ita

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

"Maintain a consistent time to wake up each day"

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

1 quart of water

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

122 mmHg

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 ml to infuse at 800 units/hour. At what rate should the nurse set the infusion pump?

8 ml/hou

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

A mole with an asymmetrical appearance

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

Arrange food in a consistent pattern on the client's plate

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

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

Calf swelling

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5 C (105 F)Cleanse the wound from the center outward Use a 20 ml syringe to irrigate the wound

Cleanse the wound from the center outward

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

Compare prescriptions with medications the client received while at the facility

A nurse is administering 1 L 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

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

Distended neck veins

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

Erythema on pressure points

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

Evacuate the client

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

Have family members wear a gown and gloves when visiting

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

Initiate an enteral feeding through a gastrostomy tube

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

N95 respirator

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears a "bruit". This sound indicates which of the following?

Narrowed arterial lumen

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

Rapid heart rate

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

Reassure the client that this is an expected response to grief

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

"They indicate the form of treatment a client is willing to accept in the event of a serious illness"

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

A client who smokes 1 pack of cigarettes a day

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

A nurse asks a nurse from another unit to assist with documentation for a client

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

Abdominal cramping

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

Administer the medication into the abdomen

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

Advocacy ensures client's safety, health, and rights

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

Ambulating a client who is postoperative

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

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

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

Apply an ankle foot orthotic device to the client's feet

A nurse is providing discharge teaching for 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? (select all that apply)

Check the cord routinely for frays or tearing Keep the unit at least 1-2 m (4 feet) away from a gas stove Observe for signs of hypoxia

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

During the admission process

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

Have the client stand with their arms at their sides and their feet together

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

Have the client take sips of water to promote insertion of the NG tube into the esophagus

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

I can take echinacea to improve my immune system"

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

Measure urine output

A nurse is on a medical surgical unit caringterm-66 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

A new is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply)

Pupil clarity Visual fields Visual acuity

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

Situation, background, assessment, and recommendation (SBAR)

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

Tell the client to keep the head of the bed elevated at least 30 degrees

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

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

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

Use a bed exit alarm system

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

What could I have done to deserve this illness?"

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 4 sides of the bed

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

Wrap monitoring cords with stockinette and tape them in place

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

You should receive a pneumococcal vaccine when you are 65 years old"

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

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

assist the client with a partial bed bathMeasure the client's BP after the nurse administers an antihypertensive medication Use a communication board to ask what the client wants for lunch

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

"You should consider getting a part time job or doing volunteer work"

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

0.3 mg

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

A client who has asthma

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 or veracity?

A client who is unaware of her cancer diagnosis asks the nurse if she has cancer and the nurse responds affirmatively

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

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

Bladder scan shows 535 ml of urine

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

Client found lying on the floor"

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

Current medications

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

Flush the tube with 15 ml of sterile water

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

Gently shake the container of medication prior to administration

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

Have the client use a trapeze bar when changing position

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

I flushed what I urinated at 7 am, and have saved all urine since"

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

I will be sure to remove my hearing aid before taking a shower"

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

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

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

Inject 10 units of air into the bottle of NPH insulin 2. Inject 5 units of air into the bottle of regular insulin 3. Withdraw the correct dose of regular insulin from the bottle 4. Withdraw the correct dose of NPH insulin from the bottle

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

Instruct the family to refrain from pushing the button for the client while she is asleep

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

Is your pain sharp or dull?"

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

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

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical surgical unit. What is it called when it sounds like blowing as air moves through the larger airways on inspiration and expiration?

Normal breath sounds

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.

Obtain the pronouncement of death from the provider 2. Remove tubes and indwelling lines 3. Wash the client's body4. Ask the client's family members if they would like to view the body 5. Place a name tag on the body

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?

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

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply

Place the client in a room with negative pressure airflow Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene

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

Practice sessions

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

Select a suction catheter that is half the size of the lumen

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

Skin blanching

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

The caregiver insists on remaining in the room

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

The client identifies the location of a fire extinguisher

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

The client's caregiver washes out the feedings bag with warm water once every 24 hours

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

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

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

Use tracheostomy covers when outdoors

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

Walking briskly

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

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

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? "We would consult the person appointed by your health care proxy to make decisions"

We would give you oxygen trough a tube in your nose"

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 the stairs, I will first shift my weight to my right leg"

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

Withhold the blood transfusion

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

Witness the client's signature on the consent form

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

You should have a fecal occult blood test every year"

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

breath sounds

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

droplet

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day". Which of the following components of the prescription should the nurse verify with the provider?

medication dose

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

place the client's arm in a dependent position

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

press gently on the tragus of the client's ear

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

the pain is like a dull ache in my stomach"