleeding. D. Hold the test strip next to the blood on the fingertip.

D