N100 Final review

A nurse is taking a client's vital signs, What is outside the expected range

145/90

A nurse is assesing a client. Which of the following findings should the nurse identify as an indication of protein calorie malnourishment

-Dry, brittle hair -Edema -Poor wound healing

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply)

-Provide oral hygiene frequently -Measure the amount drainage from the NG tube every shift -Secure NG tube to the client's gown

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply)

-Sit with your back supported -Keep your knees at hip level -Use an ergonomically designed computer keyboard

A nurse is preparing to administer a unit packed of RBC's to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? (Select all that apply)

-The clients id number -the clients name -ABO compat -RH compat

A nurse is caring for a semiconscious client who had a small bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement ? (Select all thst apply)

-Verify the intial X ray examination -Measure the Length of the exposed tube -Determine ph of aspirated fluid fluid

a nurse in a providers office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching (Select all that apply)

-black beans -whole grain bread

A nurse is preparing to change the linens of a client who has aids and is incontinent of a stool. Which of the following PPE items should the nurse don prior to providing client care? (Select all that apply)

-gown -gloves

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following ( select all that apply)

-stabilizing the position of tube -preventing aspiration of secretions -preventing air leaks

After assessing a client the nurse documents "1+pedal edema billaterally" This indicates that the nurse observed an indentation of which of the following depths after applying pressure

2mm

A client has 1L of dextrose 5% in 0.45% sodium chloride infusing IV at 125ML/hr. How many hours will it take for the liter to infuse

8

A nurse is caring for a client who is well hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

Albumin

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood

Ask client about first aid performed at the scene

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies

a nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which action should then nurse take first

Ask why the client is refusing the pain medication

A nurse on a medical surgical unit id admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assesment

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should then nurse give the client to ease the passage of the catheter through urinary meatus

Bear down

A nurse is teaching a client with lower extremity weakness how to use a 4 point crutch gait. Which of the following instructions should the nurse include in the teaching

Bear weight on both of your legs

During completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority?

Can you tell me what the pain felt like and shoe me exactly where it was?

A nurse is caring for a middle aged client l. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with others

A nurse implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check capillary refill before applying an icepack to the affected area

A nurse is caring for a client who major fecal incontinence and reports irritation in perianal area? Which of the following actions should the nurse take first?

Check clients perineum

A nurse is caring for a client who requires a dressing change. Which if the following actions should the nurse take?

Clean the drain site from the center outward

A nurse is planning care for a client who has a prescription of sputum specimen for culture sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen when client rises in the morning

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed medication that is unfamiliar to him. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit

During physical examination of a client, the nurse suspects strabismus l. Which of the following tests should the nurse use to collect additional data?

Corneal light reflex

A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviserated.

Cover the incision with a moist sterile dressing

A nurse is teaching a middle aged adult about health promotion and disease prevention. The nurse should inform the client that which of the following changes can occur?

Decreased estrogen and testosterone production

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis

A nurse is performing eye irrigation for client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open

A nurse is communicating with a group of clients about what o expect during the post operative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication

Feedback is provided

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

Gait

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces if information should the nurse include in the teaching?

Granulation tissue fills the wound during healing

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess client turgor?

Grasp a skin gold on the chest under the clavicle, release it, and note whether it springs back

A nurse is caring for a client who developed a hypovolemic shock. Which of the following laboratory values should the nurse expect forvthis client?

Hct 55%

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is teaching a client about lifestyle changes to mange a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain. And the nurse notes reddish brown urine in the client's urinary catheter bag, the nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse preparing to administer an otic antibiotic to an adult client who had otitis media. Which of the following actions should the nurse plan to take?

Hold the dropper 1 cm above the ear canal during administration

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away from the body

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, you are not putting that hose down my throat. Which of the following statements should the nurse make?

I can see that this is upsetting you

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which if the following statements by the client indicates she is experiencing psychological distress?

I keep having nightmares about my upcoming surgery

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching

I need to place between the heating pad and my skin

a nurse in the providers office is talking with an older client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the clients sleeping difficulties?

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

A nurse is caring for a client who is 48hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this post operative complication

Impaired peristalsis of the intestines

A nurse in an acute care facility is planning for a client who is alert but temporary immobile due to a hip arthroplasty. Which of the following interventions should the nurse plan to take to a complication of immobility?

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

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status m. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?

It sounds like your pain is intermittent

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater. Which of the following rationales should the nurse identify for this technique?

Keeping microorganisms from entering the wound

A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching?

Kosher diets have restrictions regarding how the food must be prepared

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?

Lentils

A nurse is caring for a client who has a terminal illness, The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family centered care?

Lets set up a meeting time with the doctor to discuss your options for home care

A nurse us reviewing a client's laboratory results and notes a WBC count of

Leukopenia

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss

A nurse is caring for a client who had a stroke and is at risk of falling: which of the following actions should the nurse take?

Monitor client once every hour

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery which of the following actions should the nurse take?

Notify the provider of the client's decision

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information?

Physical examination

a nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take.

Position the client for drainage of secretions by gravity

A nurse is planning an inservice training session about nutrition. Which of the following pieces of information should the nurse include?

Protein serves as an energy source when other sources are inadequate

A nurse is receiving intermittent feedings through an Ng tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take

Provide more water with feedings

A nurse is caring for a client in a long term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?

Reduced level of consciousness

A nurse us caring for a client who requires wrist restraints. Which if the following actions should the nurse take?

Remove restraints at least every 2 hours

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic enteral nutrition formula

A home health nurse is visiting an older client with severe dementia. The clients son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for hid mother at home. Which of the following options should the nurse suggest to the caregiver?

Respite Care

A nurse is performing a neurological assessment of a client, to promote safety during the examination l, the nurse stands nearby as the client follows the instructions for which of the following tests?

Romberg

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention?

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

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second Intercostal space to the right of the sternum

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting client with feeding?

Sit at the bedside while feeding the client

A nurse is caring for a client who has peripheral edema

Sodium

A nurse is caring for a client exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?

Sodium 123 meq/L

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room nurse discovers the client is unresponsive to verbal or painful stimuli, no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment, which of the following actions should the nurse take?

Support the clients decision

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self inject insulin . Which of the following statements should the nurse make?

Tell me what I can do to help you overcome your fear of giving yourself injections

A nurse is obtaining the vital signs of a 2 year old boy who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the childs temperature?

Temporal

A nurse is teaching range of motion exercises to a client who had osteoarthritis? Which of the following client positions demonstrates an understanding of supination of the hand

The client holds the hand with the palm up

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which if the following entries should the nurse enter into the clients medical record?

The client threw the medication on the floor

A hospice nurse is visiting with the family member of a client, the family member states that the client has insomnia almost nightly. Which if the following practices should the nurse identify as contributing to the clients insomnia?

The client watches television in her bed during the day

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the clients risk of developing complicated grief?

The death was sudden

A nurse is preparing to administer an intramuscular injection to a young adult client. Which if the following injection sites are safest for this client?

Ventrogluteal

A nursw is assessing client's repsiratory system. Which of the following breath sounds the nurse expect to hear over the periphery of the major lung fields

Vesicular

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh client on arising

A nurse is collecting a urine specimen for culture and sensitivity for a client who has urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

clamp tubing below the connection port

A charge nurse is teaching adult cardiopulmonary resuscitation to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR

confirm unresponsiveness

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

count apical pulse for 1 full min and describe rhythm in the heart

a nurse is peforming an otoscopic examination of a client's right ear. the light reflex is visible in the right lower quadrant tympanic membrane. Which of the following actions should the nurse take in response to this finding?

document this as an expected finding

A nurse is caring for a client who has the head of his bed elevated to a 45 angle. What position is this

fowlers

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

the client has slightly flexed elbows when ambulating with the crutches

A nurse observes an assitive personnel preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP

using a cuff that is too small will result in accurately high reading.

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

when lifting an object, spread your feet apart to provide wide base of support