FUNDS B

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? "Is your pain constant or intermittent?" "What would you rate your pain on a scale of 0 to 10?" "Does the pain radiate?" "Is your pain sharp or dull?"

"Is your pain sharp or dull?"

A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The nurse should set the pump to deliver how many mL/Hr?

107mL/hr

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? 2 cups of soup 1 quart of water 8 oz of ice chips 6 oz of tea

8 oz ice chips

A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement? The tube aspirate has a pH of 7. An x-ray shows the end of the tube above the pylorus. Bowel sounds are present on auscultation. The client reports relief of nausea.

An x-ray shows the end of the tube above the pylorus

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

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

A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next? Clean sutures along the incision site. Grasp at the knot of the sutures with forceps. Cut the sutures close to the skin on one side. Pull out the sutures with forceps in one piece.

Clean sutures along the incision site.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the client's room has at least 6 air exchanges per hour. Make sure the client wears a mask when outside her room if there is construction in the area. Place the client in a private room with negative-pressure airflow. Wear an N95 respirator when giving the client direct care.

Make sure the client wears a mask when outside her room if there is construction in the area?

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take? Assist the client into a prone position. Place a sleeve over the top of each leg with the opening at the knee. Make sure two fingers can fit under the sleeves. Set the ankle pressure at 65 mm Hg.

Make sure two fingers can fit under the sleeves.

A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field? The nurse opens the sterile field on a wet surface. The nurse opens the first fold away from his body. The nurse holds sterile objects above the waist. The outer edge of the sterile field is touching a bottle.

The nurse opens the sterile field on a wet surface

A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect? Numbness of the extremities Bradycardia Positive Chvostek's sign Abdominal cramping

abdominal cramping

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? Albumin level of 3 g/dL HDL level of 90 mg/dL Norton scale score of 18 Braden scale score of 20

albumin level of 3g/dL

A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? Admitting diagnosis Breath sounds Body temperature Diagnostic test results

breath sounds

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

droplet

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Make sure the reservoir bag of a partial rebreathing mask remains deflated. Use petroleum jelly to lubricate the client's nares, face, and lips.

regulate oxygen via nasal cannula at a flow rate no more than 6l/min

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

tap just bellow the kneecap

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? "We can talk about advance directives, and I can also give you some brochures about them." "You should set up a time to talk with your provider about that." "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." "Why do you want to discuss this without your partner here to plan this with you?"

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

A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client? "Rashes are very common, especially if you have dry skin. Did it go away on its own?" "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic." "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash." "We need to document the exact medication you were taking because you might be allergic to it."

"We need to document the exact medication you were taking because you might be allergic to it."

A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? "We will determine who the durable power of attorney for health care form has designated." "We will apply oxygen through a tube in your nose." "We will ask if you have changed your mind." "We will insert a breathing tube while we evaluate your condition."

"We will apply oxygen through a tube in your nose"

A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?

A teacher who brings in a 7-year-old student is incorrect. Only a parent, legal guardian, or, in emergency situations, a grandparent or adult sibling, can legally give consent for medical treatment of a young child. A 16-year-old client who is married is correct. A minor who is married is emancipated and can give consent for his own treatment. A 27-year-old client who has schizophrenia is correct. An adult client who requires psychiatric care can give consent for her own care unless the court has determined the client to be incompetent. An adoptive parent who brings in his 8-year-old son is correct. The adoptive parent of a child is a parent and legal guardian and can sign to give consent for the child's care. A 17-year-old mother who brings in her toddler is correct. A custodial parent who is a minor can legally give consent for the medical treatment of her child.

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? Oat cereal Refried beans Peanut butter Cheddar cheese

Cheddar cheese Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are examples of foods that are good sources of complete protein.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? Pad the client's wrist before applying the restraints. Evaluate the client's circulation once per shift after application. Remove the restraints every 4 hr to evaluate the client's status. Secure the restraint ties to the client's bed side rails.

Pad the client's wrist before applying the restraints.

A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? Second intercostal space at the left sternal border Fourth intercostal space at the right sternal border Fourth intercostal space at the left sternal border Second intercostal space at the right sternal border

Second intercostal space at the left sternal boarder

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter Small air bubbles are in the IV tubing. IV flow stops when the client bends her arm. Swelling and coolness are observed at the IV site. Blood is visible in the IV catheter and tubing.

Swelling and coolness are observed at the IV site

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? A client who has a history of physical abuse A client who has a permanent pacemaker A client who has ulcerative colitis A client who has asthma

a client who has asthma

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action? Encourage the client to relax and take deep breaths during the dressing change. Educate the client about the importance of the dressing change to prevent infection. Assist the client to a comfortable position for the dressing change. Administer pain medication 45 min before changing the client's dressing.

administer pain medication 45 min before changing the client's dressing

A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

an uneven shape

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

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

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation? 1Urine has an unusual odor. 2Urine specific gravity is 1.035. 3Bladder scan shows 525 mL of urine. 4Urine is positive for ketones.

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

a nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? Loss of skin turgor on the back of the hands Varicosities on the lower extremities Thick, discolored nails with ridges Bruises on the arms in various stages of healing

bruises on the arms in various stages of healing

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

decrease in heart rate MY ANSWER Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? Turn the client every 4 hr. Elevate the head of the client's bed. Hold oral care. Increase the room's temperature.

elevate the head of the client's bed

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

evacuate the client

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

normal breath sounds

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? Role play Group discussions Question-answer meetings Practice sessions

practice sessions

A nurse is caring for a patient with behind the ear hearing aid. "This type of hearing aid does not allow for fine tuning of volume." "I shouldn't have trouble keeping the hearing aid in place during exercise." "I expect to hear a whistling sound when I first insert the hearing aid." "I will be sure to remove my hearing aid before taking a shower."

remove before shower

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? Remove the outer cannula cautiously for routine cleaning. Use tracheostomy covers when outdoors. Use sterile technique when performing tracheostomy care at home. Cleanse irritated skin with full-strength hydrogen peroxide.

use tracheostomy covers when outdoors

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? Wrap blankets around all four sides of the bed. Apply restraints during seizure activity. Place the client in a supine position during seizure activity. Have a tongue depressor at the client's bedside.

wrap blankets around all four side rails

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? "I will return shortly after I document this in your record." "Most men live a long time with prostate cancer." "I am available to talk if you should change your mind." "I will make a referral to a cancer support group for you."

"I am available to talk if you should change your mind."

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. A client with a do-not-resuscitate (DNR) status has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she would give her.

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? The client is receiving formula at room temperature. The feedings infuse at a slow, continuous drip over 8 hr each night. The family member washes out the feeding bag with warm water once every 24 hr. The family member flushes the tubing with water before and after giving medications.

The family member washed out the feeding bag with warm water once every 24 hours.

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? Thread the IV catheter so that the hub rests at the insertion site. Shave excess hair from around the insertion site. Cleanse the site with hydrogen peroxide before IV catheter insertion. Palpate the site carefully just before inserting the IV catheter.

Thread the IV catheter so that the hub rests at the insertion site. MY ANSWER Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? Administer the medication with the needle at a 45° angle. Administer the medication into the client's nondominant arm. Pull the client's skin laterally or downward prior to administration. Massage the injection site after administration.

administer the medication with the needle at a 45 degree angle

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family

during the admission process

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? Reduce dietary sodium. Administer a loop diuretic. Evaluate electrolytes. Restrict intake of oral fluids.

evaluate electrolytes The first action the nurse should take when using the nursing process is to assess the client's electrolytes; therefore, the nurse should evaluate the client's laboratory results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances.

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? Examine personal values about the issue. Tell the parents that this is a necessary procedure. Inform the parents that the staff does not require their consent. Contact a spiritual support person to explain the importance of the procedure.

examine personal values about the issue

A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document? "Incident report completed." "Client climbed over the bedrails." "Client found lying on floor." "Client was trying to get out of bed."

"client was found lying on floor."

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "When descending stairs, I will first shift my weight to my right leg." "I should place my crutches 12 inches in front and to the side of each foot." "As I sit down, I will hold one crutch in each hand." "I will make sure the shoulder rests are snug against my armpits."

"when descending stair, I will first shift my weight to my right leg."

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? 1.Talk directly to the client, instead of the interpreter, when speaking. 2.Use a family member as the client's interpreter. 3.Make sure that the interpreter has a college degree. Avoid asking the client personal questions through the interpreter.

talk directly to the client, instead of the interpreter, when speaking When using an interpreter, the nurse should speak directly to the client and observe the client when the interpreter is translating.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? "I think I should take my pain medication more often, since it is not controlling my pain." "Breathing faster will help me keep my mind off of the pain." "It might help me to listen to music while I'm lying in bed." "I don't want to walk today because I have some pain."

"It might help me to listen to music while im lying in bed."

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? "Most people are happy when their children grow up and leave home." "You should be proud that your children are becoming independent." "Maybe you should consider why you are feeling useless." "People in middle adulthood often find satisfaction in nurturing and guiding young people."

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Assist the client with a partial bed bath. Measure the client's BP after the nurse administers an antihypertensive medication. Test the client's swallowing ability by providing thickened liquids. Use a communication board to ask what the client wants for lunch. Irrigate the client's indwelling urinary catheter.

1. Assist the client with a partial bed bath 2. Measure the client's BP after the nurse administers an antihypertensive medication 3. use a communication board to ask what the client wants for lunch

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Check the cord routinely for frays or tearing. Keep the unit at least 4 feet away from a gas stove. Consider purchasing a generator for power backup. Observe for signs of hypoxia. Select synthetic clothing and bedding.

1. Check the cord routinely for frays or tearing 2. consider purchasing a generator for power backup 3. observe for signs of hypoxia Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.Keep the unit at least 4 feet away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 10 feet away from open flames, such as from a fireplace or a gas stove.Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of the oxygen he needs. The nurse should also instruct the family to explore getting the client on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, and he can develop hypoxia.Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.

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

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask the client's family members if they would like to view the body 5. place a name tag on the body

A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client ass to his diet?

Avocados vocados contain no cholesterol. Plant foods contain no cholesterol; foods from animals contain cholesterol.

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first? 1, reposition the client 2 document the clients iv intake in the medical record request a new iv fluid prescription check the iv tubing for obstruction

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

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? Seal unused hospital medications in a plastic bag. Evaluate the client's ability to self-administer medications. Report an identified discrepancy to The Joint Commission. Compare prescriptions with medications the client received during hospitalization.

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

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? Insert the IV catheter into the back of the client's hand. Massage the area of the venipuncture site vigorously. Insert the IV catheter without using a tourniquet. Apply traction to the skin proximal to the insertion site to stabilize the vein.

Insert the IV catheter without using a tourniquet The nurse should insert the IV catheter using the tourniquet minimally or not at all to avoid injury of fragile skin or veins.

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next? Document the provider's statement in the medical record. Notify the nursing manager. Consult the facility's risk manager. Complete an incident report.

Notify the nursing manager

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

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

a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? Have the client wear a mask when receiving visitors. Wash her hands before and after contact with the client. Assign the client to a room with negative-pressure airflow exchange. Instruct all visitors to limit their time with the client.

wash her hands before and after contact with the client Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria. The nurse should also use standard precautions, which require the nurse to perform hand hygiene before and after direct contact with every client, regardless of their diagnosis.