Funds

A nurse is assessing a clients nutritional status. the nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10 lb) A. 10 months B. 5 months C. 5 weeks D. 10 weeks

!0 weeks

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? A. Hold the sterile drape above the waist and away from the body B. Drop sterile objects toward the edges of the sterile field C. Hold packaged supplies 7.6 (3 cm) above the sterile field D. Hold sterile objects over the field before setting them down on the field

. Hold the sterile drape above the waist and away from the body Contamination occurs wen the nurse holds any object that will be part of the sterile field below the waist or allows it to touch anything other than a sterile object

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? A. tell me what i can do to help you overcome your fear of giving yourself injections B. Your provider will not be pleased that you refuse to give yourself insulin injections C. It's okay. I'm sure your partner will be able to learn how to give you the insulin injections D. You won't be able to go home unless you learn to give yourself insulin injections

. tell me what i can do to help you overcome your fear of giving yourself injections this response illustrates the therapeutic communication techniques of clarifying and offering self. The nurse should allow the client to express feelings and fears and support the client in learning how to give injections.

After assessing a client the nurse documents 1+ pedal edema bilaterally. This indicates that the nurse observed an indentation of which of the following depts after applying pressure? A. 2 mm B. 4 mm C. 6 mm D. 8 mm

2 mm

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A. Hold the dropper 1 cm above the ear canal during administration B. apply pressure to the nasolacrimal duct following administration C. Place a cotton ball into the inner ear canal for 30 minutes following administration D. Straighten the ear canal by pulling the auricle down and back prior to administration

A. Hold the dropper 1 cm above the ear canal during administration

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the clients abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation

Auscultation

A nurse in a providers office is talking with an older adult client who report having trouble sleeping. Which of the following statements would the nurse identify as a possible cause if the clients sleeping difficulties? A. I take a warm shower when getting ready for bed B. I often have a cup of coffee with my dessert before going to bed C. I usually read a chapter in a book before i go to bed D. I make sure i do my exercises in the morning

I often have a cup of coffee with my dessert before going to bed

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. I will have the steps to my house painted a dark color B. I will put a night-light in the hallway C. I will put on socks when i get out of bed D. I will secure any wires in my home under rugs

I will put a night-light in the hallway

a nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse use to assess for pulse deficit? A. Obtain the apical and radial rates simultaneously B. Check the blood pressure in the left and right arms C. compare the pulse strength in the upper extremities D. Palpate the pulses in the lower extremities

Obtain the apical and radial rates simultaneously

A nurse is caring for an older adult who has dysphagia following a cerebral vascular accident. Which of the following action should the nurse take when assisting the client at meal time. A. Encourage the client to drink fluids before swallowing food B. offer the client tart or sour foods first C. tilt the clients head backwards when swallowing D. turn on the television

Offer the client tart or Sour Foods first To stimulate saliva production which aids chewing and swallowing

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the clients bedside? A. vest restraint B. tongue blade C. Oxygen equipment D. neck brace

Oxygen equipment

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside while feeding the client B. Order pureed foods C. Make sure feedings are provided at room temperature D. Offer the client a drink of fluid after every bite

Sit at the bedside while feeding the client

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing techniques? A. the nurse washes each part of her hands with 5 strokes B. The nurse washes from the elbows down to the hands C. The nurse holds her hands higher than her elbows while washing D. The nurse uses minimal friction when washing her hands

The nurse holds her hands higher than her elbows while washing so that water and soapsuds can drain away from the clean area toward the dirty area

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, all this equipment is making me nervous. Which of the following responses should the nurse offer? A. You wont need the equipment for very long B. All of this equipment can be frightening C. Why does the equipment bother you? D. Let me tell you about what each machine does

all of this equipment can be frightening reflecting the clients statement. encourages the client to communicate more

A nurse in an urgent care center is caring for a 15 year old client whose symptoms suggest a STI. The clients parent is unavailable but the clients grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Ask the adolescent to sign the consent form

ask the adolescent to sign the consent form

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage B. Give the medication in a safe dosage C. Give the dose the provider prescribed D. Call the provider to clarify the dosage

call the provider to clarify the dosage after assessing the client for adverse effects of the medication, the nurse should notify the provider about her observations to determine the next step

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the clients pain level D. Place a waterproof pad under the clients extremity

check the clients pain level

A nurse is preparing to asses the function of the clients trigeminal nerve (cranial nerve V). which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton wisps D. Snellen chart

cotton wisp

A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? A. Crackles in the lung fields B. Flat neck veins C. Postural hypotension D. Dark yellow urine

crackles in the lung field

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. hyperoxygenate the client before suctioning B. insert the catheter during exhalation C. Apply suction during insertion of the catheter D. apply suction for no more than 15 sec

hyperoxygenate the client before suctioning

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following action should a nurse take? A. Assign the client to a private room B. keep four side rails up while the client is in bed C. monitor the client at least once every hour D. request a PRN prescription for restraints

monitor client once per hour

A nurse on a med surge unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? A. identify goals for client care B. obtain client information C. Document nursing care needs D. evaluate the effectiveness of care

obtain client information

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A. Carminative B. Hypertonic C. Oil Retention D. Sodium polystyrene sulfate

oil retention Oil retention to soften the stool and make the procedure less painful for the client

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia? A. The client watches television in her bed during the day B. The client drinks warm milk before bedtime C. The client goes to bed at 2200 every night D. The client gets up to use the bathroom once during the night

the client watches television in her bed during the day to promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities

A nurse is assessing a clients thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. Tilt your head slightly forward B. Keep your head straight and look ahead of you C. Tilt your head back and swallow D. Turn your head to the side against my hand

tilt your head back and swallow The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland

a nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. Does the medication you're taking relieve the pain B. Can you point to where the pain is the worst C. What do you think caused the onset of your pain D. Changing positions makes your pain worse right?

what do you think caused the onset of your pain

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? A. I'll wear nonsterile gloves B. I'll use adhesive remover each time C. I'll take my pain pill after i change the dressing D. I'll fold the dressing with the soiled surface facing outward

A. I'll wear nonsterile gloves

A community health nurse is conducting a class about body mechanics for country office workers. Which of the following instructions should the nurse include? A. Sit with your back supported B. keep your knees at hip level C. Use an ergonomically designed computer keyboard D. Keep your elbows away from your body E. Adjust the monitor screen so that you have to tilt your head slightly to look at it

A. Sit with your back supported B. keep your knees at hip level C. Use an ergonomically designed computer keyboard

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? SATA A. coat the tip of the tube with a water soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

A. coat the tip of the tube with a water soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins lubricating the tube eases it passage. A water-based gel because will dissolve if the tube slips into the clients airway. Usine petroleum jelly could cause respiratory problems. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of the nasopharynx which facilitates the insertion of the NG tube

a nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? A. administer 0.9% sodium chloride until TPB is available from the pharmacy B. Check the clients capillary blood glucose level every 4 hour C. Obtain the clients weight each week D. Change the IV tubing every 3 days

B. Check the clients capillary blood glucose level every 4 hour

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the clients wound has eviscerated. Which of the following actions should the nurse take? SATA A. carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile moistened dressing E. Monitor the client for manifestations of shock

B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile moistened dressing E. Monitor the client for manifestations of shock

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? A. I should rinse my mouth out right before i use the inhaler B. After the first puff i will wait 10 seconds before taking the second puff C. I will shake the inhaler well right before i use it D. I will tilt my head forward while inhaling the medication

C. I will shake the inhaler well right before i use it shake for 3 to 5 seconds vigorously, which will mix the medication within the inhaler evenly

a nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? A. Returned the unused portion of the medication to the pharmacy B. Dispose of the wasted medication into a sharps container C. Record the amount of medication wasted on the controlled substance inventory record D. Ask an assistive personnel to witness the wasting of the controlled substance

C. Record the amount of medication wasted on the controlled substance inventory record

An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? A. Don't worry, teenagers often have friends who give bad advice B. I think you should stop seeing those friends since they discourage you from following your treatment plan C. Tell me more about how your friends discourage you D. Where did you meet these friends

C. Tell me more about how your friends discourage you

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral cortex C. Pituitary D. Cerebellum

Cerebellum The nurse should suspect an injury to the cerebellum if the client is experiencing difficulty controlling balance and coordination. A clients movements can become uncoordinated unsure and clumsy following an injury to this area of the brain

A nurse is measuring a clients vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a doppler ultrasound stethoscope B. Check the clients pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec

Count the apical pulse rate for 1 full min and describe the rhythm in the chart If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. Then, the nurse should document the irregularity in the clients medical record

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device to remove air after emptying

D. Collapse the device to remove air after emptying

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? A. From the middle of the thigh toward the wound B. from the left lower abdominal quadrant toward the wound C. From the left hip toward the would D. From the wound toward the surrounding skin

D. From the wound toward the surrounding skin

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum

D. Second intercostal space to the right of the sternum The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward

A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the clients ability to think abstractly? A. Subtract by 7 serially, starting at 100 B. Describe a previous illness C. Explain what to do if a fire happened in his bedroom D. Discuss the meaning of a common proverb

Discuss the meaning of a common proverb

A nurse on a med-surge unit observes smoke billowing from a clients room. Which of the following actions should the nurse take first? A. close the door to the clients room B. Evacuate the client from the room C. Sound the fire alarm D. Activate the fire extinguisher

Evacuate the client from the room

A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include? A. Include at least 3 g of sodium in your daily diet B. Limit wine consumption to 230 mL daily C. Include 2.5 cups of vegetables in your daily diet D. Limit water intake to 1.5 L each day

Include 2.5 cups of vegetables in your daily diet

A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? A. The RDA is a comprehensive term that includes various dietary standards and scales B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups C. The RDA defines the levels of nutrient that should not be exceeded to prevent adverse health effects D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups The RDA represents daily requirements considered adequate for healthy people. RDAs are based on estimated amounts for each nutrient, including additional amounts for individual such as women or infants

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the clients denture be removed prior to surgery. Which of the following responses should the nurse provide? A. Its for your safety. dentures can slip and block your airway during surgery B. You wouldn't want your teeth to be lost or broken during surgery would you C. the anesthesiologist requires clients to remove their dentures D. What worries you about being without your teeth?

What worries you about being without your teeth? it validates the clients feelings of agitation and seeks a reason

A nurse is caring for a group of clients in a long term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN antianxiety medication

accompany client back to his room. Escort the client back to his room to protect him from injury due to wandering

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the puncta after instilling the medication D. Place each drop of the medication directly onto the clients cornea

apply pressure to the puncta after instilling the medication The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication

a nurse is performing a focused assessment of a clients peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? A. below the medial malleolus B. In the popliteal fossa C. In the antecubital space D. on the dorsum of the food

below the medial malleolus

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away B. Prepare an incident report to document the event C. Carefully remove the gloves and proceed with hand hygiene D. Ask the provider to order a blood culture to determine the risk of infection

carefully remove the gloves and proceed with hand hygiene

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the clients provider and verify the prescription D. Ask the client if she takes this medication at home

consult the medication reference book available on the unit A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up in the medication reference on the unit

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor

increased heart rate Other findings would be increased BUN level dry mucous membranes and dark yellow urine

A nurse if replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves

don clean gloves to remove old dressing

A nurse is performing a breast exam for a female client. Which of the following techniques should the nurse use first? A. inspect both breasts simultaneously B. squeeze the nipples C. Palpate the breast and tail of spence D. Palpate the axillary lymph nodes

inspect both breasts simultaneously check both breast for asymmetry masses retraction lesions inflammation or dimpling

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. now that we have talked about your medications, lets talk about your pain B. Are you having other symptoms C. It sounds like your pain is intermittent D. It seems as though you have really had a rough time these past few weeks

it sounds like your pain is intermittent

A nurse is monitoring a clients laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L

potassium

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? A. Wake up every 2 hr to urinate during the night B. Drink citrus juices throughout the day C. Try to block the urge to urinate until the next scheduled time D. Limit fluids to no more than 1 L (34oz) during waking hours

try to block the urge to urinate until the next scheduled time When the client is following a schedule of voiding intervals and feels the urge to urinate before the next schedule time, she should try slow, deep breathing to help reduce the urge. She can also try 5 or 6 strong and quick pelvic muscle exercises

A nurse is caring for a client who has the head of his bed elevated to a 45 degree angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims B. Prone C. Supine D. Fowlers

fowlers

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? A. Skeletal muscle relaxant B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders

plasma volume expander helps correct hypovolemia in emergency situations such as after hemorrhage, or burns

A nurse is preparing to administer a unit of packed RBC to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? A .return the blood to the lab B. place the blood in the med room C. place the blood in the refer D. leave the blood at the clients bedside

return the blood to the laboratory

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the clients balance? A. 2-pt discrimination B. Glasgow coma scale C. Babinski reflex D. Romberg test

romberg test

A nurse is assessing a clients incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. sanguineous B. purulent C. Serous D. hyperemia

sanguineous

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis

scoliosis

A nurse is measuring a clients vital signs. The clients heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia

tachycardia tachycardia is over 100 brady is below 60

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene which of the following action should the nurse take. A. Select a 23 gage needle B. insert the needle into the skin at 25 degree angle C. massage the aerial if injection following removal of the needle D. circle the injection area with a pen

Circle the injection area with pen

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommended as part of this clients routine health screening? A. Annual Papanicolaou (PAP) test B. Mammogram every 2 years C. Eye examination every 2 years D. Annual colonoscopy

Eye examination every 2 years This is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? A. Independent moral development B. Acceptance of body changes C. Strengthening ties with the family of origin D. Development of concrete reasoning

Independent moral development

A nurse in an acute facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility? A. move the client from supine to fowlers position every 2-3 hour to help prevent orthostatic hypotension B. limit fluid intake to 1 L (33.8 oz) in24 hr to prevent dependent edema C. Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulations (TENS) for pain management. Which of the following responses should the nurse make? A. It provides a distraction from the pain B. It modulates the transmission of the pain impulse C. It promotes increased circulation to the painful area D. It elicits a relaxation response

It modulates the transmission of the pain impulse The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief

A nurse is reviewing the laboratory values of a client who has a positive Chvosteks sign. Which of the following laboratory findings should the nurse expect? A. Decreased calcium B. Decreased potassium C. Increased potassium D. Increased calcium

decreased calcium calcium is necessary for nerve conduction and muscle contractions. When the client total calcium level is less than 8.4, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the clients ear. If facial muscle twitching follows this stimulus, it is a positive chvosteks sign and an indication of hypocalcemia.

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis C. Decreased cardiac output D. Hypocalcemia

decreased cardiac output During immobility, the clients heart rate increases to compensate for increased venous pooling. The reduction in circulating volume increases the workload of the heart, resulting in orthostatic hypotension and decreased cardiac output

A nurse is auscultating a clients lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? A. limit the clients fluid intake B. assist the client into a supine position C. Administer oxygen at 2L/min D. Encourage the client to cough

encourage the client to cough

A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor B. Perform an abdominal thrust C. Open the airway with a head-chin tilt D. Observe the client closely

observe the client closely at this time The nurse should observe the client closely at this point in time. As long as the client is able to cough strongly, the nurse does not need to intervene

A nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Wear a gown when in the clients room D. Dispose of all bed linens used by the client

wear a gown in the clients room

a nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A. Whole milk B. chicken C. Oranges D, dried peas

whole milk

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. You look just fine to me B. Nobody expects you to look beautiful in the hospital C. I understand how you feel. I would feel the same way D. Would you like to talk about how you feel

would you like to talk about how you feel

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. give rescue breaths

Confirm unresponsiveness

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Instill proparacaine hydrochloride eye drops B. Perform ocular irrigation of the right eye C. Place the client in a supine position with the head turned toward the affected side D. Ask the client about first aid performed at the scene

D. Ask the client about first aid performed at the scene First action would be to assess if first aid was performed at the scene to determine if eye irrigation was administered

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention? A. Teaching clients to perform self-examination of breasts and testicles B. Educating clients about the recommended immunization schedule for adults C. Teaching clients who have type 1 diabetes mellitus about care of the feed D. Recommending that clients over the age of 50 have a fecal occult blood test annually

Educating clients about the recommended immunization schedule for adults Primary prevention includes health education about disease prevention

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of nonadherence B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written and easy to understand materials D. Help the client identify ways that these changes will result in positive personal outcomes

Help the client identify ways that these changes will result in positive personal outcomes the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. the client should first see how the changes directly affect his/her life thus enhancing the motivation to make the changes

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher B. Instruct the client to raise his arms above his head C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed D. Log roll the client

Lock the wheels on the bed and stretcher

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? A. BT for bedtime B. SC for subcutaneously C. PC for after meals D. HS for half-strength

PC for after meals

A nurse is leading an education session about disposing biohazardous materials. Which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean blood spills B. Discard empty blood bags in a bedside trash can C. Break used needles before discarding D. Place soiled linen in a single linen bag

Place soiled linen in a single linen bag

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? A. instruct the client to to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag

Place the stool specimen collection container in a biohazard bag

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

Pull the NG tube back slightly Pull back slightly and instruct the client to breathe slowly. Once the client relaxes the nurse should gently advance the tube as the client swallows

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A. inhale forcefully during insertion B. Raise your index finger if you need to pause during the insertion C. Bear down during insertion D. Avoid making any swallowing motions during the insertion

Raise your index finger if you need to pause during the insertion The nurse should instruct the client that the insertion of an NG tube is uncomfortable and the gag reflex will be activated during the procedure. The nurse should establish a communication technique such as having the client raise a finger or hand to indicate distress and the need to pause the insertion process

A nurse is caring for a client who is receiving a fluid infusion through a peripheral Iv catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following action to the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

Remove the IV catheter

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? A. Holding a community clinic to administer influenza immunizations B. Screening groups of older adults in nursing care facilities for early influenza manifestations C. Educating parents of young children about the dangers of influenza D. Finding rehabilitation programs for older adults who have complications related to influenza

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? A. Kidneys B. Lungs C. Gastrointestinal tract D. Skin

Skin The skin can excrete approximately 500 to 600 mL of insensible fluid loss. This type of fluid loss is continuous and can increase if they client is experiencing a fever or has had a recent burn to the skin

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A. Perform tracheostomy care using medical asepsis B. Allow enough slack under the tracheostomy ties to insert three fingers C. Soak the inner cannula of the tracheostomy tube in normal saline D. Cut a sterile gauze pad to place between the neck and tracheostomy tube

Soak the inner cannula f the tracheostomy tube in normal saline normal saline or hydrogen peroxide to loosen secretions

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. Insist that the AP attend an in=service training about standard precautions C. Talk with the AP about the technique used D. Observe the AP a second time and intervene if the techniques remains the same

Talk with the AP about the technique used the nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter side that is cool to the touch D. Bleeding at the IV insertion site

Taut skin around the IV catheter side that is cool to the touch A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress of a cold compress.

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area B. The AP tapes the catheter to the clients inner thigh C. The AP hangs the collection bag at the level of the bladder D. The AP ensures there are no kinks in the drainage tubing

The AP hangs the collection bag at the level of the bladder should be below the bladder

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate t the nurse that the client understands the procedure of the cane walking? A. The client holds the cane on the affected side B. The client advances the unaffected leg followed by the cane C. The client supports his weight on the unaffected leg when moving the care forward D. The client keeps 2 point of support on the ground

The client keeps 2 point of support on the ground 2 point can be either both feet or a foot and the cane

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? A. Assist the client into a semi-sitting position B. Have the client lean slightly backwards C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward

advise the client to tuck his chin downward To help the client swallow safely the nurse should have the client sit upright, lean slightly forward, tilt his head forward and tuck his chin. This position helps move the food downward without lodging in the throat where the client could aspirate it,

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the clients fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

daily weight

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? A. Muscle tremors B. Positive chvosteks sign C. Depressed DTR D. Numbness around the mouth

depressed deep-tendon reflexes A total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed DTR nausea vomiting bone pain lethargy and weakness

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first? A. Refer the client to a nutritionist B. Discuss eating strategies with client C. Determine the clients intention to change current eating habits D. Instruct the client to perform 30 min of vigorous exercise daily

determine the clients intention to change current eating habits when using the nursing process the nurse should first assess the clients readiness to commit to a change in behavior

A nurse is performing an otoscopic examination of a clients right eat. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Obtain an audiology referral B. Document this as an expected finding C. Irrigate the ear with warm water D. Document mild inflammation

document this as an expected finding the light of the otoscope reflects off the tympanic membrane, which is cone-shaped or triangular. In the right ear, it in visible in the right lower quadrant of the eardrum. in the left ear, it is visible in the left lower quadrant of the eardrum

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

evaluate pedal pulses for a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot

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? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

explain the procedure to the client

A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A. supine B. lateral C. Fowlers D, Trendelenburg

fowlers

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated B. The wound is closed at a later date C. A skin graft is placed over the wound bed D. Granulation tissue fills the wound during healing

granulation tissues fills the wound during healing A beefy red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days.

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing

grimacing

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

hold the medication bottle with the label against the palm of the hand when pouring The nurse should hold a multidose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. increased blood pressure B. Decreased blood glucose level C. Decreased oxygen use D. Increased gastrointestinal motility

increased blood pressure

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor

increased heart rate An increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit.

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium

sodium

A nurse is preparing to administer a medication to a client which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? A. stat prescription B. PRN prescription C. Standing prescription D. Single prescription

stat prescription