Fundamentals ATI final exam practice questions
A nurse is preparing to administer a pre-packaged medication to a client and complete the final medication check. Which of the following is an appropriate action by the nurse? Check the medication A. at the client's bedside before administration. B. in the area where the medication is obtained. C. at the time of documentation. D. in the nurse's station while review the provider's order.
A. at the client's bedside before administration.
A client receiving chemotherapy has developed stomatitis. An appropriate lunch selection for this client is A. cheese omelet, cherry gelatin, milkshake. B. hot dog on a soft roll, potato chips, orange juice. C. Haddock, french fries, tomato juice. D. Chicken Caesar salad, lemon-lime soda.
A. cheese omelet, cherry gelatin, milkshake.
A nurse is collecting subjective and objective data about a toddler who has otitis media. The nurse's observation of this child are likely to include A. tugging on the affected ear's lob. B. clear drainage from the affected ear. C. pain when manipulating the affected ear's lobe. D. erythema and edema of the affected auricle.
A. tugging on the affected ear's lob.
A nurse receives a new prescription from the provider which reads "give 14 units of regular insulin and 28 units of long-acting insulin to be given subcutaneously at the breakfast hour." What is the total number of units of insulin the nurse will prepare in the insulin syringe? A. 14 units B. 28 units C. 32 units D. 42 units
D. 42 units
A nurse has a prescription to administer an adult client penicillin that is to be given intramuscularly. Which of the following angles should the nurse use for the injection into the ventrogluteal muscle? A. 45º angle B. 60º angle C. 75º angle D. 90º angle
D. 90º angle
A client who has a nasogastric tube in place is prescribed a sublingual medication. Which of the following is an appropriate action by the nurse?A. Administer the medication in a liquid form orally. B. Administer the crushed medication trough the NG tube. C. Administer the medication dissolved in water through the NG tube. D. Administer the medication under the client's tongue.
D. Administer the medication under the client's tongue.
A nurse is assisting with the admission of a client who has tuberculosis and a productive cough. Besides standard precautions, which type of precautions should the nurse contribute to the client's plan of care? A. Contact B. Droplet C. Protective D. Airborne
D. Airborne
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?
"I am going to listen to your abdomen." Rationale: a common reason why client's experience nausea and vomiting after a surgery is bc of delayed gastric emptying time or decreased peristalsis determine presence of bowel sounds before liquids can be administered
A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following is an appropriate action during this procedure? A. Pull the skin 1.3 cm (1/2 inch) to the side. B. Insert the needle slowly and gently. C. Use a 45º angle of insertion. D. Aspirate for 5 to 10 seconds.
D. Aspirate for 5 to 10 seconds. Rationale: The nurse should pull the skin 2.5 vm (1 inch) to the side to make it easier to insert the needle.
A nurse preparing medication for a client is called away to an emergency. What should the nurse do?
Lock the medications in a cart and finish them upon return.
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?
Lower abdomen. Rationale: The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and tissue injury.
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation.
Montgomery straps. Rationale: The nurse should apply the least restrictive priority-setting framework.
A nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL should the nurse administer to the client? (Round to the nearest tenth.)________mL
0.4
A nurse is preparing to administer pain medication to a client. The provider's order is for meperidine (Demerol) 35 mg IM q6h PRN for pain. The available vial contains 75 mg/mL. How many mLs should the nurse administer? (Round to the nearest hundredth.)________mL
0.47 ml
A nurse is preparing to administer digoxin (Lanoxin) 0.25 mg PO. Available is digoxin 0.125 mg tablets. How many tablets should the nurse administer to the client? (Round to the nearest whole number.)__________
2
A provider prescribes 2 g of a medication to give to a client in eight divided doses over the next 24h. How many mg should the nurse administer for each dose?__________
250 mg
A nurse is caring for an infant who is prescribed amoxicillin (Amoxil) 320 mg PO q12h. The medication is available as 400 mg/5 mL. How many mL will the nurse__________ mL
4 ml
A nurse is preparing to administer amoxicillin (Amoxil) 300 mg PO. Available is 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)_______mL
6 ml
A nurse is preparing to administer amoxicillin (Amoxil) 350 mg PO. Available is 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)_______mL
7 ml
nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask.
A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by a secondary intention. When changing the client's dressing, which observation should the nurse report to the charge nurse? A halo of erythema on the surrounding skin B. Pink, shiny tissue with a granular appearance C. Seriosanguineous drainage D. Tenderness when touched
A halo of erythema on the surrounding skin. Rationale: The nurse should report to the provider when the client has a ring of erythema on the surrounding skin, which might indicate underlying infection. This and any other manifestion of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.
A nurse is reinforcing teaching with a group of active personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching? A. "As long as I am changing gloves between clients, it is not necessary to wash my hands." B. "I should wash my hands when my hands are visibly soiled." C. "I will not wear artificial nails when providing client care." D. "It is acceptable to use alcohol-based hand products after most client contact."
A. "As long as I am changing gloves between clients, it is not necessary to wash my hands."
A client is about to start using gentamicin (Garamycin) ointment to treat a serious skin infection. Which of the following instructions should the nurse reinforce when talking with the client about using the preparation? A. "I'll wash the area with soap and water before I apply the cream." B. "After I apply the cream, I will leave the area open to the air." C. "I can expect a little blurry vision while I'm using this cream." D. "I should apply the cream to large areas around the infection."
A. "I'll wash the area with soap and water before I apply the cream."
Before administering a medication to a client, the nurse needs to identify the client. Which of the following methods of identification should the nurse perform? A. Ask the client's full name and date of birth. B. Check the client's ID bracelet and scan the bar code. C. Check the client's name on the medication administration record. D. Check the client's name with family member.
A. Ask the client's full name and date of birth. Rationale:The nurse should request the client to state his/her full name along with their date of birth. This is part of the 7 Rights of Medication of Administration.
A nurse is administering morning medications and realizes that nifedipine (Procardia) was administered to the wrong client. Which of the following is the priority nursing action? A. Check the client's vital signs. B. Notify the client's charge nurse. C. Fill out an occurrence form according to institutional policy. D. Administer the medication to the correct client.
A. Check the client's vital signs.
A nurse is preparing to administer acetaminophen (Tylenol) to a child with a fever. The nurse observes that the client appears small for her age. Which of the following actions should the nurse take? A. Compare the dose with the calculated dosage range based on the child's weight. B. Administer half of the prescribed dose. C. Give the dose as prescribed by the provider. D. Call the provider to verify the dosage.
A. Compare the dose with the calculated dosage range based on the child's weight.
A nurse is caring for an older adult client who has several medications prescribed and expresses reluctance to take them because of difficulty swallowing. Which strategy should the nurse use for this client? A. Crush the medications and mix them with soft foods. B. Disguise the medications by placing them in meat. C. Request the injectable medications be prescribed. D. Place the client in semi-Fowler's position.
A. Crush the medications and mix them with soft foods.
A nurse is instilling ear drops to a young child and must straighten the ear canal by pulling the auricle of the ear. The nurse will pull the auricle in which directions? A. Down and backward. B. Down and outward. C. Upward and backward. D. Upward and outward
A. Down and backward.
A nurse suspects that another nurse on the unit is removing a small amount of morphine sulfate from the syringe before administering the medication to the client. Which of the following actions by the nurse is appropriate? A. Inform the nurse manager about her suspicions. B. Approach the nurse involved to discuss her suspicions. C. Ask the (AP to observed the other nurse's actions. D. Report the incident to the hospital's security department.
A. Inform the nurse manager about her suspicions.
A nurse's inadvertent medication error results in a severe allergic reactions and prolonged hospitalization. The client could rightfully sue the nurse for which of the following? A. Malpractice B. Assault C. Battery D. Abuse
A. Malpractice
A nurse is preparing a medication and is converting 0.8 grams to milligrams. The nurse should do which of the following? A. Move the decimal point 3 places to the right. B. Move the decimal point 3 places to the left. C. Move the decimal point 2 places to the right. D. Move the decimal point 2 places to the left.
A. Move the decimal point 3 places to the right.
A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply) A. Repeat the order back to the prescriber. B. Question any part of the prescription that is unclear or inappropriate. C. Transcribe the prescription into the clients medical record. D. Obtain the prescriber's signature within 8 hours. E. Implement a voice mail prescription if the nurse can hear and understand it well. Study These Flashcards
A. Repeat the order back to the prescriber. B. Question any part of the prescription that is unclear or inappropriate. C. Transcribe the prescription into the clients medical record.
The nurse is to administer rectal suppository to a client. The nurse should instruct the client to lie in which of the following positions while in bed? A. Sim's position B. Prone position C. Lying on the right side D. Lying on the left side
A. Sim's position Rationale: The Sim's position exposes the anus and helps the client relax the external sphincter while lying in bed. This allows easier insertion of the suppository
A nurse is caring for a surgical client and accidentally sticks her hand with the needle used to administer the client's pain medication. Which of the following actions should the nurse take first? A. Wash with soap and rinse under water. B. Report the incident to the employee health office. C. Complete an incident report and obtain an HIV test. D. Determine the HIV and Hepatitis B status of the client.
A. Wash with soap and rinse under water.
A nurse is caring for a client with bacterial conjunctivitis of the right eye, for which an antibiotic ointment has been prescribed. Which of the following is an appropriate statement by the nurse? A. "When washing your face, wash the infected eye first." B. "Apply the ointment in a thing line into the conjuctival sac." C. "Always wipe from the outer to the inner canthus when wiping away secretions." D. "Use a sterile glove and applicator to apply the antibiotic ointment."
B. "Apply the ointment in a thing line into the conjuctival sac."
A nurse is preparing to administer ofloxacin drops (Floxin) to an adult client. Which of the following actions should the nurse take? A. Hold the dropper against the ear canal and drip the medication slowly down the canal. B. Apply gentle pressure with a finger to the tragus of the ear. C. Chill the medication prior to administration. D. Straighten the external auditory canal by pulling it down and back
B. Apply gentle pressure with a finger to the tragus of the ear.
A nurse is caring for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse recommend for inclusion in the plan of care? A. Apply a heat lamp twice a day. B. Cleanse with saline solution. C. Cleanse with povidone-iodine solution. D. Massage reddened areas with dressing changes.
B. Cleanse with saline solution. Rationale:Isotonic saline solution, a nonionic agent, is used to prevent disruption of tissue healing.
A nurse is caring for a client who has just had a mastectomy and has a closed wound-suction device (Hemovac) in place. Which nursing action will ensure proper operation of the device? A. Emptying the device when it's full B. Collapsing the device whenever it is 1/2 to 2/3 full of air C. Keeping the tubing above the level of the surgical incision D. Irrigating the tubing with sterile 0.9% sodium chloride q8h
B. Collapsing the device whenever it is 1/2 to 2/3 full of air
A nurse is caring for a client and promotes the nurse-client relationship by asking the client to share personal stories. Which type of intervention is the nurse using? A. Symbolic communication B. Narrative interaction C. Hands-off technique D. Social conversation
B. Narrative interaction
A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection. Which of the following techniques should the nurse use when instilling the medication? A. Pull the child's ear auricle upward and outward. B. Pull the child's ear auricle down and backward. C. Pull the child's ear lobe towards the front and downward. D. Pull the child's ear lobe down and outward.
B. Pull the child's ear auricle down and backward.
While starting an intravenous infusion (IV) for a client, a nurse notices that her gloved hands are spotted with blood. The client has not been diagnosed with any bloodborne infections. Which of the following should the nurse do as soon as the task is completed? A. Wash the gloved hands and then throw the gloves away. B. Remove the gloves carefully and follow with hand hygiene. C. Prepare an incident report so that this occurrence will be documented. D. Ask the charge nurse to request that the provider order a blood culture to determine risk.
B. Remove the gloves carefully and follow with hand hygiene.
The nurse is planning to administer ear drops to an adult client. Which is the correct method for the nurse to do it? A. The ear lobe is pulled down and forward B. The auricle is pulled up and back C. The tragus is pulled away from the ear canal D. The pinna is pulled down and back
B. The auricle is pulled up and back
The on-coming nurse arrives for her shift and is asked to count the narcotics with the off-going nurse. The on-coming nurse should be the nurse who does which of the following? A. Visually counts the actual number of the narcotics in the locked narcotic cabinet after the previous nurse leaves the unit. B. Visually counts the actual number of the narcotics that remain in the locked narcotic cabinet before the previous nurse leaves the unit. C. Visually counts the actual sign-out sheet for the balance of the narcotics administered by nurses before the previous nurse leaves the unit. D. Visually counts the actual sign-out sheets for the balance of narcotics administered by nurses after the nurse leaves the unit.
B. Visually counts the actual number of the narcotics that remain in the locked narcotic cabinet before the previous nurse leaves the unit.
A nurse is creating discharge planning. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? A. "I will begin 48h before discharge." B. "I will begin once the discharge order is written." C. "I will begin upon the patient's admission to the facility." D. "I will begin once the insurance company approves discharge coverage."
C. "I will begin upon the patient's admission to the facility."
A nurse is preparing to administer medications to an older adult client who had a cerebrovacsular accident (CVA) and has difficulty swallowing medications. The client asks teh nurse if the prescribed enteric-coated aspirin (Ecotrin) can be crushed to make it easier to swallow. Which of the following would be an appropriate response by the nurse? A. "That would release all the medication at once, rather than over time." B. "I will crush it and mix it in some ice cream for you." C. "If I crush it you may experience a stomach ache or indigestion." D. "If I do that some of the medication will be inactivated by stomach acid."
C. "If I crush it you may experience a stomach ache or indigestion."
A nurse is preparing to administer potassium chloride (KCL). The provider prescribes potassium chloride (KCL) 20 mEq suspension PO daily. The bottle is labeled KCL elixir, 10 mEq/mL. Which of the following should the nurse administer? A. 1 mL B. 1.5 mL C. 2 mL D. 2.5 mL
C. 2 mL
A nurse has received a new order. The order reads amoxicillin 250 mg PO q8h. The pharmacy has 125 mg chewable amoxicillin tablets in stocks. How many tablets should the nurse administer? A. 1/2 tablet B. 1 tablet C. 2 tablets D. 4 tablets
C. 2 tablets Rationale:250 mg/125 mg * 1 tablet = 2 tablets
When administering a liquid medication to a 10-month-old infant who is crying, which of the following approaches by the nurse minimizes the possibility of aspiration? A. Mix the medication in a bottle with the infants regular formula and administer. B. Administer the medication quickly while the infant is securely restrained. C. Administer the medication with a needless syringe placed in the buccal pouch. D. Hold the infant in a supine position for a few seconds after administration.
C. Administer the medication with a needless syringe placed in the buccal pouch.
A nurse is preparing to administer heparin subcutaneously to a client. Which of the following techniques should the nurse use? A. Cleanse the skin with an alcohol swab, insert the needle, and aspirate and inject the heparin. B. Cleanse the skin with an alcohol swab, insert the needle, aspirate and inject the heparin, and massage the site. C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. D. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and aspirate and observe for bleeding.
C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding.
A nurse is planning to administer a nicotine transdermal patch (Nicoderm) to a female client who is trying to quit smoking. Which of the following actions should the nurse plan to include? A. Wear sterile gloves when applying the patch. B. Remove the old patch after applying the new one. C. Date, time, and initial the patch before applying to the client. D. Apply the patch to the client's breast.
C. Date, time, and initial the patch before applying to the client.
A nurse is caring for a client who is requesting prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client. B. Administer the medication C. Determine the location of the pain. D. Review the effects of the pain medication.
C. Determine the location of the pain.
A nurse is preparing a client's evening dose of resperidone (Risperdal) 2 mg when the tablet falls on the countertop. Which of the following interventions is appropriate? A. Pick the tablet up from the counter using clean gloves. B. Wash the tablet off with alcohol and place it in a cup. C. Discard the tablet and obtain another dose of medication. D. Place the tablet directly into a medication cup.
C. Discard the tablet and obtain another dose of medication.
A nurse is preparing to administer an ophthalmic solution to a client. Which of the following is an appropriate action by the nurse? A. Instill the drops into the inner canthus. B. Instill the drops in the center of the upper conjunctival sac. C. Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac. D. Ask the client to look down when instill the solution.
C. Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.
A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data? A. Blood pressure B. Cyanosis C. Nausea D. Petechiae
C. Nausea Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.
When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. The nurse calls the provider but he is unavailable for several days. Which of the following actions should the nurse take? A. Contact the pharmacy and confirm the dosage is safe to administer. B. Withhold the medication until the prescribing provider is available. C. Request to speak with the provider who is covering for the prescriber. D. Inform the charge nurse and administer the usual dose of the medication.
C. Request to speak with the provider who is covering for the prescriber.
In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will A. require skin grafting for the wound to heal. B. have the wound sutured closed at a later date. C. be at an increased susceptibility for infection. D. have well-approximated wound edges.
C. be at an increased susceptibility for infection.
A client's postoperative orders include administering a medication the nurse has never heard of. The drug reference available on the nursing unit does not list the medication. The nurse should A. call the charge nurse and ask her to question the order. B. give the medication as prescribed by the provider. C. call the facility's pharmacy and ask for a package insert. D. Ask a more senior staff nurse for more information
C. call the facility's pharmacy and ask for a package insert.
A client has just had an indwelling urinary catheter inserted. If the nurse took all of the following actions, he used improper technique when he A. inserted the catheter an additional 1 to 2 inches after observing urine in the drainage tubing. B. placed the client in the dorsal recumbent position with knees bent and legs apart. C. cleansed the client's urinary meatus with soap and water prior to inserting the catheter. D. used sterile 0.9% sodium chloride to inflate the catheter's retention balloon.
C. cleansed the client's urinary meatus with soap and water prior to inserting the catheter.
A nurse is reinforcing teaching with a client who is being discharged following an episode of status asthmaticus. The client has a prescription for two inhalations, four times a day from an albuterol (Proventil) metered-dose inhaler. The nurse determines that the client understands the teaching when the client A. exhales as the medication is released from the inhaler. B. takes a deep breath just prior to releasing the medication from the inhaler. C. holds his breath at least 10 seconds after inhaling the medication. D. waits 10 min between each inhalation
C. holds his breath at least 10 seconds after inhaling the medication.
A nurse is caring for a client who is paralyzed on the right side following a cerebrovascular accident (CVA). When preparing to give a bed bath to the client, the nurse A. put the bed in low semi-Fowler's position. B. adjust the bed to the lowest position. C. raise the bed to the high horizontal position. D. unplug the bed.
C. raise the bed to the high horizontal position.
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?
Check the client's perineum.
A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?
Collect the specimen upon arising in the morning. in the morning it's easier to cough up secretions deepest specimens are usually collected in morning try to collect before breakfast prior to coughing into container: rinse mouth and deep breathe
A nurse is must administer levothyroxine (Synthroid) 100 mcg to a client. The computerized medication delivery system on the unit supplies individually dispensed pills labeled "Synthroid 0.2 mg." how many pills should the nurse dispense to the client. A. 0.2 pills B. 2 pills C. 5 pills D. 0.5 pills
D. 0.5 pills
A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?
Check to determine if the catheter tubing is kinked. first apply least invasive framework
A nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?
Clamp the tubing below the collection port. Rationale: The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.
nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?
Clamp the tubing below the collection port. Rationale: The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.
A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching.
Cleanse the skin around the stoma with warm water. using soap can leave a residue and cause poor adherence of pouch
A nurse is preparing to administer a flu vaccine, which of the following techniques should the nurse use to locate the deltoid muscle? A. By locating the center of the arm between the elbow and the shoulder. B. By locating the midpoint o the lateral aspect of the upper arm. C. By palpating the lower edge of the acromion process and measuring 4 inches below to the center of the lateral aspect of the upper arm. D. By palpating the lower edge of the acromion process and measuring 4 finger-widths below to the midpoint and center of the lateral aspect of the upper arm.
D. By palpating the lower edge of the acromion process and measuring 4 finger-widths below to the midpoint and center of the lateral aspect of the upper arm.
A nurse is preparing to administer an enema when the client states, "My doctor didn't tell me I was supposed to receive an enema." Which of the following actions is appropriate for the nurse to take? A. Inform the charge nurse that the client refused the enema. B. Explain to the client that the provider prescribed the procedure. C. Assure the client that enemas are commonly prescribed for constipation. D. Check the client's chart for the provider's prescription. Study These Flashcards
D. Check the client's chart for the provider's prescription. Study These Flashcards
A nurse is caring for a client. The client states, "I don't want to take any medication." Which of the following actions should the nurse take? A. Tell the client the physician wants the client to take the medicine. B. Ask the client why the client refuses to take the medication. C. Explain the purpose for the medication. D. Document that the client refuses the medication
D. Document that the client refuses the medication
The nurse is preparing a medication and observes the date of expiration on the vial occurred two months ago. Which action should the nurse perform? A. Give the medication. B. Discard the medication. C. Notify the provider. D. Return the medication to the pharmacy.
D. Return the medication to the pharmacy.
A nurse is preparing an injection using a single dose glass ampule. which of the following techniques should the nurse use when opening the glass ampule? A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side. B. Wear sterile gloves and break off the neck of the glass ampule with a single snap downward motion. C. Tap the bottom of the ampule, place a gauze pad or alcohol swab around the ampule neck, and break off the bottom with a forward motion away from the hands. D. Tap the top of the ampule, place a gauze pad or unwrapped alcohol swap around the ampule neck, and break off the top with a forward motion away from the hands.
D. Tap the top of the ampule, place a gauze pad or unwrapped alcohol swap around the ampule neck, and break off the top with a forward motion away from the hands.
When reinforcing teaching about colostomy care, the nurse reminds the client to replace the bag. A. every other day. B. every 4 to 6 hr. C. daily. D. as often as needed.
D. as often as needed.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?
Determine whether the client is able to breathe. before you can notify what is going on with the patient, you have to collect vital data from the patient
A nurse is replacing the surgical dressings on a client who has abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing. Rationale: The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Elevate the client's head of bed 45 degrees before the feeding. Rationale: the nurse should do this to prevent aspiration
A nurse is preforming eye irrigation for a client who has exposed to smoke and ash. Which of the following actions should the nurse take?
Exert pressure on the bony prominences when holding the eyelids open. Rationale: The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
Explain the procedure to the client.
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching.
Granulation tissue fills the wound during healing,
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?
Hold breath for 5 seconds after goal volume is reached. decreases collapse of alveoli, which helps prevent risk of atelectasis and pneumonia
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?
Hold the linens away from the body and clothing.
A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?
Inability of the toddle to cry or speak. bc no sounds passing through vocal cords use heimliech maneuver
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
Insert the tip of the tubing 8 cm. will prevent dislodging of the tubing during the procedure and injury to rectal mucosa
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?
Offer the client tart or sour foods first. Rationale: , The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.
nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?
Pinch the NG tube while removing the tube. decreases risk of aspiration of any GI contents
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
Place the stool specimen collection container in a biohazard bag.
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?
Pull suction catheter back 1 cm if the client starts coughing. will remove catheter from mucosal wall
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?
Purulent exudate.
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?
Renew the prescription for the use of restraints within 24 hours. after provider has evaluated condition
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?
Start chest compressions. give priority to the factor or situation posing the greatest safety risk.
A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?
Turn the stockings inside out up to the heel before applying. Rationale: The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.
A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse to decrease the risk of a fall?
Use a gait belt during ambulation. The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall.
nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?
Use the pain scale to determine the client's pain level.
nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?
Vitamin C and Zinc. both help fight wound infection
A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?
Weigh the client on arising. on rising, after voiding, and before breakfast accurate weight - same garments, same scale,
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
Wipes the labia minor in an anteroposterior direction.
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
face the client when speaking.
A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take?
remove the sleeve of the gown from the arm without the IV line. do line arm last bc that will allow least amount of disruption to the line
nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?
taut the skin around the IV catheter site that is cool to the touch. stop infusion, elevate extremity, and apply warm moist compress
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection. .
the side hip between the iliac crest and anterior iliac spine ventrogluteal injection