Fundamentals A+ B Review

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis

Calf Swelling; swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body. *this increases support and maintains alignment

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

We can talk about advance directives, and I can also give you some brochures about them.

A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative.

A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints; the use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leave the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind" *When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client.

A nurse is caring for a client who has terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time." *This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis.

A nurse is caring for a client who has terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time."; this statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. The first step is to obtain the death pronouncement from the provider. 2. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. 3. After cleansing, the nurse should ask the family members if they wish to view the body. 4. Finally, the nurse should place a name tag on the body before transfer.

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day

A nurse enters a clients room and finds her on the floor. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

Client found lying on the floor. *The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area *allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds.

Normal breath sounds

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear *Pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. *Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it. *This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

a home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

The client's caregiver washes out the feeding bag with warm water once every 24 hours. *Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

The pain like like a dull ache in my stomach. The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion *The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse has accepted a verbal prescription "for three-tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg *The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position *The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is caring for a client who requires informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

Witness the client's signature on the consent form. *The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client uses nonacetone nail polish remover. *The client should use nonflammable materials, such as non-acetone nail polish remover, while using supplemental oxygen. No wool, oxygen tanks should be stored upright, and equipment should be checked daily.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

Use the complete name of the medication magnesium sulfate *The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place. *Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nursing is talking with an older adult who is contemplating retirement. The client states, "I keep thinking how much I enjoy my job. I'm not sure I want to retire." which of the following responses should the nurse make?

"Let's talk about how the change in your job status will affect you." *This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should receive a pneumococcal vaccine when you are 65 years old." *The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance *An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse is caring for a client who has a sodium level of 125 mEq?L. Which of the following findings should the nurse expect?

Abdominal cramping *This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Determine the reasons why the client is refusing to use the incentive spirometer. *The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.

A nurse is preparing to administer 0.5mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration. *ensure that the medication is mixed. The nurse should not transfer prepackaged liquid medication to a medicine cup to reduce the risk of altering the premeasured dose. The nurse should place the client in high-Fowler's position when administering an oral liquid medication to reduce the risk of aspiration. The nurse should not transfer prepackaged liquid medication to a measuring device to reduce the risk of altering the premeasured dose.

A charge nurse is discussing the responsibility of nurses caring for clients who have C. Diff infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting. *Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees. *The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. The nurse should rinse the feeding bag with warm water to reduce the risk of bacterial growth; however, there is another action that is the priority. The nurse should make sure the enteral formula is at room temperature to prevent the cramping and discomfort that can result from instilling cold formula; however, there is another action that is the priority. The nurse should wipe the top of the formula can with alcohol to remove or disinfect any dirt or micro-organisms that could contaminate the formula; however, there is another action that is the priority.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

What would I have done to deserve this illness *The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

A nurse is assessing a clients readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning" *The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

A nurse is caring for a client who requires 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since." *For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hands over the stairs of my front porch." *Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch."

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull" *Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. Asking the client whether the pain radiates determines the pain's location. Asking the client to rate the pain using the pain scale determines the intensity of the pain. Asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness" *Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if i arrived at the emergency department and I had difficult breathing?" Which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose" *Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the clients understands the teaching?

"When descending stairs, I will first shift my weight to my right leg." *To descend stairs, the client should first shift his body weight to his right, unaffected leg. The client should place his crutches 15 cm (6 in) in front and to the side of each foot. Just before sitting down, the client should hold both crutches by their hand bars in one hand. To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae.

A client who is postoperative is verbalizing pain as a 2 on a scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management.

"it might help me to listen to music while i'm lying in bed" *Listening to music is an effective nonpharmacological intervention for the management of mild pain.

A nurse is planning care for a patient who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

- Assist the the client with a partial bath - Measure the client's BP after the nurse administers antihypertensive medication - Use a communication board to ask what the client wants for lunch *Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function. Measuring a client's BP poses minimal risk to the client and is within the AP's range of function. Using a communication board poses minimal risk to the client and is within the AP's range of function.

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

- Pupil clarity - Visual fields - Visual acuity *Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is preparing to obtain lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mmHg to which the nurse should inflate the cuff when obtaining the blood pressure?

120 mmHg *To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP) select all that apply

1. assist with partial bed bath 2. measure BP after nurse gives antihypertensive meds 3. test the clients swallowing ability by providing thickened liquids 4. use a communication board to ask what the client wants for lunch 5. irrigate indwelling catheter 1,2,4

a nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. the nurse should set the infusion pump to deliver how many mL/hr?

107 mL/hr 1. what is the unit of measurement to calculate? mL/hr 2. what is the volume needed? 750 mL 3. what si the total infusion time? 7 hr 4. should the nurse convert the units of measurement? no 5. set up equation and solve for X. volume/time = X 750/7= X 107.14 rounded = 107

A nurse is preparing to administer enoxaparin subcut to a client. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45 degree angle *The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips *The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma *Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate veracity?

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively *Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance?

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client. *Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition isa contraindication for which of the following therapies?

Acupuncture *The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

Administer pain medication 45 min before changing the client's dressing *The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen. *The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures clients safety, health, and rights. *Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An X-ray shows the end of the tube above the pylorus *The tube aspirate has a pH of 7. Gastric aspirate from a client who has been fasting for several hours should have a pH of 4.0 or less. Intestinal fluid or fluid from the client's airway usually has a pH higher than 6.0. Therefore, a pH of 7.0 does not indicate gastric placement of an NG tube.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

Apply an ankle-foot orthotic device to the client's feet. *The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter. *The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

A nurse is planning care for a client who as vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the client's plate *Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage. *A second nurse must witness the disposal of any portion of a dose of a controlled substance.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension. *The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessment should the nurse identify as the priority?

Auscultate lung sounds *The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine. *A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds *When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

Current medications *The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries. *The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is providing discharge teaching for a client who has new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward *The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received while at the facility *When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions; the nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the providers prescriptions *The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A nurse is admitting a client who has an abdominal wound with large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions *Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse recieves report on a client who is recieving 0.9% sodium chloride at 125 mL/hr. When the nurse performs the inital assessment she notes that the client has recieved 80 mL for the last 2 hrs. Which of the following actions should the nurse first take? A. reposition the client B. document the client's IV intake in the medical record C. request a new IV fluid prescription D. check the IV tubing for obstruction

D: Check the IV tubing for obstruction *The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has a fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate *Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is post-op and has volume deficit. Which of the following changes should the nurse identify as an indication that treatment was successful.

Decrease in heart rate: fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins *Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet *Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies. Clients who have a compromised immune system, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus *Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A nurse is caring for a client who has pharygeal diphtheria. Which of the following types of transmission precaution should the nurse initiate?

Droplet *Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process. *Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is assessing four adult clients. Which fo the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. *The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points *Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.

A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client *According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. the second action in response to a fire is to activate the alarm. the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire. the fourth action in response to a fire is to attempt to extinguish the fire.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which fo the following actions should the nurse take?

Examine personal values about the issue *Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL fo sterile water. *The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet together. *A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is caring for a client who has limited mobility in his lower extremities. Which o the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position. *By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid *Stage 1: Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. Stage 2: Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. Stage 3: Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. Stage 4: Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

I can take echinacea to improve my immune system.

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

I will be sure to remove my hearing aid before taking a shower. *Clients should remove any hearing devices before showering because exposure to water can damage them. Whistling during insertion can be a sign that the hearing aid does not fit properly. A buildup of cerumen or fluid in the ear can also cause a whistling sound. Physical activity can easily dislodge this type of hearing aid. A behind-the-ear hearing aid allows for fine tuning of the volume of the device. It is useful for clients who have mild to severe hearing loss.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrotomy tube. *It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep. *The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

Maintain a consistent time to wake up each day. *The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A nurse is caring for a client who is postoperative following a knee anthroplasty and requires the use of thigh-high sequential compression sleeves. Which of the following actions should the nurse take?

Make sure 2 fingers can fit under the sleeves *The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.

A nurse is planning care for a client who has TB. The nurse should use which of the following pieces of PPE when providing care for the client?

N95 respirator *The nurse should wear a gown when providing care for a client who requires contact precautions to prevent the transmission of bacteria. The nurse should wear shoe covers when proving care for a client who is in the surgical suite to reduce the risk for contamination and potential infection. The nurse should wear a surgical cap when proving care for a client who is in the surgical suite to reduce the risk for contamination and potential infection.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 minutes and to report back in 1 hour. Which of the following actions should the nurse take next?

Notify the nursing manager. *The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the patients wrist before applying the restraints *The use of restraints without padding can abrade the client's skin, resulting in client injury.The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints. The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury.

A middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." Which of the follow responses should the nurse make?

People in middle adulthood often find satisfaction in nurturing and guiding young people. *According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of the infection?

Place a client who has TB in a room with negative-pressure airflow. *A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission.

a nurse is planning to insert a peripheral IV catheter in an older adult client. which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position; the nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L *This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

Practice sessions *Question-answer meetings promote cognitive learning. Group discussions assist adolescents with cognitive and affective learning. Role play is a technique that promotes cognitive and affective learning.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear; pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief. *During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload *The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

Role overload; the partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a section catheter that is half the size of the lumen. *The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia. The nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation solution to decrease trauma to the mucosa. The nurse should adjust the suction pressure to approximately 120 mm Hg and no higher than 150 mm Hg to prevent hypoxemia and trauma to the mucosa.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR) *SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

Skin blanching *Skin blanching, edema, and coolness at the IV site indicate infiltration. Bleeding can have a mechanical cause or can occur as the result of anticoagulation. It is not a sign of infiltration. Warmth indicates phlebitis, not infiltration. Exudate indicates infection, not infiltration.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output. *The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A home health nurse is completing an administration assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as the potential indication of elder abuse?

The caregiver insists on remaining in the room. *A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

The client's caregiver washes out the feeding back with warm water once every 24 hours; feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hours to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. *The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is caring for a client who has TB. Which of the following actions should the nurse take?

The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. he nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hours *The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system. *The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system; the nurse should identify that the client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at risk for falling, therefore, a bed alarm system can alert the staff members that the client is trying to get out of bed and requires assistance.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors. *Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse impliment?

Using the planning step of the nursing process to prioritize client care delivery. *Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly *Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is caring for a client who has diarrhea due to shigella. Which of the follow precautions should the nurse implement for this client?

Wear a gown when caring for the client. *The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces.

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's care plan?

Wrap blankets around all four sides of the bed. *The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.

A nurse in a clinic for a middle adult client who states "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

You should have a fecal occult blood test every year. *Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually. Blood tests do not detect colorectal cancer. One option for screening is a double-contrast barium enema every 5 years. Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. One option for screening is a flexible sigmoidoscopy every 5 years.

A nurse is caring fro a client who is postoperative and has signs of hemorrhagic shock. when the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. from a legal perspective, which of the following actions should the nurse take next?

notify the nurse manager; the greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care.