Fundamentals exam, NCLEX review questions Safety

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take

Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

The nurse is encouraging a client to participate in recreational therapy. The client states that it is best to stay alone and not bother others. Which statement is an appropriate response from the nurse?

"Can you tell me more about your feelings?"

A transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse provides information to the client about the TENS unit. Which client statements indicate the need for further teaching? Select all that apply.

1. "The unit should be turned off if I begin to feel pins and needles." 2."Needles are inserted in the subcutaneous tissue to stimulate the nerve."

The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? Select all that apply.

1. Allowing the client sufficient time to eat 2.Providing oral hygiene after each meal 3.Maintaining a suction machine at the bedside

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply.

1."I drink hot chocolate before bedtime." 2. "I plan out my goals for work for the next day"

The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.

1.Adequacy of circulation in the body area that is restrained 2.Type of restraint and body area where the restraint was applied 3.Communication with client and family member about need for restraint 4.The alternative measures that were attempted before restraints were applied

A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.

1.Avoid activities that involve pulling or pushing. 2.Do not lift objects weighing more than 5 pounds. 3. Do not climb stairs until after the follow-up appointment with the surgeon.

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

1.Do you have a history of seizures? 2.Do you have a history of a clotting disorder? 3.How long and why have you been using ginkgo? 4.Have you been diagnosed with diabetes mellitus?

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

1.Eat a nutritious diet with adequate protein. 2.Use a pressure relief pad while in a wheelchair. 3.Check the bottom sheet for wetness and wrinkles.

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply.

1.Explain the procedure to the client. 2.Irrigate the NG tube with saline. 3. Elevate the head of the bed to 45 degrees.

The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.

1.Handgrips are positioned so the elbows are bent approximately 30 degrees. 2.The space between the axilla and the top of the crutch pad is 1½ to 2 inches. 3.The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.

The nurse has just received report on a newly admitted client who is cognitively impaired and experiencing pain. Which data collection techniques should be included in this client's plan? Select all that apply.

1.Observe for grimacing. 2.Listen for vocalizations. 3.Observe facial expressions. 4.Monitor for changes in behavior.

The nurse is reinforcing instructions to an oriented client and the client's family regarding how to use the patient-controlled analgesia (PCA) pump. The nurse should include which instructions? Select all that apply.

1.Report an inability to void or bladder discomfort. 2.Explain that the nurse will assess the pain level at frequent intervals. 3.Notify the nurse if the client begins to feel nauseated or is likely to vomit. 4.Instruct the client to push the button when the pain level begins to increase. 5.Explain that there is a lockout on the machine so the client cannot overdose.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

1.Socialize with the restrained client. 2.Remove the restraint and perform range of motion activity. 3.Reapply the restraint after assisting the client to the bathroom.

A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse understands the client is at risk for cardiac side effects if the primary health care provider prescribes which medications? Select all that apply.

1.Verapamil 2.Propranolol 3.Sumatriptan

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse should include which actions to safely administer the medication? Select all that apply.

1.Wear gloves while administering the injected medication. 2.Dispose of the needle and syringe in a puncture-resistant container.

A client is going to be transfused with a unit of packed red blood cells the nurse understands that it is necessary to remain with the client for what time. After the transfusion has started

15 minutes

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

1.Wearing gloves when emptying the client's bedpan 2.Keeping all linens in the room until the implant is removed 3.Wearing a film (dosimeter) badge when in the client's room 4.Wearing a lead apron when providing direct care to the client

The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 40,000 mm3 (40 × 109/L)

Which of the clients is/are MOST LIKELY to develop fluid (circulatory) overload?

A premature infant A 101 yr old man A client with heart failure A client receiving renal dialysis

The nurse is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

The nurse is preparing an intravenous solution and tubing for a client who requires IV fluids while preparing to prime the tubing the tubing drops and hits the top of the medication cart the nurse should plan to take which action?

Change the IV tubing

The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints?

Checking color, sensation, and pulses distal to the restraints

The nurse is assisting with the caring for a client who is receiving a unit of packed red blood cells. the nurse should tell the client that it is most important to report which signs immediately

Chills, itching, or rash

The nurse is preparing to initiate a tube feeding for a client and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action should the nurse implement?

Contact the electrical maintenance department for assistance.

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

The nurse is reinforcing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with security devices (hand restraints). How often should the nurse instruct the UAP to check the client's skin and circulation under the security devices?

Every 30 minutes

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy how frequently?

Every hour

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

The nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse should make note of which finding to detect an adverse effect of this medication?

Frequency of bowel movements

The nurse is doing a routine assessment of the clients peripheral intravenous IV site. The nurse notes that the site is cool, pale and swollen as that the IV has stopped running. The nurse determines that which has probably occurred?

Infiltration

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

Insert the suppository 1 to 2 cm into the rectum.

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

Institute contact precautions.

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to avoid medication errors.

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse is checking the insertion site of the peripheral venous IV catheter the nurse notes the site to be reddened, warm, painful and slightly edematous in the area of the vein proximal To the IV catheter the nurse interprets that this is likely the result of which?

Phlebitis of the vein

The nurse has been instructed to remove the intravenous line the nurse remove the catheter by withdrawing the catheter by applying pressure to the site with which item?

Sterile 2x2 gauze

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse send the blood bag that was used for the client to which area?

The blood bank

The nurse takes a client's temp before giving a blood transfusion. The temp is 100• F (37.7• C) orally. the nurse reports findings to the RN and anticipates which action will take place?

The blood will be held, and the primary health care provider will be notified

A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?

The client adjusts the setting downward slightly.

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now?

The nurse should extend one leg to use to slide the client's body down to the floor.

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?

There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client?

Upright in a chair

The nurse is assisting with the caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?

Vital Signs

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

We will be sure not to leave hot liquids unattended."

A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.

1. aspirin 2.Furosemide 3.Gentamycin

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

1. provide a soft toothbrush 2. check oral mucous membranes 3. check for missing teeth and cavities

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply

1.Time the start and stop of the seizure. 2.Apply oxygen at 2L with nasal cannula. 3.Turn the client to the side and do not restrain. 4.Note the distinguishing characteristics of the seizure. 5.Turn on the suction machine with oral catheter.

Which client is the safest one for a licensed practical nurse (LPN) to care for?

A client recovering from a scheduled cesarean delivery

The nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. The nurse should instruct the UAP to prepare to assist which client first?

A client who was admitted 2 days ago with a pelvic fracture

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel

The nurse is discussing the care needs with an unlicensed assistive personnel (UAP) who is preparing to bathe a client who has mild dementia and requires minimal help with hygiene. The nurse identifies which client need as the highest priority when giving the instructions?

Maintain client safety.

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

alternating air pad

The nurse prepares to administer a prescribed dose of scopolamine. The nurse should monitor for which side effect of this medication?

dry mouth

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the UAP is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

every 2 hours

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

every hour

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

gown and gloves

The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply.

1.Place the client flat in bed. 2.Notify the registered nurse of the drainage.

The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall? Select all that apply.

1.Keeping the bathroom light off at nighttime 2.Placing the client in the quiet area of the nursing unit in a room away from the nurse's station

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply.

1.Monitoring the skin around the stoma site for skin irritation 2. Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube

The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply.

1.A soft toothbrush 2.Irrigation syringe 3.Bite stick or a padded tongue blade 4. suction with oral suction catheter attached

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which actions? Select all that apply.

1.Check the placement of the tube. 3. Aspirate the contents from the nasogastric tube. 4. Observe the characteristics and pH of the aspirate from the nasogastric tube.

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

Closes the roller clamp on the IV tubing

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.

1. restraints 2. padded tongue blade

The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply.

1. turn on the bed alarm 2. Ask the client about needing to void or move bowels. 3. Turn on the nightlight in the hospital room and bathroom.

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply.

1."I need to refer to medication as 'candy' only when really necessary." 2."I can place several medications in the same bottle if I am going for an overnight trip."

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions should the nurse ask the client? Select all that apply.

1."What does the pain feel like?" 2."Where is the pain located?" 3."How does the pain affect you?" 4."What makes your pain better or worse?"

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply.

1.Listen to the client's bowel sounds. 2.Question the client regarding nausea. 3. Determine whether the client has abdominal distension. 4. Hold the feeding after flushing the tubing with 30 mL saline.

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply.

1.Obtain a Medic-Alert bracelet. 2Prevent debris from entering the stoma. 3. Avoid exposure to people with infections. 4 Avoid swimming and use care when showering.

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply.

1.Preoxygenating the client before suctioning 2.Moistening the catheter tip in sterile saline solution before suctioning 3.Introducing the catheter into the tracheostomy tube using a sterile gloved hand

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

1.Provide adequate lighting. 2.Ensure that frequently used items are easily accessible. 3.Have the bedside stand and overbed tray table within reach.

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

1.Securing the oxygen tubing to the client's bottom sheet 2.Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply.

1.Testing stools and urine for blood 2.Using a soft toothbrush for mouth care

The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information? Select all that apply.

1.That aspiration as a complication is a primary concern 2.To determine correct placement by aspirating contents from the tube to observe characteristics and check pH

The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit? Select all that apply.

1.The client answers questions incorrectly. 2.The client states she quit attending social events. 3.The client does not respond to a person unless facing the speaker

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply.

1.Use a friction-reducing slide sheet. 2.Use a mechanical lift to move the client 3.Keep elbows close and work close to the body. 4.Obtain assistance of a second caregiver to assist with mechanical aids.

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.

1Clamp the NG tube for 30 minutes after medication administration. 2.Before medication administration, verify correct placement of tube. 3.Flush the NG tube with saline before and after medication administration. 4.Discontinue the suction from the tube during administration of medication.

The nurse is instructing a group of unlicensed assistive personnel (UAP) in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the UAP doing which action?

Positioning a box that is to be lifted between the knees

The nurse is reinforcing instructions to a client with chronic vertigo that is poorly controlled. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?

Removing throw rugs and clutter in the home

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

A licensed practical nurse is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother?

"You should seek community after-school programs or activities for your children."

The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply.

1. Place a gait belt on the client. 2.If stretch bands are used, reinforce the correct use. 3.Observe for any signs/symptoms of dizziness the first time the client gets out of bed. 4.After the client sits on the side of the bed, remind the client to stand on the unaffected leg.

The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which actions? Select all that apply.

1. Positioning the client supine 2.Using products with lemon or alcohol

The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply.

1. clean towel 2. sterile 10- or 12-ml syringe

The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions should the nurse place the client in to prepare for the procedure? Select all that apply.

1. high fowlers position 2. slight extention of the neck

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.

1. homeopathy 2.herbal supplements

The nurse is performing an environmental assessment in the home of an older client. Which observations require immediate attention? Select all that apply.

1. unsecured scatter rugs 2. cigarette pack and lighter on the bedside stand

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

1.Removing any toy with bright blinking lights 2.Keeping the sides rails of the child's bed padded 3.Turning the infant on the side during any seizure 4.Having oxygen and suction available at the bedside

The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol? Select all that apply.

1.The surgeon is the person that marks the area of the operative procedure. 2.The site marking is done before the client is brought to the surgical suite in the operating room.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

Activate the fire alarm

A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2° C (97.2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take first?

Attempt to arouse the client.

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible.

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?

Remove the clients from the waiting room.

The nurse enters the room to find that the client's trash can is in flames. The client is in bed and the edge of the gown is smoking. The nurse should take which action first?

Remove the gown from the client and remove the client from the room.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)?

a bottle of alcohol

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider?

valerian

A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?

"Let me go over your prescribed medications with you again."

The nurse is encouraging an older client who has difficulties with incontinence to participate in recreational therapy. Which nursing interventions should the nurse consider performing before assisting the client to go to the recreational therapy session? Select all that apply.

1. Make sure the client is wearing a clean undergarment. 2. Encourage the client to use the restroom just before the activity.

The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply

1."I will remove the ice pack if I start to feel numbness." 2. "I should wrap the frozen ice pack in a towel to help adjust to the cold."

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measures to reduce the risk of adverse effects from this medication? Select all that apply.

1.Encourage fluids when not NPO. 2.Encourage coughing and deep breathing. 3.Monitor the number of bowel movements.

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

1.Question the client about feelings of dizziness. 2.Put the client's shoes on to help the client avoid slipping on the floor during the transfer. 3.Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed?

Aiming at the top flames of the fire

The nurse is preparing to apply a mitten restraint to the client's hand. The nurse does which to ensure that the restraint is applied correctly?

Makes sure that two fingers can be inserted under the restraint

The nurse is assisting in monitoring a pregnant client receiving nalbuphine for pain management. Which statement is true with regard to the use of nalbuphine?

Nalbuphine is not likely to cause significant respiratory depression.

The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next?

Places the client in an upright position

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply.

1. Warfarin 2.Glimepiride 3.Amlodipine

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply.

1. a glass of warm milk 2. a cube of swiss cheese 3. a cup of caffeine-free tea

A client arrives at the clinic complaining of a severe headache. The client states "It's a 10/10 headache. I took 600 mg of ibuprofen over the past few hours, and it has not decreased the pain." The nurse suspects that the client is experiencing a migraine but wants to validate the suspicion by asking which questions associated with a migraine? Select all that apply.

1."Can you describe the pain?" 2."What other symptoms are you experiencing?" 3."What did you experience right before the headache began?" 4."Do you or a family member have a history of severe headaches?

A client on the medical unit tells the nurse of back discomfort but does not want any pain medication. Which nonpharmacological interventions should the nurse offer the client to help reduce the pain? Select all that apply.

1.distraction 2. back massage 3. relaxation breathing

The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding clients' hygiene needs. Based on the client needs, the nurse instructs the UAP to bathe which client first?

A confused client who is incontinent of stool and urine

The nurse is assisting with the caring of a client who has received a transfusion of platelets the nurse determines that the client is benefiting most from this therapy if the client exhibits which findings?

A decrease in losing from the puncture sites and gums *platelets are necessary for proper blood clotting.

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

A pair of scissors

A client has a prescription to receive 1000 ml of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse take which action FIRST before spiking the IV bag with tubing?

Closes the roller clamp on the IV *to prevent the solution from running freely through the tubing after it's attached to the IV bag.

A client who is receiving a blood Transfusion pushes the call light for the nurse. When entering the room, the nurse notices that the. Client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?

Transfusion Reaction

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

1. pedal pulses 2. capillary refill 3. color of the extremity 4.temp of the skin 5. presence of numbness

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide, penicillin, and ibuprofen. He has received ibuprofen twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool?

9 total points (moderate risk)

The nurse is assigned to the care of a client with a peripheral intravenous IV infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client

The nurse is providing eye care to an unconscious client. Which interventions are included in the procedure? Select all that apply.

1.Cleanse each eye moving from the inner canthus to the outer canthus. 2.Use a clean wet cotton ball or different area of a clean wash cloth for each eye.

A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?

Placing food on the affected side of the mouth

The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?

Promoting venous return to the heart

The nurse assists in conducting a home safety assessment with a client preparing for discharge. The client tells the nurse that a space heater is used to heat part of the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The space heater needs to be placed at least 3 feet from anything that can burn.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?

Place two fingers under the restraint to determine snugness.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

Aim at the base of the fire.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?

Reset the degrees of flexion or extension according to comfort.

The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client?

Wrap a light roll of gauze to cover the IV site.