Level 4 Written Skills
To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe and from the earlobe to the
xiphoid process plus 20 to 30 cm more
A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document?
Rebound tenderness
A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?
Use a cuff of the appropriate size for the client
A nurse is preparing a blood transfusion for a client who has type A blood. The nurse should know that the client can safely receive blood from blood group O because
type O blood contains no A antigens
A nurse administers the first dose of a client's prescribed antibiotic via intermittent IV bolus. During the first 10 to 15 min of administration, which of the following assessments is the nurse's priority?
Assess the client for a systemic allergic reaction
A nurse is assessing a newborn who was born 2 days ago. Which of the following findings should the nurse report to the provider?
Redness of the skin at the base of the umbilical cord stump
A nurse is teaching a client who has a new diagnosis of type 2 diabetes mellitus about metformin. The nurse should explain that this type of medication works by which of the following mechanisms?
Reducing hepatic glucose production
A nurse is caring for a client who is about to receive a unit of packed RBCs and states, "This is my third unit of blood today. I don't want to get some disease from all this blood." Which of the following responses should the nurse make?
"Donated blood is carefully screened for infectious diseases"
A nurse is providing teaching to an assistive personnel (AP) about the use of sterile gloves. Which of the following instructions regarding the open-gloving method should the nurse give?
"Grasp only the inside of the glove with your ungloved hand."
A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?
"Hold the crutches on your unaffected side when preparing to sit in a chair."
A newly hired nurse is reviewing information about the HIPAA Privacy Rule during facility orientation. Which of the following statements by the nurse indicates an understanding of the Privacy Rule?
"I can give information about a client over the phone if the client gives permission."
A nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first?
Cleanse the stoma and the peristomal skin
A nurse is caring for a client who has dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client?
Elemental
A nurse is assessing a client's respiration. Which of the following actions should the nurse take?
Elevate the head of the client's bed 45 to 60 degrees
Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings?
Elevated blood pressure
A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include?
Empty the pouch when it is less than half full
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experiencing social isolation. Which of the following interventions should the nurse recommend?
Encourage the client to go to the dining room at meal times to talk with other clients
Which of the following actions should a nurse take prior to starting a blood transfusion?
Ensure that informed consent has been obtained from the client
A nurse has just initiated a new peripheral IV infusion with 5% dextrose in water for continuous infusion. How often should the nurse plan to replace the primary infusion tubing?
Every 96 hr
A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take?
Extend one leg and allow the client to slide down the leg to the floor
Which of the following routes of medication administration has no barriers to absorption?
Intravenous
Which of the following describes a medication's generic name?
It is the same as its nonproprietary name
A nurse is obtaining a client's blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?
It might not follow with a fifth Korotkoff sound
Which of the following is an advantage of using alcohol-based gel?
It takes less time to use than washing with soap and water
A nurse is reviewing self-administration of insulin using a pre-filled pen with a client who started using the pen the previous week. The client asks what can be done to help reduce injection pain. Which of the following instructions should the nurse give the client?
Keep the pen at room temperature for a few minutes
A nurse is teaching a client who was recently diagnosed with type 1 diabetes mellitus how to check blood glucose levels. Which of the following instructions should the nurse include in the teaching?
"To collect a sample for testing, hold the test strip next to the blood on the fingertip."
A nurse providing education to a client who has a prescription for a blood transfusion. Which of the following statements should the nurse include in the teaching?
"You must immediately report any symptoms like chills, nausea, or itching."
A nurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field? (Select all that apply)
-A cotton ball dampened with sterile normal saline is placed on the field -The nurse turns to address the client's question concerning the procedure -The procedure is postponed 30 min to accommodate the client -A liquid is poured into a sterile container form a distance of 25 cm (10 in)
A nurse is teaching a newly licensed nurse about using a computer to document in a client's health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I should remain aware of my surroundings when documenting in the computer."
A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include?
"Insert the earpieces at a downward angle toward your nose."
A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include?
"Place the oxygen tank in a clutter-free environment."
An assistive personnel (AP) is collecting a 24-hour urine specimen from a client. Which of the following statements by the AP indicates that the specimen collection will have to be restarted?
"The client just told me that they forgot to put the urine in the container."
A nurse is preparing to administer an intramuscular injection at the ventrogluteal site. Which of the following needle lengths should the nurse select for an adult of average size?
1 1/2 inches
A nurse is preparing to open a sterile package of instruments. Identify the order in which the nurse should perform the following steps.
1. Position the tray so that the top flap is farthest away from their body -Open the flap furthest from their body -Open the side flaps -Open the flap closest to their body
A nurse is reviewing the results of routine laboratory tests performed as part of a client's annual physical examination. Which of the following values indicates a fasting blood glucose measurement that is outside of the expected range?
118 mg/dL (fasting blood glucose measurement is generally between 74 and 106 mg/dL)
A client drinks 8 oz of water. Which of the following is a correct conversion of the client's intake?
240 mL
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line. The nurse should identify that which of the following information is true about this type of IV route?
A PICC line is a long catheter inserted through the veins of the antecubital fossa
A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI?
A Salmonella infection that occurs after eating contaminated food from the cafeteria
A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?
A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line
A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding?
A client who has dysphagia
Which of the following clients is exhibiting medication tolerance?
A client who requires an increased dose of a medication to achieve continued therapeutic benefit
A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear?
A face shield
A nurse in a pediatrician's office is speaking on the telephone with the guardian of a school-age child who will become a new client at the office. The nurse should instruct the guardian to call the child's previous provider's office to request which of the following?
A form authorizing release of copies of the child's medical records to be signed by the guardian
A nurse obtains a capillary blood glucose result of 180 mg/dL from a client who has diabetes mellitus. Which of the following actions should the nurse take?
Administer insulin according to the patient's sliding scale orders
Which of the following actions demonstrates correct use of one of the Ten Rights of Medication Administration?
Administering a client's medication by the route the provider has prescribed
A nurse is inserting a peripheral IV catheter and observes a blood return in the flashback chamber after puncturing the skin and selected vein. Which of the following actions should the nurse perform next?
Advance the catheter into the vein with the finger hub
A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressing should the nurse select to help promote homostasis?
Alginate
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique?
Aligning the nurse's knees with the client's knees just before the transfer
A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the nurse take?
Allow 2 min in between suctioning to reoxygenate lungs
A nurse is checking the client's nasogastric tube for placement. Which of the following procedures should the nurse implement?
Aspirate stomach contents and check the pH
A nurse is preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics?
Balance
A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury?
Barrier creams
A nurse has a handwritten prescription that is difficult to read. Which of the following actions should the nurse take to avoid an error in medication administration?
Call the provider for clarification of the prescription
A nurse is caring for a client who has a central venous catheter. When flushing the catheter, the nurse should use a 10-mL syringe to prevent which of the following complications associated with central vascular access devices?
Catheter rupture
A nurse is caring for a client who is receiving 0.9% sodium chloride IV at 75 mL/hr through a triple lumen central venous access device. The IV pump alarm sounds, indicating that there is an occlusion. Which of the following actions should the nurse take first?
Check the line at or above the hub for kinked tubing that is creating a resistance to flow
A nurse is teaching the parents of a newborn about bathing techniques. Which of the following instructions should the nurse include?
Clean the newborn's face first using plain water
A nurse is preparing to initiate the transfusion of a unit of packed RBCs to a client. After the unit of blood has arrived, which of the following procedures will help the nurse protect the client against the possibility of a blood-group incompatibility?
Comparing the ID numbers on the blood unit with those on the order form and the client's wristband
Which of the following actions should a nurse take after witnessing a breach of a client's confidentiality in a provider's office?
Complete a health information privacy complaint form
A nurse is preparing to administer an oral medication to a client. Which of the following actions is the nurse's priority?
Confirm the client's identity using two methods
A nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The client tells the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend?
Consume foods that are low in fiber content
A nurse has just initiated an IV infusion and is teaching the client about possible complications. The nurse should include that which of the following findings is an indication of early infiltration?
Coolness
A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?
Corticosteroids
A nurse is caring for a client who is in early labor and has a fetus in the occipitoposterior presentation. The client reports pain in their lower back with contractions. Which of the following pain management techniques is most likely to be effective in relieving low back pain caused by this type of fetal presentation?
Counterpressure
A nurse is caring for a client who has an implanted port that needs to be accessed for an infusion. Which of the following actions should the nurse take?
Cover the device and the needle with a sterile transparent dressing
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings?
Crackles
A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first?
Develop a plan of care
A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange?
Diagnosis
A nurse is reviewing a group of prescriptions. Which of the following should the nurse identify as an example of a complete prescription?
Digoxin 1.25 mg PO daily
A nurse assess a client's IV insertion site and finds that it is red, warm, and slightly edematous. Which of the following actions should the nurse take?
Discontinue the IV line
What should the nurse do to maintain standard precautions?
Disinfect hands immediately after removing gloves
A nurse is preparing to administer an IV medication to a client. The nurse should identify that which of the following is a disadvantage of administering IV medications?
IV medications are irreversible
A nurse is caring for a client who is receiving a medication that typically causes drowsiness. While assessing the client, the nurse notes that the medication has caused the client to become hyperactive. Which of the following terms describes the client's unexpected response to the medication?
Idiosyncratic effect
A nurse is preparing to administer a subcutaneous injection to a client. Which of the following should the nurse assess first?
If the client has allergies to the medication
A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure?
Ileostomy
A nurse is caring for a client who has a nasogastric tube connected to suction. Which of the following findings indicates the the tube has become occluded?
Increased abdominal distention
Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?
Infectious diarrhea
A nurse in the emergency department is caring for a client following a motor-vehicle crash. The client is unresponsive and the client's spouse is not present at the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client's surgery?
Inform the provider of the spouse's contact information so consent can be obtained over the telephone
A nurse is caring for a client who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects an air embolism and clamps the catheter immediately. The nurse should reposition the client into which of the following positions?
On their left side in Trendelenburg position
A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?
Over the fifth intercostal space at the left midclavicular line
A nurse should recognize that which of the following findings is an indication for oxygen therapy?
Oxygen saturation (SaO2) 90%
Which of the following terms indicates that a medication is given via an injection?
Parenteral
A nurse is providing teaching about risk for aspiration with a client who is receiving intermittent bolus nasogastric feedings Which of the following findings should the nurse instruct the client to report?
Persistent coughing
Which of the following products can affect the permeability of latex gloves?
Petroleum-based hand lotion
A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration?
Place the client in Fowler's position
A nurse is preparing to administer several PO medications to a client. The client states they can only take one pill at a time. Which of the following actions should the nurse take?
Remain at the bedside until the client has taken all of the medications
A nurse is caring for a client who has a cuffed endotracheal (ET) tube in place. Which of the following actions should the nurse plan to take?
Repositioning the ET tube in the client's mouth every 12 hr
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?
Respiration 30/min
A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hr. Which of the following assessment findings help indicate that oxygen therapy has been effective?
Respiratory rate 14/min
A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions should the nurse plan to take?
Reuse the catheter repeatedly
A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first?
Right lower quadrant
A nurse is caring for a client who has a stage III pressure injury on the sacral area. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury?
Rotate a sterile swab in the area of drainage
A nurse is preparing to administer an insulin injection to a client. Which of the following actions should the nurse take?
Rotate the injection sites
A nurse caring for a group of clients in an ambulatory care clinic is collecting urine for several prescribed diagnostic tests. For which of the following tests is a random sample voided into a clean cup appropriate?
Routine urinalysis
A nurse is collecting a blood specimen for culture from a client. Which of the following actions should the nurse take?
Rub the client's arm at the selected site prior to venipuncture
A nurse is informed during shift report that a client has a nasogastric tube connected to continuous suction. The nurse should identify that this client must have which of the following types of tubes?
Salem sump tube
A group of nurses on a clinical unit are planning to research the incidence of falls among clients following joint replacement surgery. Which of the following actions should the nurses take to ensure the study complies with the HIPAA Privacy Rule?
Submit their proposal to the institutional review board for review and describe how they will de-identify client information
A nurse should identify that which of the following areas of the hands requires special attention during the prescrub wash?
The area under each fingernail
A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact?
The client can identify a minty scent
A nurse is performing a general client survey and finds that the client has a body mass index (BMI) of 23. Which of the following should the nurse document?
The client has a BMI within the expected reference range
A nurse is documenting a client's response to a pain medication. Which of the following is an example of correct documentation regarding the client's response to pain?
The client reports pain decreased 30 min after medication administration to 3 on a scale of 0 to 10
After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately?
The gloves
When donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand?
The inner edge of the cuff will lie against the skin and thus will not be sterile
A nurse is providing teaching about breastfeeding to a client who gave birth 8 hr ago. Which of the following information should the nurse include?
The newborn should have six wet diapers per day after day 4
A nurse is washing their hands with soap and water prior to repositioning a client in bed. During the handwashing procedure, it is important to take which of the following actions?
Wash for at least 20 seconds
After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take?
Wash their hands with soil and water
A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs?
When the semilunar valves close
While waiting for a sterile procedure to begin, how should a nurse position their hands and arms?
With hands clasped together in front of the body above waist level
A nurse caring for a client who has diabetes mellitus is having difficulty obtaining a capillary fingerstick blood sample for point-of-care blood glucose testing. Which of the following actions should the nurse take to help increase blood flow to the client's finger?
Wrap the finger in a warm cloth
A nurse is preparing to suction a client's oral airway. Which of the following devices or methods should the nurse use?
Yankauer catheter
A client who is anticipating total hip replacement is considering autologous transfusion. When teaching this client about autologous transfusion, it is important to emphasize that
it reduces the risk of mismatched blood
When administering a transfusion of packed red blood cells, it is important to
make sure the entire unit is transfused within 4 hr
A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must
reposition the elastic band frequently
A nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the right
stops the flow of oxygen
A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement?
Obtain an x-ray
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?
Apply oxygen at 2L/min via nasal cannula
A nurse is teaching a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs nasogastric tube intubation for gastric decompression?
A 40-year old client who has a postoperative bowel obstruction
Which of the following represents the correct administration of the prescribed medication?
Amoxicillin 1 g PO prescribed; two 500-mg tablets given
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39 C (102 F). Which of the following other vital signs should the nurse expect?
An elevated pulse rate
A nurse is assessing a client who is receiving 0.9% sodium chloride IV at 125 mL/hr. Which of the following should the nurse recognize as a possible complication related to the IV therapy?
Client reports coughing and shortness of breath
A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. The action facilitates proper insertion of the tube by achieving which of the following?
Closing off the glottis
A nurse is caring for a client who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flange of the outer cannula?
Commercially prepared fenestrated dressing
A nurse is teaching a client about home collection of a stool specimen for fecal occult blood testing. Which of the following instructions should the nurse include?
Obtain specimens from three different stools
A nurse started a transfusion of packed RBCs for a client 1 hr ago. The client has suddenly developed shaking chills, muscle stiffness, and a temperature of 38.6 C (101.5 F). The client appears flushed and reports a headache and "nervousness." The nurse should identify that the client has most likely developed which of the following types of transfusion reaction?
Febrile nonhemolytic
A nurse is performing a gestational age assessment using the New Ballard Score. Which of the following findings should indicate to the nurse that the newborn is preterm?
Flat areola
A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?
Flexing the shoulder by raising the arm from a side position to a 180 angle
Which of the following actions should a nurse take when converting an IV infusion to a saline lock?
Flush the IV catheter to confirm patency
A nurse is caring for a client who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the client's tracheostomy tube after cleaning it?
Folded pipe cleaners
A nurse is caring for a client who has type 1 diabetes mellitus and reports feeling anxious and having palpitations. The glucometer reads 50 mg/dL. Which of the following actions should the nurse take?
Give the client 4 oz of apple juice
A nurse caring for a client who needs to collect a midstream urine specimen. Which of the following actions should the nurse take?
Have the client urinate a small amount of urine before starting the collection
When opening a sterile pack, which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack?
Holding the sterile pack below waist or table level
A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?
Hydrogel
A nurse is performing a nasogastric intubation on a client and has reached the tube's predetermined length. Which of the following actions should the nurse take first?
Inspect the oropharynx with a penlight and a tongue blade
A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first?
Inspection
A nurse is caring for a client who has type 1 diabetes mellitus and is in need of a long-acting insulin preparation. The nurse anticipates receiving a prescription for which of the following insulins?
Insulin glargine
A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary elimination?
Kock's pouch
A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging?
Kyphosis
A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?
Leaves the bed in the lowest position throughout the procedure
A nurse is caring for a client who has a suspected urinary tract infection (UTI). Which of the following urinalysis results should the nurse identify as a manifestation of a UTI?
Leukocyte esterase
A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding?
Limit the time the formula hangs to 8 hr
A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?
Measure the client's calf circumference and leg length from heel to knee
A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?
Move their leg behind their body
A nurse is teaching a client who has type 1 diabetes mellitus about the peak time of neutral protamine Hagedorn (NPH) insulin. Which of the following statements by the client indicates an understanding of the teaching?
NPH insulin peaks in 6 to 14 hours
A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Through which of the following agencies should the nurse instruct the client to file the complaint?
Office for Civil Rights (OCR)
A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?
Place the probe in the posterior lingual pocket lateral to the midline
A nurse is teaching a client about collecting stool specimens for fecal occult blood testing. Which of the following should the nurse instruct the client to avoid before and during the testing period?
Poultry
A nurse is providing teaching about danger signs during pregnancy to a client who is at 20 weeks of gestation. The nurse should instruct the client to report headaches, blurred vision, and epigastric pain because these are indications of which of the following complications of pregnancy?
Preeclampsia
A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence?
Press gently around the barrier for 30 seconds to 1 min
A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client?
Protect their eyes
A nurse is caring for a client who is recovering from gastric surgery, is NPO, and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes?
Provide frequent mouth care
A nurse is removing a client's IV catheter. Which of the following actions should the nurse take?
Pull the catheter straight back from the insertion site
A nurse is preparing to use a tympanic thermometer to acquire a client's temperature. Which of the following actions should the nurse take to ensure an accurate reading?
Pull the pinna back and upward gently
A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?
Pulsating lavage
A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting?
Pulse pressure
A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest?
Push the skin away from the barrier while removing it
A nurse is documenting data about a deep necrotic wound on a client's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document?
Slough
A nurse is staging a pressure injury over a client's right heel area. The pressure injury has no eschar or slough and no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following?
Stage 3
A nurse is caring for a client who is receiving a blood transfusion and reports itching. The nurse observes areas of urticaria on the client's skin. Which of the following actions should the nurse take?
Stop the blood transfusion
A nurse is teaching a client who has type 1 diabetes mellitus about the use of an insulin pump. Which of the following information should the nurse include in the teaching?
The risk of developing DKA can be increased with the use of an insulin pump
A nurse is assessing the fundal height for a client who is at 28 weeks of gestation. The nurse should measure the distance in centimeters between which two anatomical landmarks?
The symphysis pubis and the top of the fundus
A nurse is preparing to flush and change the dressing on a client's central venous catheter. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis?
To control the introduction of micro-organisms at the catheter site
A nurse should identify that which of the following is the goal of surgical asepsis?
To create and maintain a micro-organism-free environment
A nurse is preparing to wash their hands prior to surgery. For which of the following reasons should the nurse keep their hands above their elbows?
To encourage water and soap to flow away from the clean hands
A nurse is caring for a client who sustained trauma to their head and neck and will require long-term airway support. Which of the following pieces of equipment will be required for home health care for this client?
Tracheostomy tube
A nurse is preparing to obtain a blood sample from a client who has a triple-lumen central catheter in place. Which of the following actions should the nurse take?
Turn off the distal infusions for 1 to 5 min before obtaining the blood sample
A nurse is caring for a client who has a central venous access device in place. Which of the following routine interventions should the nurse use to prevent lumen occlusion?
Use a pulsatile action while flushing
A nurse is preparing to administer an intradermal injection. Which of the following actions should the nurse take to ensure proper technique?
Use a tuberculin syringe with a 5/8-inch, 25 gauge needle
A nurse is caring for a client who is receiving dextrose in 5% water with 20 mEq of potassium chloride at 75 mL/hr. The provider has prescribed 1 g ceftriaxone IV. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take first?
Verify the medication's compatibility with the primary IV solution
A nurse is performing chest physiotherapy for a client who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the client exhales, the nurse should use which of the following techniques?
Vibration
Which of the following methods of information exchange can occur without client authorization?
Walking rounds that involve two nurses discussing an assigned client at the client's bedside in a private room
A platelet transfusion is indicated for a patient who
has thrombocytopenia
A nurse is teaching about circumcision care to the parents of a newborn who was circumcised using the Gomco clamp method. Which of the following instructions should the nurse include? (Select all that apply)
-Apply petroleum jelly to the penis with each diaper change for one week -Apply gentle pressure with a sterile gauze pad to control slight bleeding -Apply the diaper loosely over the penis
A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? (Select all that apply)
-The client who has a BMI of 35 -The client is reporting a "stuffy" nose -The client is taking digoxin for an irregular heart rate -The client had a mastectomy 2 years ago
Prior to entering the surgical-scrub area, which of the following personal protective equipment (PPE) items should a nurse don? (Select all that apply)
-protective eyewear -hair cover -mask -shoe covers
A nurse is caring for a client who is in early stage renal failure and has a prescription for the infusion of IV fluids. Which of the following IV fluids does the nurse anticipate a prescription for and why?
0.45% sodium chloride because it dilutes extracellular fluid and rehydrates the cells
A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following central venous access devices should the nurse anticipate being inserted?
A nontunneled percutaneous central catheter
A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client?
A tracheostomy collar
A nurse is caring for a client who requires long-term central venous access and is an avid swimmer. Which of the following central venous access devices is the best choice for this client?
An implanted port
A nurse is discontinuing a peripheral IV catheter. Upon removal, the nurse should assess the catheter for which of the following?
An intact catheter tip
A nurse has just inserted a peripheral IV catheter. Which of the following actions should the nurse take to secure the catheter?
Apply an IV securement device
A nurse is providing discharge teaching to a client who is 3 days postpartum and is formula feeding their newborn. Which of the following instructions should the nurse include when discussing engorgement?
Apply ice packs to the breast for 15 min to relieve swelling and discomfort
A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates and adverse effect of oxygen therapy?
Cracks in the oral mucosa
A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses?
Dorsalis pedis
To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry?
Drying provides the full antiseptic effect
A nurse is taking an adult client's temperature rectally. Which of the following actions should the nurse take?
Insert the probe about 2.5 cm (1 in) into the client's anus
A nurse is caring for a client who was admitted to the hospital for same day surgery and has a new prescription for continuous IV therapy. Which of the following actions should the nurse take when administering the IV therapy?
Inspect the IV solution for fluid color, clarity, and expiration date
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional support for about 2 weeks because they are unable to consume adequate nutrients orally. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe?
Nasointestinal tube
A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take?
Observe the client's chest movements while appearing to assess their pulse
A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of the client's respiration?
Observe the degree of chest-wall movement during inspiration and expiration
A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the INITIAL placement of the tube?
Obtain an x-ray
Administering oxygen therapy with a nonrebreather mask has which of the following advantages?
Offers the highest oxygen concentration of the low-flow systems
A nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage?
Serosanguineous
A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching?
Use irrigation to help establish a regular bowel pattern
A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle. Which of the following actions should the nurse take to locate the site of injection?
Use the heel of the hand and index finger to locate the vastus lateralis muscle
A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client?
Venturi mask
