N117 Exam 1 (Unit 1 - 7A)

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? "I'Il urinate a little then stop." "I'Il use the cleansing wipe from front to back." "I'Ill clean the inside of the container with a wipe." "I'll use each cleansing wipe twice."

"TIl use the cleansing wipe from front to back." The client should cleanse the perineal area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus.

A nurse is preparing a medication and calculates the dosage as 1.42 mL. Rounding this amount to he nearest tenth, the nurse should administer how many mL?

1.4 mL

A nurse is preparing to administer doxepin 75 mg PO at bedtime. Available is doxepin 50 mg tablets. How many tablets should the nurse administer?

1.5 tablets

A nurse is preparing to administer furosemide 60 mg PO daily. Available is furosemide 40 mg tablets. How many tablets should the nurse administer daily?

1.5 tablets

A nurse is preparing to administer ethosuximide 750 mg PO daily. Available is ethosuximide syrup 250mg/tsp. How many mL should the nurse administer

15 mL

A nurse is preparing to administer dextrose 5% in water 2 L to infuse over 6 hr. The nurse should administer how many mL?

2000 mL

A nurse is preparing to administer magnesium gluconate 270 mg PO. Available is magnesium gluconate liquid 54mg/5mL. how many mL should the nurse administer?

25 mL

A nurse is preparing to administer levothyroxine 0.075 mg PO to a client. Available is levothyroxine 25 mcg tablets. How many tablets should the nurse administer?

3 tablets

What is the daily recommended volume of fluid intake for a man?

3.7 L

A nurse is preparing to administer epinephrine hydrochloride 0.5 mg subcutaneous stat. How many mcg should the nurse administer?

500 mcg

A nurse is preparing a medication and calculates the dosage as 6.25 mL. Rounding this amount to the nearest tenth, the nurse should administer how many mL?

6.3 mL

enema insertion length for adult

7.5 cm to 10 cm (3 to 4 in)

A cleansing enema is prescribed for an adult patient before intestinal surgery. What is the maximum amount of fluid the nurse should give? 150-200 mL 200-400 mL 400-750 mL 750-1000 mL

750-1000 mL

A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? A. 8-year-old male: respiratory rate 34/min, SaO2 97% B. 16-year-old female: respiratory rate 18/min SaO2 98% C. 11-year-old male: respiratory rate 28/min, SaO2 99% D. 3-year-old female: respiratory rate 32/min, SaO2 96%

8-year-old male: respiratory rate 34/min, SaO2 97%

A nurse is preparing to administer fluoxetine 35 mg PO daily. Available is fluoxetine solution 20mg/5mL. How many mL should the nurse administer daily?

8.8 mL

The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? A) "Ask the patient not to eat, drink, or smoke for 15 minutes and then assess the patient's oral temperature." B) "Since the soup was not hot, go ahead and take the patient's temperature." C) "Change to the red thermometer probe and take the patient's temperature rectally." D) "Take the patient's temperature using the axillary route and when you record the reading, add 1°F."

A

A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering? a) nicotine product b) opioid antagonist c) antihypertensive d) bronchodilator

A bronchodilator

The nurse identifies that the use of a fracture pan for a bowel movement would be beneficial for which patient? A patient who is obese A patient experiencing confusion A patient on bed rest A patient recovering from a total hip replacement

A patient recovering from a total hip replacement

The nurse is reviewing medical records for assigned patients. Which patient should the nurse identify as being at the greatest risk for developing a pressure injury? A patient admitted to the obstetrical unit at 33 weeks' gestation and on bedrest A patient who is unable to transfer into and out of a wheelchair without assistance A patient who experienced a stroke 6 months ago and has residual left-sided weakness A patient admitted to the step down unit recovering from pneumonia

A patient who is unable to transfer into and out of a wheelchair without assistance

A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? (Select all that apply.) A. Provide the client with low-sodium meals and snacks .B. Encourage the client to participate in physical activity each day. C. Instruct the client in the use of relaxation techniques. D. Inform the client of the importance of abstaining from using products that contain nicotine. E. Encourage the client to increase their fluid intake to 2 L per day.

A, B, C, D

a nurse is preparing to administer an oral medication. Which of the following actions should the nurse take? (select all that apply) A. Provide client education about the medication. B. Check the expiration date of the medication. C. Verify the dosage of the medication.Call the client by name to confirm their identity. D. Ask the client if they have any allergies.

A. provide client education B. check expiration date C. verify dosage D. ask client if allergies

a nurse is assessing a client following administration of an antibiotic. The nurse should identify that which of the following findings is a manifestation of an anaphylactic reaction to the medication? A. Swollen lips B. Hypertension C. Low heart rate D. Constipation

A.Swollen lips

A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? A. Apex of the heart B. Right side of sternum C. 4th intercostal space D. Midclavicular line below right clavicle

Apex of the heart

A woman who is 26 weeks' gestation presents with a temperature of 93.9°F (34.4°C) and severe shivering. Which nursing intervention is the priority? Rapidly rewarm the affected areas in circulating warm water. Apply warming pads and begin fetal monitoring. Support respiratory and cardiac function. Place a hat on the patient's head.

Apply warming pads and begin fetal monitoring.

A nurse is assisting the health care provider assess a patient with altered urinary elimination. After assessing the patient, the health care provider suspects that the patient has an obstruction of the ureters. Which diagnostic test does the nurse expect the patient to undergo? Cystoscopy Abdominal roentgenogram Ultrasound of the urinary bladder Axial computed tomography scan

Axial computed tomography scan

If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? A) 37° C to 39° C B) 96.8° F to 100.4° F C) 96.8° F to 98.6° F D) 35° C to 36° C

B

Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, you should consider: A) Checking the carotid pulse. B) Using a stethoscope and assessing the quality of the apical pulse as well as the rate. C) Counting the pulse again for 30 seconds and multiplying the results by two. D) Checking the radial pulse on the opposite side.

B

You should routinely auscultate the apical pulse with the bell side of the stethoscope. A) True. B) False.

B

n which of the following patients would you expect to find a decrease in pulse rate? (Select all that apply.) A) A newborn. B) A patient returning from OR after having a hip replacement. C) A patient who received morphine for severe cancer pain. D) A student who is getting ready to take a final exam. E) A patient who had a bleeding episode.

B C

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching? a. "I should consume a diet high in carbohydrates." b. "I should increase my protein intake." c. "I should include fruit and vegetables with every meal." d. "I should avoid meat products."

B. "I should increase my protein intake."

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect? a. A red incision site with a small amount of exudate b. A bright pink incision site that is absent of exudate c. A pale pink incision site with moderate amounts of exudate d. A white or silver incision site with absent of exudate

B. A bright pink incision site that is absent of exudate

A nurse is caring for a client who is to receive topiramate XR 100 mg PO daily. The client tells the nurse that the capsule is too hard to swallow. Which of the following actions should the nurse take? A. Crush the contents of the capsule to administer in a small amount of pudding. B. Request extended-release sprinkles from the pharmacy. C. Ask the charge nurse to clarify the prescription with the provider. D. Withhold the medication until the time for the next dose.

B. Request extended-release sprinkles from the pharmacy

A nurse is preparing to administer glipizide 5 mg PO AC. At which of the following times should the nurse administer the medication?

Before meals

The nurse is caring for a patient who reports urine leakage with laughter and coughing. Which is an appropriate assessment for the nurse to perform? Bilateral strength the inner thigh muscles Bulging of the bladder into the vagina when bearing down Lung sounds Capillary refill

Bulging of the bladder into the vagina when bearing down

A 58-year-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient has undergone a small intestinal resection.

C

A patient tells the nurse, "My father had a severe fever from the anesthesia when he had surgery." Which diagnostic test should the nurse anticipate that the healthcare provider will order? Computed tomography Magnetic resonance imaging Complete blood count Caffeine halothane contracture test

Caffeine halothane contracture test

The nurse notes that the patient's indwelling catheter bag has been empty for 4 hours. Which action is priority? Irrigate the indwelling catheter. Check for kinks in the tubing. Notify the health care provider. Assess the patient's intake.

Check for kinks in the tubing.

The nurse reviews the types of radiological tests performed to assess the abdomen. The nurse identifies that the preparation for which procedure requires a dietary restriction? Select all that apply. Computed tomography scan without contrast Colonoscopy A plain film of the abdomen Ultrasound imaging Barium swallow

Computed tomography scan without contrast Colonoscopy Barium swallow

The nurse is assessing a patient who reports feeling weak after running outside in a temperature of 95°F (35°C). The nurse should monitor for which sign of heatstroke? Excitability Loss of sensation Pain Confusion

Confusion

An older adult was found unresponsive in the home. The heat was off and the environment was cold. The patient has cyanotic nail beds, a weak pulse, and slow capillary refill. Which finding should the nurse anticipate? Core body temperature 106.2°F (41.2°C) Core body temperature 98.6°F (37°C) Core body temperature 101.8°F (38.8°C) Core body temperature 82.6°F (28.1°C)

Core body temperature 82.6°F (28.1°C)

The nurse suspects that a patient has a bowel obstruction based on which assessment finding? Clay-colored stool; noxious change in the odor of the stool Low-pitched and hypoactive bowel sounds Cramping; absence of bowel movements Abdomen that is dull to percussion

Cramping; absence of bowel movements

The nurse notes that a patient's wound has purulent drainage and a foul odor. Which should the nurse expect to be prescribed first for this wound? Culture Antibiotic therapy Debridement Sterile dressings

Culture

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? Nephrosclerosis Uremia Diverticulitis Cystitis

Cystitis A sudden anset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult

A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity? a. Cellulitis b. Skin tears c. Premature wrinkling d. Dermatitis

Dermatitis

The nurse is caring for a patient diagnosed with urinary retention. Which medication on the patient's medical administration record should the nurse question? Bethanechol chloride Acetaminophen Ibuprofen Diphenhydramine hydrochloride

Diphenhydramine hydrochloride

A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse? A. Eupnea B. Dyspnea C. Heart rate of 84/min D. SaO2 of 96%

Dyspnea

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis? a. Hypertension b. Increased blood glucose c. Decreased WBC count d. Increased BUN

Increased blood glucose

An obese patient reports leaking urine while coughing. Which management strategy should be included in the patient's treatment plan? Select all that apply. Adequate fluid intake Kegel exercises Heavy weight lifting Weight control measures Caffeinated beverages

Kegel exercises Weight control measures

The nurse is supervising an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP? Determining a patient's hydration status Analyzing urine test results Evaluating color of urine Measuring intake and output

Measuring intake and output

A patient is scheduled for a plain film x-ray of the kidney, ureter, and bladder. Which preparation will be included on the patient's treatment plan? No preparation required Magnesium citrate bowel preparation Administration of a light sedative the night before the procedure Fasting after midnight

No preparation required

A patient experiences chronic constipation but has no other symptoms. The nurse anticipates the health care provider will prescribe which medication to provide relief for the condition? Castor oil Mineral oil Polycarbophil Docusate sodium

Polycarbophil

The nurse is caring for a patient who has severe hyperthermia and dehydration. Which diagnostic test should the nurse expect the healthcare provider to order? Platelets Clotting factors Thyroid function Renal function

Renal function

A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent? a. reservoir b. susceptible host c. portal of entry d. portal of exit

Reservoir

A patient needs a bowel preparation before a procedure. The nurse anticipates that which type of agent will be prescribed? Psyllium Polycarbophil Methyl cellulose Sodium phosphate

Sodium phosphate

The nurse notes in the medical record that the patient's incontinence is related to an overactive detrusor muscle. Which type of urinary incontinence should the nurse suspect the patient is experiencing? Stress Urge Overflow Functional

Urge

The labor and delivery nurse is caring for the postpartum mother. Which risk factor places the pregnant and postpartum female at an increased risk for urinary retention? Vaginal delivery Low birth weight Short course of anesthesia Use of analgesia

Use of analgesia

The nurse is looking for an effective strategy for eliminating inappropriate or unnecessary medical care. Which strategy should the nurse use? Utilization review Point of care Current procedural technology Risk management

Utilization review

A nurse is caring for a group of clients who are at risk for an alteration in urinary elimination. Which of the following groups should the nurse identify as being at an increased risk? (Select all that apply.) a. Uncircumcised infants b. School-age children c. Middle adults d. Older adults e. Young adults

a, b, d

nurse is preparing to insert an indwelling urinary catheter for a client. which of the following actions should the nurse instruct the client to perform during the insertion procedure? a. Bear down b. Take deep breaths c. Sip water d. Tighten the perineum

a, bear down

The nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for? a. hernia b. GERD c. crohn's disease d. ulcerative colitis

a, hernia

a nurse is reviewing a client's prescriptions. The nurse should contact the provider to clarify which of the following prescriptions? A) Ampicillin 100 mg/kg/day by mouth in 4 equally divided doses B) Phenytoin 300 mg by mouth every 12 hours C) Metronidazole 500 mg IV bolus every 6 hr D) Acetaminophen 325 mg every 6 hr PRN for headache

acetaminophen 325 mg every hr PRN for headache this prescription contains name of medication, dosage, frequency, and circumstance for administration, but not the route.

what are 5 bladder irritants

alcohol, acidic fruits, chocolate, soda, and spicy foods

A nurse is educating a client about a new temporary ileostomy. Which of the following statements by the client indicates an understanding of the teaching? a. "My ileostomy has an internal reservoir that collects waste." b. "My ileostomy is allowing my colon time to heal from the surgery." c. "My ileostomy must be accessed with a catheter to drain the waste." d. "My ileostomy is designed to be a permanent solution."

b, "My ileostomy is allowing my colon time to heal from the surgery."

client has stress incontinence. which finding should nurse expect? urine leakage... a. prior to reaching toilet b. following coughing c. as a result of nerve damage d. due to not reaching toilet in time from a physical impairment

b, after coughing

nurse is caring for a client who reports occasional dark, tea-colored urine. which of the following can contribute to this? a. attending a yoga class b. alcohol c. 2000 mL of fluid during day d. consuming fish for dinner

b, alcohol

A nurse is teaching a client about foods that can irritate the bladder. Which of the following statements by the client indicates an understanding of the teaching? a. "I will still be able to drink chocolate milk.' b. "I should avoid fruits that are acidic." c. "I will need to switch from regular soda to diet soda.' d. "I can still use jalapeno peppers when cooking."

b, avoid acidic fruit

A nurse is caring for a client who has a prescription for a vitamin K injection. The nurse should identify that vitamin K is naturally produced in which of the following locations in the body? a. small intestine b. large intestine c. esophagus d. stomach

b. large intestine

A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? a. 2.5 cm to 3.75 cm (1 to 1.5 in) b. 5 cm to 7.5 cm (2 to 3 in) c. 7.5 cm to 10 cm (3 to 4 in) d. 10 cm to 12.5 cm (4 to 5 in)

c, 7.5-10 cm (3-4 in)

nurse teaching new nurse about urinary retention. which client has increased risk for it? a. client w enlarged uterus b. client w frequent UTIs c. client w enlarged prostate d. client w chronic hypertension

c, client w enlarged prostate

nurse is evaluating a client's bladder treatment program. which of the following statements by the client indicates the bladder training was successful? a. "I'm having accidents daily" b. "I am voiding a small amount when I use the bathroom" c. "I use the bathroom every hour" d. "I am experiencing less than one urinary accident per week"

d, "I am experiencing less than one urinary accident per week"

nurse is providing perineal care for female client with indwelling urinary catheter. which area should nurse cleanse last? a. urethral meatus b. labia minora c. perineum d. anus

d, anus

a nurse is reviewing a client's prescriptions. The nurse should contact the provider to clarify which of the following prescriptions? A. Phenytoin 100 mg PO every 8 hr B. Morphine 2.5 mg IV bolus PRN for incisional pain C. Regular insulin 7 units subcutaneous 30 min before breakfast and dinner D. Lisinopril 20 mg PO every 12 hr. Hold for systolic BP less than 110 mm Hg

morphine 2.5 mg IV bolus PRN for incisional pain this prescription requires clarification because it is missing the frequency of medication administration

A nurse is preparing to administer acetaminophen 325 mg PO every 6 hr. Available is acetaminophen oral suspension 160mg/ 5mL. How many mL should the nurse administer

10 mL

A nurse is preparing to administer trazodone 25 mg PO at bedtime. Available is trazodone 50 mg tablets. How many tablets should the nurse administer per dose?

0.5 tablets

A nurse is preparing the administer cephalexin 500 mg PO every 6 hr. Available is cephalexin suspension 250mg/5mL. How many mL should the nurse administer per dose?

10 mL

A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria? 720 mL 550 mL 380 mL 600 ml

380 mL This urinary output indicates oliguria, which is defined as less than 400 mL of total output in 24 hr or less than 30 ml per hr.

Which adult body temperature should the nurse reassess and report to the healthcare provider? 37.5°C (99.5°F) 37°C (98.6°F) 36°C (96.8°F) 39°C (102.2°F)

39°C (102.2°F)

A nurse is preparing to administer hydromorphone 4 mg PO every 4 hr PRN for pain. Avaliable is hydromorphone oral liquid 1mg/1mL. How many mL should the nurse administer per dose?

4 ml

A nurse is preparing to administer amlodipine 10 mg PO once per day to a client. The amount available is amlodipine 2.5 mg/tablet. How many tablets should the nurse administer?

4 tablets

enema insertion length for child

5 cm to 7.5 cm (2 to 3 in)

A patient with head trauma has been admitted with hypothermia. Which observation should lead the nurse to expect hemodialysis will be ordered to treat this patient? Damage to the renal system Damage to the hypothalamus Damage to the vascular system Damage to the blood

Damage to the hypothalamus

The nurse should identify which risk factor as contributing to bowel incontinence? Damage to a nerve Ingestion of a high-residue diet Performing Kegel exercises Overeating at night

Damage to a nerve

A nurse is preparing to administer amoxicillin/clavulanate 250 mg PO to a client. Refer to the medication label below. How many mL should the nurse administer?

10 mL

A nurse is preparing to administer diphenhydramine 25 mg PO to a client. The amount available is diphenhydramine elixir 12.5mg/5mL. How many mL should the nurse administer?

10 mL

A nurse is preparing to administer furosemide 40 mg PO in 0.5 oz of orange juice. How many mL of orange juice should the nurse administer?

15 mL

A nurse is preparing to administer lamivudine 150 mg PO every 12 hr. Available is lamivudine oral solution 10mg/mL. How many mL?

15 mL

A patient at risk for a pressure injury responds to verbal commands, has no sensory deficits, has moist skin, ambulates occasionally, makes slight position changes, and eats approximately 50% of each meal. Which Braden scale score should the nurse identify for this patient? 16 6 21 12

16

A nurse is preparing to administer codeine 30 mg PO every 4 hr PRN for pain. The client last received the medication at 1 p.m. The earliest the nurse should administer the next dose is at which of the following times?

1700

A nurse is preparing to administer potassium chloride powder 20 mEq PO in 6 oz of water. How many mL of water should the nurse administer?

180 mL

A nurse is preparing to administer amoxicillin 500 mg PO every 8 hr. Available is amoxicillin oral suspension 250mg/5mL. How many tsp should the nurse give?

2 tsp

A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr. Available is diphenhydramine syrup 12.5mg/5mL. How many tsp should the nurse administer per dose?

2 tsp

Which statement by the nurse explains the difference between a pathogen and an opportunistic pathogen? "A pathogen causes disease in a susceptible individual, while an opportunistic pathogen causes disease in healthy individuals." "A pathogen does not pose a danger to the human body." "A pathogen causes disease in a healthy individual, whereas an opportunistic pathogen causes disease in susceptible individuals." "A true pathogen causes illness in those already sick."

"A pathogen causes disease in a healthy individual, whereas an opportunistic pathogen causes disease in susceptible individuals." Microorganisms vary in pathogenicity (ability to produce disease); thus, a pathogen is a microorganism that causes disease. Many microorganisms that are normally harmless can cause disease under certain circumstances. A "true" pathogen causes disease or infection in a healthy individual, whereas an opportunistic pathogen causes disease only in susceptible individuals. Microorganisms also vary in their virulence, or severity of the diseases they produce, and in their degree of communicability. For example, the common cold virus is more readily transmitted than the bacillus that causes leprosy.

A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching? - "The procedure will be cancelled if the urinalysis indicates the presence of red blood cells." - "High frequency sound waves will be used to identify renal system structures." - "You will be able to resume your regular diet as soon as the test is complete." - "After the procedure you will be encouraged to drink plenty of fluids."

"After the procedure you will be encouraged to drink plenty of fluids." The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure.

The nurse is describing the effects of using standardized patient teaching materials as part of the electronic health record (EHR). Which statement by the nurse is accurate? "Nurses using standardized materials do not have to review the content with the patient." "Allows patients in any healthcare setting to receive the same materials." "The materials should not use internet links to give additional information." "Most are in the dominant language of the geographical area."

"Allows patients in any healthcare setting to receive the same materials."

The nurse asks colleagues from other institutions for suggestions on how to use informatics to improve patient safety and incorporate nursing research at the point of care. Which suggestion by a colleague is appropriate? "Consider using clinical care classification." "Consider using perioperative nursing data sets." "Consider using a clinical decision support system." "Consider using current procedural technology."

"Consider using a clinical decision support system."

The patient has a wound that has been requiring frequent surgical debridement. Which patient statement indicates a correct understanding of the purpose of debridement? "Debridement reduces pain." "Debridement is a nonsterile procedure." "Debridement is done to remove dead skin." "Debridement is applying a sterile dressing."

"Debridement is done to remove dead skin." Wound irrigation and debridement are done to remove dead tissue, slough, and debris from the wound bed. Wound debridement is an important factor in the healing process, and after debridement a special dressing is applied to keep the site moist and ensure appropriate healing. Other surgical interventions, such as amputation of a toe or foot with gangrene, may be used, depending on the site of the infection. Debridement can sometimes be painful, so it should be done with extreme care. To avoid infection, it should be a sterile procedure.

The nurse reviews with a new graduate nurse the care of a patient on an active low-air-loss bed. Which statement by the graduate nurse indicates correct understanding of this patient's care? "This mattress requires the use of a petroleum ointment on bony prominences." "This device increases the risk of pneumonia, so the patient needs to sit up at least twice a day." "As long as the turning mechanism on the mattress is functioning properly, the mattress will automatically move the patient." "Despite the use of the special mattress, the patient needs to be repositioned every 2 hours."

"Despite the use of the special mattress, the patient needs to be repositioned every 2 hours."

The nurse is talking to a young child's grandmother, who can't remember whether she gave aspirin or acetaminophen when the child had a fever. Which is the best advice the nurse should give the grandmother for the future? "Write down the medication given as soon as possible." "Do not give aspirin to children with a fever." "Do not give acetaminophen to children with a fever." "Aspirin or acetaminophen work equally well for fevers."

"Do not give aspirin to children with a fever." Aspirin is not given to children with fevers because of the risk of Reye syndrome. Although recording the medication is important, this action is not as important as avoiding the 30% mortality rate of Reye syndrome. For that reason, aspirin or acetaminophen cannot be said to work equally well for fever. Acetaminophen can be given to children with a fever.

The nurse is teaching a patient measures to facilitate defecation. Which suggestion should the nurse include? "Drink a glass of warm water before breakfast." "Take a laxative if a bowel movement does not occur daily." "Consume up to 1000 mL of fluid per day." "Eat a pureed diet."

"Drink a glass of warm water before breakfast."

The nurse is planning a webinar about electronic medical records (EMRs). Which statement should the nurse include? "The EMR is also called the administrative information system." "EMRs are not useful in identifying the need for routine preventive maintenance." "Most EMRs are designed to be portable." "EMRs focus on diagnosis and treatment."

"EMRs focus on diagnosis and treatment."

Which nonpharmacologic information should the nurse include when preparing a teaching session for a patient with a history of constipation? "Take a bulk-forming laxative each morning." "Drink 3-4 glasses of fluid per day." "Eat raw fruits and vegetables." "Take a protein supplement daily."

"Eat raw fruits and vegetables."

The nurse is giving a presentation about the applications of geographic information system (GIS) technology. Which statement should the nurse include? "GIS technology can be used to plot and analyze lifestyle choices." "GIS technology is used strictly within the healthcare system." "GIS technology is not useful for tracking acute health problems." "GIS technology is not dependent on satellite imaging or global positioning systems."

"GIS technology can be used to plot and analyze lifestyle choices."

The nurse is developing a presentation about the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Which statement should the nurse include in the presentation? "Because of HIPAA, healthcare providers are able to correct the patient's health record." "HIPAA requires increased general access to the patient's health information in written, oral, or electronic form." "Because of HIPAA, patients are prohibited from accessing their personal medical records." "HIPAA requires organizations to notify patients how their information may be used or shared."

"HIPAA requires organizations to notify patients how their information may be used or shared."

A nurse is assessing the severity of a patient's urinary elimination problem. Which question is most appropriate for the nurse to ask? "Does your urinary problem restrict you from doing your usual activities?" "Do you dribble urine before voiding, after voiding, or at other times?" "Have you been hospitalized or have you received a diagnosis of a new medical problem recently?" "How often are you awakened with the urge to void while you are sleeping?"

"How often are you awakened with the urge to void while you are sleeping?"

A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? A. "Hypertension is diagnosed with two elevated measurements on two separate occasions." B. "Successive blood pressure measurements of 126 over 78 is classified as stage I hypertension." C. "Stage II hypertension is diagnosed when the blood pressure measurement is 132 over 86." D. "A blood pressure measurement of 176 over 102 is classified as a hypertensive crisis."

"Hypertension is diagnosed with two elevated measurements on two separate occasions."

The nurse is teaching a patient on the use of Kegel exercises for stress incontinence. Which patient statement indicates an understanding of the teaching provided? "I have practiced them and keep passing gas." "I am able to stop and start the urine stream." "I should do these no more than once a day." "I know they are working because my butt muscles are sore."

"I am able to stop and start the urine stream."

The nurse is teaching infection control to a patient with an open wound on their lower leg. Which patient statement would require additional teaching? "I can scratch my wound around the edge of my bandage if it itches." "I should wash my hands before eating." "I should avoid touching my eyes after applying a warm compress to the affected area." "I should wash my hands after toileting."

"I can scratch my wound around the edge of my bandage if it itches." It is important to reinforce the teaching to avoid touching the wound unless medically necessary. Washing hands before eating and after toileting is good hand hygiene and demonstrates understanding of infection control. Avoiding touching the eyes and other mucous membranes is also a proper infection control measure.

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? "I drink at least 2 quarts of fluid every day." "The last time I voided it was painful and red-tinged." "My period ended 2 days ago." "I don't eat shellfish because it gives me hives."

"I don't eat shellfish because it gives me hives." The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.

The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. Which statement by the patient indicates the need for further teaching? "I will perform my Kegel exercises every day." "I joined a weight loss program." "I drink two glasses of wine with dinner." "I have tried urinating every 3 hours."

"I drink two glasses of wine with dinner."

The nurse is evaluating the use of e-health in a group of patients. Which patient statement reflects an effective use of e-health? "I have started a diet that came highly recommended by a doctor who is on television." "I looked up my symptoms on a website and I think I know what medications I should take." "I got a Fitbit to help me monitor my physical activity and I'm up to 12,000 steps per day." "I use an accucheck device to monitor my blood glucose levels on a daily basis."

"I got a FitBit to help me monitor my physical activity and I'm up to 12,000 steps per day."

The nurse is providing discharge teaching to a patient diagnosed with urinary incontinence. Which patient statement indicates the need for further teaching regarding preventive methods for urinary incontinence? "I have begun a smoking-cessation program." "I drink six to eight 8-ounce glasses of water each day." "I have switched to a low-fiber diet." "I have decreased the amount of coffee I drink each day from eight cups to two."

"I have switched to a low-fiber diet."

The nurse provided teaching to a patient about the relationship between diarrhea and fecal impaction. Which patient statement indicates effective teaching? "I may be eating too much food at night, causing my feces to become liquid." "I may be eating too many fried foods that is causing my feces to be loose and liquid." "I may have a blockage in my rectum that only allows liquid feces to get through." "I may have a bowel infection that has caused my feces to be liquid."

"I may have a blockage in my rectum that only allows liquid feces to get through."

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? "I will wipe from the back to front with the cleansing cloth." "I should not collect a urine sample when I am menstruating." "I should let the urine cool to room temperature before sending it to the lab." "I need to urinate a small amount in the toilet before collecting the sample."

"I need to urinate a small amount in the toilet before collecting the sample." The client should begin the stream of urine in the toilet first, and then pass the container through the urine stream to obtain the sample. This action will wash off any bacteria at the distal urethra that could contaminate the sample.

The nurse is providing discharge teaching for a patient admitted for a back injury. The nurse instructs the patient on proper body mechanics for lifting. Which patient statement indicates that further teaching is needed? "I should stand with my feet apart with one foot slightly ahead of the other." "I should stand close to the object that I am lifting." "I should use my feet to pivot to move the object." "I should bend my back when I pick up an object."

"I should bend my back when I pick up an object."

The nurse taught a 65-year-old patient about interventions to prevent constipation. Which patient statement demonstrates that the teaching was effective? "I should not eat after 7 p.m." "I should avoid fruits high in sugar." "I should drink more fluids throughout the day." "I should continue to take a laxative for the next month."

"I should drink more fluids throughout the day."

The nurse provided teaching to the parents of a young child who was treated for febrile seizures. The nurse provided information on how to care for the child at home. Which statement by the parents indicates effective learning? "My child is not likely to have a second febrile seizure." "I should administer an antifever medication once my child's temperature goes above 101°F (38.33°C)." "I should implement seizure precautions as soon as my child's temperature starts to go up." "I need to bring my child into the emergency department as soon as the temperature is above 99°F (37.22°C)."

"I should implement seizure precautions as soon as my child's temperature starts to go up."

The nurse taught a patient on the use of Milk of Magnesia (MOM). Which patient statement demonstrates effective teaching? "I should drink no more than 4 glasses of water when taking MOM." "I should include MOM on my medicine list in case I am prescribed an antibiotic." "I can take MOM while I'm breastfeeding." "I can take MOM whenever I have constipation."

"I should include MOM on my medicine list in case I am prescribed an antibiotic."

The nurse teaches a patient with altered mobility about the importance of exercise. Which patient statement indicates that further teaching is necessary? "I should not exercise when I am on bedrest." "Exercise will prevent my muscles from becoming weak." "Exercise helps reduce the stiffness in my joints." "I should exercise to increase my endurance."

"I should not exercise when I am on bedrest."

The nurse is teaching a wife about contact precautions when changing a dressing on her husband after discharge. Which statement demonstrates that the wife understands the teaching? "I should wash my hands after removing the gloves." "I should wash my hands before putting on gloves and after removing them." "I should only wear the gloves when removing and discarding the old dressing." "I should use an alcohol-based cleanser before putting on gloves."

"I should wash my hands before putting on gloves and after removing them." Contact precautions are used for a patient who has or is suspected of having serious illnesses that are easily transmitted by direct patient contact or by contact with items in the patient's environment. Hand hygiene should be performed prior to donning gloves to protect the patient from any pathogens that may be on the caregiver's hands in case of a break in the barrier that could risk exposure to the patient. It should be performed after in case any small break in the gloves occurred and may have caused pathogens to come in contact with the caregiver's skin.

Which statement by a patient with an ileostomy indicates the need for additional teaching? "I'll change the pouch before it begins to leak." "I can eat dairy products after I recover from my surgery." "I won't drink too much so the amount of stool is less." "I won't need to buy new clothing that better accommodates the pouch."

"I won't drink too much so the amount of stool is less."

A nurse is educating a patient who has altered urinary elimination on how to maintain a healthy bladder. Which statement by a patient indicates a need for further education? Select all that apply. "I'll drink 6-8 glasses of water a day." "I'll avoid drinking beverages that contain caffeine." "I'll avoid drinking fluids 4 hours before bedtime to decrease nocturia." "I'll immediately tell my doctor if I experience pain when voiding." "After each voiding and bowel movement, I'll cleanse my perineum from back to front."

"I'll avoid drinking fluids 4 hours before bedtime to decrease nocturia." "After each voiding and bowel movement, I'll cleanse my perineum from back to front."

The nurse is teaching a new parent about how to protect their infant from hypothermia. Which statement by the parent indicates that further teaching is needed? "If my baby feels cool, I will place a hat on their head." "I will make sure I keep my baby warm and dry at all times." "If my baby feels cool, I will wrap them in a warm blanket." "If my baby feels cool, I'll place them in direct sunlight with as much skin exposed as possible."

"If my baby feels cool, I'll place them in direct sunlight with as much skin exposed as possible."

The nurse is teaching the family of a patient with an alteration of mobility how to protect the patient from injury. Which instruction about the patient's environment is appropriate for the nurse to include? "Keep the lights turned down low." "Avoid helping the patient do things they can do for themselves." "Encourage the patient to learn something new." "Watch for slip hazards like loose carpets on the floor."

"Watch for slip hazards like loose carpets on the floor."

A pregnant patient asks the nurse, "Is there anything I can do to help with my fecal incontinence?" Which response by the nurse is most accurate? "We can discuss utilizing an exercise bike." "We can discuss the benefit of dietary changes." "We can discuss the changes caused by prenatal vitamins." "We can discuss the benefit of Kegel exercises."

"We can discuss the benefit of Kegel exercises."

The nurse is caring for an older adult patient in a long-term care setting. The patient's family states, "With our mother's recent memory lapses, we are concerned about her recent urinary accidents." Which statement by the nurse best addresses the patient's risk for urinary incontinence? "We can insert a urinary catheter." "There are medications we can give your mother." "We can get your mother a wheeled walker to help in getting to the bathroom." "We can institute scheduled toileting for your mother."

"We can institute scheduled toileting for your mother."

The family of a patient with limited mobility asks, "Why is our father not moving now? He moved well before." Which response from the nurse addresses the most likely cause of the patient's limited mobility? "Your father may have limited mobility because he is depressed." "Your father's inability to hear well may be limiting his mobility." "Your father's limited mobility is likely due to pain." "Your father's reduced flexibility is the likely cause of his limited mobility."

"Your father's limited mobility is likely due to pain."

A patient who is prescribed larval therapy for a chronic pressure injury asks why this treatment is being used. Which response should the nurse make to this patient? "Your pressure injury should have healed by now, and the maggots are the fastest method for treating a pressure injury." "Your ulcer has bacterial growth, and the maggots will decrease the amount of bacteria." "Your pressure injury will be less painful because the maggots secrete an enzyme." "Your ulcer needs to drain, and the maggots will help drain it."

"Your ulcer has bacterial growth, and the maggots will decrease the amount of bacteria."

A nurse is preparing to administer cephalexin 0.25 g PO every 6 hr. Available is cephalexin 500 mg tablets. How many tablets should the nurse administer per dose?

0.5 tablet

A nurse is preparing a medication and calculates the dosage as 0.893 mL. Rounding this amount to the nearest hundredth, the nurse should administer how many mL?

0.89 mL

The nurse is caring for a patient who is diagnosed with diabetes mellitus. Which evaluation statement should indicate that the plan of care is working? 04/03/2018, 1800: Goal partially met: Patient is able to identify three foods instead of five foods high in sugar content. 04/03/2018: Goal unmet: Patient demonstrates use of insulin injection successfully. 04/03/2018, 1750: Goal met: Patient voices understanding of treatment therapy. 04/03/2018, 1830: Goal partially met: Patient demonstrates use of home oxygen machine.

04/03/2018, 1800: Goal partially met: Patient is able to identify three foods instead of five foods high in sugar content.

A nurse is preparing to administer codeine oral solution 30 mg PO to a client. The amount available is codeine 10mg/5mL. How many Tbsp should the nurse administer?

1 Tbsp

A nurse is preparing to administer sucralfate 1 g PO twice daily to a client. Available is sucralfate 1,000 mg tablets. How many tablets should the nurse administer per dose?

1 tablet

A nurse is preparing to administer erythromycin ethylsuccinate 800 mg PO every 12 hr. Available is erythromycin ethylsuccinate suspension 400mg/5mL. How many mL should the nurse administer per dose?

10 mL

A nurse is preparing to administer potassium chloride 15 mEq PO every 12 hr. Available is potassium chloride liquid 20 mEq/15 mL. How many mL should the nurse administer per dose?

11mL

A 55-year old man is admitted to the hospital with urinary retention. The health care provider prescribes catheterization for the patient. When setting up the supplies for catheterization would the nurse select for this patient? 8 Fr 10 Fr 14 Fr 18 Fr

14 Fr

A nurse is preparing to administer doxycycline 100 mg PO every 12 hr. Available is doxycycline 50 mg tablets. How many tablets should the nurse give?

2 tablets

A nurse is preparing to administer quinapril 40 mg PO daily. Available is quinapril 20 mg tablets. How many tablets should the nurse administer daily?

2 tablets

A nurse is preparing to administer triazolam 0.25 mg PO. Available is triazolam 0.125 mg tablets. How many tablets should the nurse administer per dose?

2 tablets

A nurse is preparing to administer 0.9% sodium chloride 2,500 mL to infuse over 12 hr. The nurse should administer how many L?

2.5 L

enema insertion length for infant

2.5 cm to 3.75 cm (1 to 1.5 in)

What is the daily recommended volume of fluid intake for a woman?

2.7 L

The nurse is scheduling the lab technician to draw an antibiotic peak and trough level for a patient receiving an intravenous antibiotic. At which time should the nurse schedule the peak level? 1-2 hours after administration 15 minutes prior to administration of the next dose 1 hour prior to the next dose 30 minutes after administration

30 minutes after administration By measuring blood levels at the predicted peak (1-2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough (lowest level, usually a few minutes before the next scheduled dose), healthcare personnel can determine whether the patient is maintaining a level within the therapeutic range at all times, thereby ensuring maximal effect from the drug.

Your newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? A) Temporal artery B) Tympanic C) Chemical dot D) Rectal electronic

A

A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first? A. A 45-year-old client who is postoperative and has a BP of 130/82 mm Hg B. A 28-year-old client who runs marathons and has a heart rate of 54/min C. A 52-year-old client who has an SaO2 of 92% D. A 78-year-old client who has a temperature of 35.9°C (96.6°F)

A 52-year-old client who has an SaO2 of 92%

The nurse discusses scoliosis with a group of parents of school-age children. The nurse includes degrees of curvature of the spine in the discussion. Which curvature of the spine should the nurse include as being severe? A curve that affects other organs A curve between 20 and 40 degrees A curve 40 degrees or greater A curve greater than 100 degrees

A curve 40 degrees or greater

Which patient with urinary incontinence would benefit most from using a bedpan and elevating the head of the bed? A patient with a wheeled walker A patient who is pregnant A patient who is bedridden A patient with multiple sclerosis

A patient who is bedridden

Which patient would the nurse anticipate to require the use of a short or long-term urinary catheter? Select all that apply. A patient who has chronic urinary retention A patient who has reflex urinary incontinence A patient who has stress urinary incontinence A patient who needs accurate monitoring of urine output after a gynecological procedure A patient who is unable to completely empty the bladder because of a neurological condition

A patient who needs accurate monitoring of urine output after a gynecological procedure A patient who is unable to completely empty the bladder because of a neurological condition

The nurse is reviewing the plan of care for a patient who is ready for discharge. Which is an application of decision support that can be utilized in the home care setting? A home health nurse contacting a provider to report a change in patient assessment A patient's electronic health record issuing an alert when a patient's vital signs are out of normal range A home health nurse's notes being printed out and delivered to the provider's office A patient keeping a daily log of blood glucose levels

A patient's electronic health record issuing an alert when a patient's vital signs are out of normal range

A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include? A. A pulse strength of +4 indicates that the pulse is of normal strength upon palpation. B. A femoral pulse that is bounding upon palpation is an expected finding in a young adult. C. A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. D. A pedal pulse that is weak upon palpation is an expected finding in an older adult.

A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation.

A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention? A. An adolescent who has a respiratory rate of 20/min B. An older adult who has a respiratory rate of 16/min C. An infant who has a respiratory rate of 52/min D. A school-age child who has a respiratory rate of 14/min

A school-age child who has a respiratory rate of 14/min

A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include? A. Wait 5 min after a client has consumed a hot drink to obtain an oral temperature. B. Place a tape or patch thermometer over a client's spatula. C. A tympanic thermometer reflects a client's body surface temperature. D. A temporal probe thermometer uses infrared scanning to determine a client's temperature.

A temporal probe thermometer uses infrared scanning to determine a client's temperature.

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? A. Move their leg behind their body. B. Move their leg forward and up. C. Move their leg medially toward their other leg. D. Turn their foot and leg away from their other leg.

A. Move their leg behind their body. Rationale: This movement demonstrates hyperextension of the hip. B. flexion C. adduction D. external rotation

A nurse is caring for a client who received lisinopril 30 min ago and is now reporting dizziness and headache. Which of the following actions should the nurse take first? A. Obtain the client's vital signs. B. Notify the provider. C. Document the client's response in the medical record. D. Tell the client to change positions slowly.

A. Obtain the client's vital signs

A nurse on a medical unit is assisting with the orientation of a newly licensed nurse. The nurse should remine them to have a second nurse review the dosage of which of the following medications prior to administration? A. Heparin B. Acetaminophen C. Acetylcysteine D. Hydroxychloroquine

A. heparin high-alert medications

a nurse is preparing to administer digoxin 225 mcg for a pediatric client who has a heart rate above 90/min. Which of the following actions should the nurse take to ensure administration of the right dose? (select all that apply) A. Validate that the dosage is within the safe range. B. Confirm the medication amount is appropriate for the child. C. Verify that the medication is not expired. D. Check the client's heart rate prior to administration. E. Document the administration in the medication administration record.

A. validate that the doge is within the safe range B. confirm the medication amount is appropriate for the child

A patient in the third trimester of pregnancy has a fever caused by an infected hand wound. Which collaborative intervention should the nurse expect to implement? Administering naproxen Administering ibuprofen Administering acetylsalicylic acid Administering acetaminophen

Administering acetaminophen

An adult presents with severe heatstroke and hyperthermia. Which collaborative intervention should the nurse expect to implement to prevent renal failure in this patient? Inserting an indwelling catheter Administering intravenous fluids Monitoring BUN and creatinine Assessing body temperature hourly

Administering intravenous fluids

The nurse is presenting issues related to alterations in mobility with a group of community members. Which major risk factor should the nurse include? Gender Genetics Aging Fluid level

Aging

A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? A. An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. B. A school-age child who received two units of packed red blood cells now has a BP of 76/54 mm Hg. C. A toddler who received an antibiotic injection now has a heart rate of 148/min while sleeping in their parent's arms. D. An older adult client who received an antipyretic medication 1 hr ago now has a temperature of 38.7° C (101.6° F).

An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min.

Which condition should the nurse recognize as a cause of fecal incontinence? Irregular defecation habits Irritable bowel syndrome Anorectal injury Gastrointestinal reflux disease

Anorectal injury

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include? a. use a brush to scrub the surface of the hands b. rinse the solution from the hands before it dries c. apply chlorhexidine and ethanol to the hands d. leave jewelry on the hands when cleansing them

Apply chlorhexidine and ethanol to the hands.

The nurse assesses a 55-year-old patient as part of a routine physical. The nurse instructs the patient to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT) based on which criterion? If patient reports rectal bleeding If there is a family history of polyps As part of a routine examination for colon cancer If a palpable mass is detected on digital examination

As part of a routine examination for colon cancer

The nurse is formulating a plan of care for a pregnant patient. One goal set by the nurse is that the patient should attend all prenatal classes. Which step should the nurse take to motivate the patient to attain the goal? Inform the patient that insurance will not pay for the hospital stay for nonattendance at prenatal classes. Tell the patient that it is in her best interest to attend classes. Associate the goal with a personal meaning for the patient. Attend the classes with the patient to ensure compliance.

Associate the goal with a personal meaning for the patient.

Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

B

You are supposed to take your patient's vital signs preoperatively and record them on the patient's record as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) A) To see if the patient is "feeling funny." B) To provide a set of vital signs to use for comparison during and after surgery. C) To make sure the patient is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention at this time. D) To provide the patient with reassurance that he or she is being cared for by a competent staff.

B C

Which of the following patients would you suspect would be at risk for having an alteration in peripheral pulse? (Select all that apply.) A) a 76-year-old with diabetes who is otherwise healthy. B) A patient who was just informed of a diagnosis of cancer. C) A patient with peripheral vascular disease. D) A patient who is receiving bolus IV fluids. E) A patient with Alzheimer's disease.

B C D

A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which information should be provided to the NAP delegated to take her temperature? (Select all that apply.) A) The patient's age. B) The type of temperature required. C) The patient's diagnosis. D) The frequency for taking or monitoring the temperature. E) What changes to report immediately to you, the physician, or their delegate.

B D E

a nurse is transcribing medication prescriptions for a group of clients. Which of the following is the appropriate way for the nurse to record medications that require the use of a decimal point? A. .4 mL B. 0.6 mL C. 8.0 mL D. 125.0 mL

B) 0.6 mL

Which assessment finding should the nurse note in a patient diagnosed with urinary incontinence? Bladder bulging Hypoactive bowel sounds Use of alternative therapies Enlarged prostate

Bladder bulging

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? Pernicious anemia Dehydration Prostate enlargement Bladder infection

Bladder infection The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.

What is the normal pulse range for an adult? A) 120 to 160 beats per minute. B) 90 to 140 beats per minute. C) 60 to 100 beats per minute. D) 50 to 80 beats per minute.

C

Which of the following patients would require follow-up? A) A child with a respiratory rate of 24 breaths per minute. B) An adolescent with a respiratory rate of 16 breaths per minute. C) An adult with a respiratory rate of 10 breaths per minute. D) A newborn with a respiratory rate of 50 breaths per minute.

C

a nurse is providing teaching regarding medication administration to a group of newly licensed nurses. Which of the following is a legal responsibility of the nurse? A. Prescribing the correct dosage B. Modifying the medication regimen C. Reporting medication errors D. Delegating administration to assistive personnel

C. Reporting medication errors

The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met? Collect data related to patient-specific outcomes for accrediting bodies. Collect data related to the goal and make decisions about nursing care effectiveness. Collect data to develop new nursing diagnoses for the home health nurse to follow. Collect data to provide discharge instructions to follow when at home.

Collect data related to the goal and make decisions about nursing care effectiveness.

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? Urinary retention Low back pain Incontinence Confusion

Confusion Confusion is a clinical finding of UTis specifically associated with older adult clients.

A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions? a. protective b. contact c. droplet d. airborne

Contact

A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following precautions should the nurse plan to implement? a. protective b. contact c. standard d. airborne

Contact (and Droplet)

The nurse is conducting a health history on a patient diagnosed with a spinal cord injury. Which data is most appropriate for the nurse to collect? Current medications Vital signs Bowel sounds Spinal reflexes

Current medications

Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

D-assess for shock

A patient presents with a 5-day history of diarrhea. The patient states "I initially experienced nausea and vomiting that lasted 24 hours." For which additional symptom does the nurse assess to determine the plan of care? Select all that apply. Bradycardia Dizziness Dry skin Peripheral edema Dark-colored urine

Dizziness Dry skin Dark-colored urine

The nurse states, "Informatics can provide a global overview of a patient's health, encompassing multiple clinicians and disciplines. Further, it can provide a means of communication about the care of the particular patient." The nurse is referring to which type of informatics? Discharge database Electronic health records (EHRs) Statewide prescription tracking system Electronic medical records (EMRs)

Electronic health records (EHRs)

The nurse is caring for a bedbound female patient. Which intervention should the nurse implement to support voiding and avoid urine retention in the female patient? Providing a urinal Elevating the head of the bed Remaining at the bedside during voiding Cooling the bedpan

Elevating the head of the bed

A 70-year-old woman complains about involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when she coughs. The nursing assessment reveals that the patient is obese, has had 3 pregnancies, and has already gone through menopause. The nurse understands that the patient is at an increased risk of developing a urinary tract infection. Which nursing intervention can help prevent a urinary tract infection in the patient? Select all that apply. Emphasize reduced fluid intake. Emphasize wearing cotton underwear. Emphasize the need for continuous bladder catheterization. Promote complete emptying of bladder by double voiding. Emphasize the importance of perineal hygiene.

Emphasize wearing cotton underwear. Promote complete emptying of bladder by double voiding. Emphasize the importance of perineal hygiene.

The nurse analyzes the characteristics of a patient's feces and identifies that which substance indicates and abnormality? Select all that apply. Excess fat Blood Mucus Bile pigment Dead bacteria

Excess fat Blood Mucus

The nurse is caring for a patient who performs self-catheterization for urinary retention. Which assessment finding indicates a potential complication related to the care of this patient? Intake of 3 L of fluids per day Complete emptying of bladder Increased intake of caffeine Fever

Fever

A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include? A. Fever can increase a client's respiratory rate. B. Opioid analgesics can increase a client's respiratory rate. C. Pain can decrease a client's respiratory rate. D. Anxiety can decrease a client's respiratory rate.

Fever can increase a client's respiratory rate.

The nurse is listing examples of e-health. Which examples should the nurse include? Teleneurology, teleradiology, remote access to specialties Electronic health records, medical history, family history Automated input of data into a medical record, trending vital signs Fitbit, Map-My-Walk, Healthgrades

Fitbit, Map-My-Walk, Healthgrades

The nurse assesses a patient diagnosed with an alteration in mobility. Which assessment finding should the nurse determine as not related to immobility? Atelectasis Pneumonia Pressure injury on the coccyx Increased gastrointestinal motility

Increased gastrointestinal motility

A patient presents to the nurse with complaints of urine leakage with constipation. Which dietary change should the nurse advise to the patient to help diminish urinary incontinence? Increasing fiber Increasing caffeine Increasing alcohol Increasing spicy food

Increasing fiber

A child presents to the clinic with a fever of 38.4°C (101.1°F). The nurse should suspect which condition as being the most likely cause of the child's fever? Dehydration Overactivity Sunburn Infection

Infection

A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan? Instruct the client to take antibiotics until dysuria is no longer present. Instruct the client to avoid drinking carbonated beverages. Instruct the client to drink 240 mL of tomato juice each day. Instruct the client to drink 1 Lof fluid each day.

Instruct the client to avoid drinking carbonated beverages. The nurse should instruct the client to avoid drinking carbonated beverages and caffeine to reduce bladder irritation.

A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take? A. Instruct the client to bear down like they are having a bowel movement. B. Offer the client hot caffeinated tea to drink early in the morning. C. Hold the client's thyroid medication. D. Encourage the client to take a warm shower.

Instruct the client to bear down like they are having a bowel movement.

When mucus is noted in a patient's feces, the nurse suspects which cause? Constipation Intestinal infection Increased peristalsis Malabsorption of fat

Intestinal infection

A patient is being assessed for a possible urinary tract infection (UTI). Before sending a urinalysis specimen to the laboratory, the nurse collects a small amount of urine to perform a dipstick test. If the patient has a UTI, which component should be detected in the urine? Protein Glucose Ketones Leukocytes

Leukocytes

Which data is the least important for the nurse to document after re-evaluating an existing pressure injury? Color of the wound bed Signs of infection Location in relation to bony prominences Level of mobility

Level of mobility

The nurse is assessing a patient who was found sleeping in a park in the snow. The nurse should ask the patient about which risk factor? Skin disorders Living situation Trauma Educational level

Living situation

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine? Pale pink Bright yellow Bright red Dark amber

Pale pink The client should expect to pass some small clots and tissue in his urine for few a days, which may give the urine a pale pink color. By 2 to 3 days after surgery, around the time of discharge, his urine should be clear yellow.

The nurse comes upon an older adult patient outside their home who has collapsed, is not wearing a coat, and feels cool to the touch. The temperature outside is cool with a chilly breeze. Which is the priority intervention for the nurse? Place a warm towel or warm plastic bottle on the patient's trunk. Apply hand warmers to the patient's hands and arms. Place a hat on the patient's head. Begin cardiopulmonary resuscitation (CPR) immediately.

Place a warm towel or warm plastic bottle on the patient's trunk.

A nurse is assessing a 3-month-old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? A. Count the number of beats heard in 15 seconds and multiply by 4. B. Notify the provider if the apical pulse rate is greater than 110/min. C. Place the stethoscope over the 4th intercostal space to the left of the sternum. D. Palpate the infant's sternum for the presence of a murmur.

Place the stethoscope over the 4th intercostal space to the left of the sternum.

When caring for patients of varying ages with disorders of bowel elimination, which information does the nurse consider? Adolescents have a decreased metabolic rate. The ability to control defecation is absent until 2 to 3 years of age. Peristalsis is enhanced and esophageal emptying is accelerated in older adults. Infants have little secretion of digestive enzymes and slow intestinal peristalsis.

The ability to control defecation is absent until 2 to 3 years of age.

A patient with impaired mobility has been prescribed axillary crutches. The nurse teaches the patient crutch walking. Which part of the body should the nurse instruct the patient to use for bearing weight when using the crutches? The wrists The axillae The fingertips The legs

The wrists

The nurse is caring for a pregnant patient who reports feeling constipated and burning upon urination. Which condition should the nurse suspect as the cause? Bladder infection Urinary tract infection Hormonal shift from the pregnancy Sexually transmitted infection

Urinary tract infection

nurse is administering a return-flow enema to a client. after instilling 100 mL of enema fluid, which of the following actions should the nurse take? a. Instruct the client to retain the fluid. b. Lower the container to allow the solution to flow back out. c. Help the client to the toilet or bedside commode d. Wait 5 min and instill another 100 mL of fluid

b, lower container so fluid can flow back out

The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? "A nursing diagnosis is developed after the nurse evaluates the interventions provided." "A nursing diagnosis is derived after the nurse develops the plan of care for the patient." "A nursing diagnosis is based on clinical judgment that is derived from assessment data." "A nursing diagnosis is determined by the medical diagnosis and current patient needs."

"A nursing diagnosis is based on clinical judgment that is derived from assessment data."

A nurse is preparing to administer methylprednisolone 4 mg PO daily. Available is methylprednisolone 8 mg tablets. How many tablets should the nurse administer daily?

0.5 tablets

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) "Your provider might prescribe anticholinergic medications." "You should limit fluids in the evening." "You should restrict your intake of caffeine." "You might require intermittent urinary catheterization." "You might require an anterior vaginal repair."

"Your provider might prescribe anticholinergic medications" Anticholinergic medications suppress bladder contractions and increase bladder capacity. "You should limit fluids in the evening" . Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. "You should restrict your intake of caffeine" The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant.

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching? a. "Your staples will dissolve in about 4 weeks." b. "You will need to be placed under general anesthesia for the staples to be removed." c. "Staples are unlikely to become embedded in the skin, making removal simple." d. "Your staples will be removed in about 2 weeks."

"Your staples will be removed in about 2 weeks."

A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client? - "If the medicine causes an upset stomach, take an antacid at the same time." - "Limit your daily fluid intake while taking this medication." - "This medication can cause photophobia, so be sure to wear sunglasses outdoors." - "You should report any tendon discomfort you experience while taking this medication,"

- "You should report any tendon discomfort you experience while taking this medication," The nurse should instruct the client to report any tendon discomfort as well as swelling or inflammation of the tendons due to the risk of tendon rupture.

Identify the factors that may have an effect on an 82 year old patient's temperature.

-drinking a cold glass of water -participation of strenuous physical therapy exercises -infection -room temperature

A nurse is preparing to administer famotidine 20 mg PO every 12 hr. Available is famotidine 40 mg tablets. How many tablets should the nurse administer per dose?

0.5 tablets

A nurse is preparing to administer gabapentin 1,800 mg per day divided in three equal doses. The amount available is gabapentin 300 mg capsules. How many capsules should the nurse administer per dose?

2 capsules

The nurse is assigned to care for four patients today. Which patient is at highest risk for developing acute urinary retention? A 20-year-old female with infertility A 28-year-old female one day postpartum A 50-year-old female with ovarian cancer A 60-year-old female with mastitis

A 28-year-old female one day postpartum

A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up? A. A client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position. B. A client has a radial pulse of +4 bilateral. C. An older adult client has a tympanic temperature of 35.9° C (96.6° F). D. A newborn has a respiratory rate of 56/min while sleeping.

A client has a radial pulse of +4 bilateral.

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? a. "You should shift your weight off your buttocks at intervals throughout the day." b. "You should be sure your legs are placed on the floor prior to transferring." c. "Position yourself in the back of the wheelchair after transferring." d. "Lock your brakes when you are sitting in the wheelchair."

A. "You should shift your weight off your buttocks at intervals throughout the day."

A nurse is administrating medications to four clients. The nurse should identify which of the following nursing actions as a part of the evaluation phase of the nursing process? A. Collecting information about a client's pain level following administration of a narcotic B. Taking the blood pressure of a client before administering an antihypertensive medication C. Lowering the level of a client's bed before administering a benzodiazepine medication D. Instructing a client to rinse their mouth following administration of an inhalation corticosteroid

A. collecting information about a client's pain level following administration of a narcotic

Why do you take BP in both arms on a "new" patient? A) To practice your technique. B) To ensure that you obtain an accurate BP reading. C) Because there is always a difference in dominant and nondominant hands, and it is good to know what that is. D) To assess for a pulse deficit.

B

Which complications may result from a patient who regularly ingests castor oil to relieve constipation? Select all that apply. Abdominal cramping Constipation Fluid and electrolyte imbalance Damage to the intestinal mucosa Toxic buildup of magnesium

Abdominal cramping Fluid and electrolyte imbalance

An older adult patient presents with mild hypothermia and has been initially treated with blankets and forced warm air. Which intervention should the nurse expect to implement next? Massage the patient's extremities. Administer whirlpool therapy. Encourage the patient to ambulate. Administer warm IV fluids.

Administer warm IV fluids.

The nurse is planning care for a patient with hypothermia. Which independent nursing intervention is appropriate? Obtain the blood glucose level. Administer warm oral fluids. Administer warm IV fluids. Order a social worker referral.

Administer warm oral fluids.

The nurse is planning care for a patient who has a fever and dry mucous membranes. Which intervention should the nurse include in the plan of care? Keeping the air conditioner on in the room Changing the bed linens frequently Administering lip balm for lubrication Inserting an indwelling urinary catheter

Administering lip balm for lubrication

A nurse is providing discharge teaching to a client who will be performing intermittent self-catheterization. Which of the following instructions should the nurse include? Use sterile technique during the insertion procedure. Inflate the catheter balloon with 20 mL of sterile water. Advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow. Use water to lubricate the catheter tip prior to inserting it.

Advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow. The nurse should instruct the client to advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow to make sure that it is completely in the bladder.

A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves? a. after donning a gown and before collecting vital signs on the client b. after removing food items off the clients tray and before removing soiled linens from the clients bed c. after helping the client stand up and before helping them brush their teeth d. after changing a dressing on the client and before documenting findings on a computer

After changing a dressing on the client and before documenting findings on a computer

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission? a. airborne b. droplet c. direct contact d. indirect contact

Airborne

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask? a. protective isolation b. contact c. droplet d. airborne

Airborne

A patient has a pressure injury with deep exudate. Which dressing should the nurse use because it forms a gel when in contact with wound exudate? Alginate Hydrofiber Hydrocolloid Proteolytic enzymes

Alginate

The patient is incontinent, and a condom catheter is placed. The nurse should take which action? Secure the condom with adhesive tape Change the condom every 48 hours Assess the patient for skin irritation Use sterile technique for placement

Assess the patient for skin irritation

The nurse is caring for a patient who wears a brace on their right ankle. Which action should the nurse take first? Assess the right foot for impaired sensation. Assess the right foot for redness. Remove the brace when the patient uses the bathroom. Wash and dry the area covered by the brace.

Assess the right foot for impaired sensation.

An unresponsive patient is brought into the emergency department after being found outside in the cold. Which is the priority intervention by the nurse? Applying warming blankets Hanging warmed intravenous fluids Assessing respiratory status, oxygenation, and perfusion Assessing the patient's skin for frostbite

Assessing respiratory status, oxygenation, and perfusion

a nurse is preparing to administer a time-critical medication to a client at 0800. Which of the following times are appropriate for the nurse to administer the medication (select all that apply) A) 0700 B) 0745 C) 0830 D) 0845 E) 0900

B) 0745 C) 0830 within 30 minutes of critical time

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention? a. "This type of healing carries a lower risk of infection than others." b. "This type of healing begins in the wound bed with the generation of granulation tissue." c. "These would heal faster than those that heal by other processes." d. "These wounds require a dry wound bed in order to healing to occur."

B. "This type of healing begins in the wound bed with the generation of granulation tissue."

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take? a. Obtain the culture using a clean cotton applicator b. Clean the wound with 0.9% sodium chloride c. Collect drainage from the area surrounding the wound d. Place the applicator in a dry vial until cultures are complete

B. Clean the wound with 0.9% sodium chloride.

A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection? a. incubation b. convalescence c. acute infection d. prodromal

B. Convalescence

A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete? A.Radial pulse regular at 84/min B. Respirations observed as even, nonlabored at 20/min with client in supine position C. BP 124/82 mm Hg, lying in bed D. Temporal temperature 36.9° C (98.4° F)

BP 124/82 mm Hg, lying in bed

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger? a. burn b. frostbite c. bacteria d. radiation

Bacteria

The nurse is reviewing a list of patients who are all at risk for a pressure injury. Which patient should the nurse identify that would benefit the most from a kinetic bed? A patient admitted to the obstetrical unit on bedrest A patient with left-sided weakness following a stroke Bedridden patient with limited mobility A patient with paraplegia confined to a wheelchair

Bedridden patient with limited mobility

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests? a. c-reactive protein b. troponin c. creatine kinase d. lactic acid

C-reactive protein

A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? A. "The first step in checking for orthostatic hypotension is obtaining a client's blood pressure while they are standing." B. "An increase of 5 millimeters of mercury in the diastolic pressure with a position change indicates orthostatic hypotension." C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension." D. "Wait 5 minutes to check the client's blood pressure after each position change."

C. "A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension."

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? A. "Lean on the crutches to support your body weight when standing." B. "Fully extend your arms when holding onto the hand grips." C. "Hold the crutches on your unaffected side when preparing to sit in a chair." D. "Hold the crutches 9 inches in front of and to the side of each foot."

C. "Hold the crutches on your unaffected side when preparing to sit in a chair." Rationale: The crutches should be held on the unaffected side when preparing to sit in a chair. Incorrect rationale: - crutches should be fitted so the client's arms are flexed ~ 30° at elbows when holding onto hand grips. - crutches should be held 6 inches in front of & to side of each foot to assist w/ balance

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information? a. "I should expect a small separation along the incision line." b. "If I feel like something popped, I should sit up in bed." c. "I should report pain at my wound site." d. "Recurrent vomiting is expected after surgery."

C. "I should report pain at my wound site."

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound? a. Hydrofiber b. Alginate c. Hydrogel d. Transparent film

C. Hydrogel

The nurse is caring for a patient with urinary incontinence. Which action would the nurse perform to promote comfort for the patient? Select all that apply. Change dressings & linens when wet. Limit fluid intake. Use absorbent pads. Increase coffee intake. Catheterize the patient.

Change dressings & linens when wet. Use absorbent pads. Catheterize the patient.

The nurse is caring for a patient with urinary incontinence. Which action would the nurse perform to promote comfort for the patient? Select all that apply. Change dressings and linens when wet Limit fluid intake Use absorbent pads Increase coffee intake Catheterize the patient

Change dressings and linens when wet Use absorbent pads Catheterize the patient

The nurse is caring for a patient in a long-term care facility who has not had a bowel movement in 5 days. The unlicensed assistive personnel reports that the patient is passing a very small amount of liquid stool. Which should be the nurse's first action? Check the patient for an impaction. Advise the healthcare provider of the situation. Document the findings. Administer a prescribed laxative.

Check the patient for an impaction.

A patient who has had a hip replacement is being discharged. The electronic health record (EHR) safety alert indicates that the patient has need of services or equipment after discharge. Which informatics function does this observation describe? Telehealth Device integration Order management Clinical decision support

Clinical decision support

An elderly African American patient reports a change in bowel habits with rectal bleeding and a sense of incomplete bowel evacuation. Which disorder would the nurse suspect in this patient? Infection Colorectal cancer Irritable bowel syndrome Inflammatory bowel disease

Colorectal cancer

A patient with a stage 3 pressure injury reports pain at the site which has developed a yellow-white exudate on the wound bed. Which laboratory test should the nurse anticipate being prescribed? Hemoglobin and hematocrit Arteral blood gas (ABG) Serum protein Complete blood count

Complete blood count

A 12-month-old infant has a temperature of 102.4°F (39.1°C). Which diagnostic test should the nurse anticipate the healthcare provider to order Genetic testing Computed tomography of the head Complete blood count with differential Magnetic resonance imaging

Complete blood count with differential

The nurse is assessing an older adult patient who was outside in 100°F (37.78°C) weather. Which finding indicates that the patient may be experiencing heatstroke? Pain Hypertension Confusion Ruddy complexion

Confusion

A 60-year-old patient presents with multiple episodes of fecal incontinence over the past week. Which condition should the nurse consider related to decreased muscle tone and rectal sensation? Excessive eating Limited mobility Dehydration Constipation

Constipation

a nurse is teaching a newly licensed nurse about crushing medications. The nurse should explain that which of the following medication can be crushed? A. Extended-release oxycodone B.Sublingual nitroglycerine C. Enteric-coated aspirin D. Sucralfate tablets

D. sucralfate tablets

A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching? a. "Pressure injury documentation includes the location, stage, measurement, and condition of the wound bed and any drainage present." b. "Drainage from a pressure injury only needs to be documented if a foul oder is present." c. "If the pressure injury is healing as expected, documentation can be completed with every other dressing change." d. "Pressure injuries found on the mucous membranes should be documented as stage 1 pressure injuries."

D. "Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present."

A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? a. "Skin changes cause the synthesis of vitamin B to decrease with age." b. "The layer of skin becomes detached with age." c. "Older adults clients have more mositiue in the skin, placing them at risk for maceration." d. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

D. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing? a. "The dressing will need to be changed every 24 hours." b. "This type of dressing is used in small wonder with small amounts of drainage." c. "This dressing may develop a foul-smelling, yellow, gelatinous film on its underside as bacteria are trapped." d. "This type of dressing will need a secondary dressing for reinforcement."

D. "This type of dressing will need a secondary dressing for reinforcement."

A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition? A. Decrease in contractility B. Increase in blood viscosity C. Decrease in respiratory rate D. Increase in preload

Decrease in contractility

The nurse is caring for an older adult patient with delayed wound healing. Which dermal change should the nurse associate with this finding? Decreased epidermal thickness Decreased vitamin D production Redistribution of adipose tissue Increased skin permeability

Decreased epidermal thickness

Which laboratory test result should indicate to the nurse that the patient requires vitamin D supplements? Presence of human leukocyte antigen-B27 (HLA-B27) Decreased phosphorous Decreased creatine kinase Increased uric acid

Decreased phosphorous

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications? a. Dehiscence b. Evisceration c. Hematoma d. Fistula

Dehiscence

How would the nurse position a female patient for examining the genitalia for inflammation and infection related to urinary elimination problems? Supine Fowler's Squatting Dorsal recumbent

Dorsal recumbent

The nurse is providing care to a patient diagnosed with urinary urgency. The healthcare provider prescribes an anticholinergic medication to increase bladder capacity and inhibit bladder contractions for the patient. Which finding would alert the nurse to an adverse effect resulting from the anticholinergics? Diarrhea Dry mouth Increased urinary output Decrease in blood pressure

Dry mouth

An infant has a temperature of 101.9°F (38.8°C) and is listless, fatigued, and eating poorly. Which blood test should the nurse anticipate the healthcare provider to order? Electrolyte levels Liver enzymes Renal function testing Albumin level

Electrolyte levels

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take? a. Decrease the drainage suction force b. Place the bulb on a flat surface and measure the amount of drainage c. Empty and measure the drainage d. Kink the tubing to precept further drainage

Empty and measure the drainage.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections, Which of the following actions shouid the nurse include in the client's plan of care? Cleanse the perineum from back to front. Obtain a prescription for an indwelling urinary catheter. Encourage fluid intake at and between meals. Offer the client the bedpan every 2 hr.

Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital- acquired) UTI is reduced, even for a client who has a spinal cord injury.

A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take? A.Encourage the client to change positions slowly. B. Restrict the client's oral intake of fluids .C. Encourage the client to take a short walk. D. Discontinue IV fluids.

Encourage the client to change positions slowly.

The nurse observes the presence of a tympanic note when percussing the abdomen of a patient and suspects which cause? Gas Fluid Tumor Thick pus

Gas

The nurse is conducting a teaching session regarding significant potential barriers to telehealth. Which factor should the nurse include? Access to care Cost of services Healthcare quality Healthcare provider licensure

Healthcare provider licensure

An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to: Help him stand to void. Place a condom catheter. Have him practice the Credé method. Initiate Kegel exercises.

Help him stand to void.

A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect A. Increase in blood pressure B. Increase in respiratory rate C. Decrease in cardiac output D. Decrease in preload

Increase in blood pressure

An older adult patient tells the nurse that they are always cold. The nurse understands that which physiological change is the cause of this patient's discomfort? Less efficient thermoregulation An increase in subcutaneous fat A high-fat, high-protein diet Presence of brown adipose tissue and fat

Less efficient thermoregulation

A 4-month-old infant presents with a respiratory infection and a fever of 40.5°C (104.9°F). The nurse notices that the infant is sweating and breathing faster. Which finding is most important to note in the assessment? Lethargy Nasal congestion Difficulty nursing Positive Babinski sign

Lethargy

A patient who is scheduled for surgery tells the nurse, "I do not respond well to anesthesia and get really hot." Which action should the nurse take first? Review the patient's white blood cell count. Notify the surgeon. Suggest that the surgery be cancelled at this time. Document the comment in the medical record.

Notify the surgeon.

A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? A. Oxygen saturation is determined by the amount of oxygen bound to white blood cells. B. Oxygen saturation reflects the amount of oxygen being delivered to body tissues. C. The expected reference range for oxygen saturation is 90% to 100%. D. A capillary refill time is less than 5 seconds ensures a reliable oxygen saturation measurement.

Oxygen saturation reflects the amount of oxygen being delivered to body tissues.

The nurse is caring for a patient with limited mobility. Which action should the nurse take to prevent a skin injury caused by friction? Avoiding use of a draw sheet when repositioning the patient Placing the patient in the prone position Sprinkling baby powder on the sheets to keep the skin dry Elevating the head of the bed to a 60-degree angle

Placing the patient in the prone position

The nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. Which phase of the nursing process will the nurse use to develop interventions? Implementation Planning Nursing diagnosis Assessment

Planning

The nurse assesses a patient and finds a temperature of 38.3°C (101°F). The patient does not report feeling warm or cold. In which phase of the fever should the nurse suspect the patient to be in? Plateau Chill Flush Resolution

Plateau

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include? a. empty sharps containers when they become full b. report needlestick injuries to the nursing supervisor c. engage the safety device on a needle after documenting the medication administration d. recap needles after the medication administration

Report needlestick injuries to the nursing supervisor.

The nurse preceptor is reviewing the plan of care for a patient with urinary incontinence created by a graduate nurse. Which dietary intervention submitted by the graduate nurse should the preceptor correct? Restricting fluid intake Altering nutrition to maintain a healthy weight Avoiding bladder irritants Promoting a diet that is high in fiber

Restricting fluid intake

The nurse is evaluating the current plan of care for a patient who is receiving care in a long-term healthcare facility. The evaluation indicates that the patient is not meeting goals related to mobility. Which is an appropriate nursing action at this time? Determining that the patient does not have any risk factors Concluding that the problem is resolved Revising the plan of care Asking the patient to try harder

Revising the plan of care

The nurse notes that a patient has shearing tissue damage on the skin over their back. Which reason should the nurse consider as the cause of the injury? External pressure on bony prominences for more than 2 hours Shearing forces as a result of the patient sliding down in the bed and being pulled back up Shearing forces that interrupt blood flow in capillary beds, resulting in tissue ischemia External pressure that tears and damages blood vessels

Shearing forces as a result of the patient sliding down in the bed and being pulled back up

The nurse is reviewing options for preventing pressure injuries with a patient at high risk for skin breakdown. Which support surface should the nurse instruct the patient to avoid? Supportive backboard Kinetic bed Foam overlay mattress High-air-loss bed

Supportive backboard

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? Perform catheterization when you recognize the urge to void. Hold the penis at a 30° to 45° angle when inserting the catheter. The client should Inflate the balloon when the urine flow stops. Use soap and water to wash the catheter after each use.

Use soap and water to wash the catheter after each use. The client should wash the catheter using soap and water and store it in a clean container after each use.

The nurse is planning interventions for a patient with a nursing diagnosis of Activity Intolerance related to weakness, as evidenced by inability to walk two steps. Which part of the nursing diagnosis statement is used as the framework for planning nursing interventions? Inability to walk two steps Previous health history Weakness Activity Intolerance

Weakness

nurse is preparing male for urinary catheterization. which action should nurse take? a. grasp penis at base b. lift penis perpendicular to body c. hold penis parallel to body d. lift penis to 45º angle to body

b, perpendicular

nurse is reviewing the primary function of the urinary tract with a group of newly licensed nurses. which of the following information should the nurse include? Also, are these all functions of urinary tract? a. The urinary tract regulates the production of red blood cells. b. The urinary tract produces hormones for blood pressure regulation. c. The urinary tract keeps bones strong. d. The urinary tract eliminates waste and excess fluid from the body.

d, eliminates waste and excess fluid; yes, all are functions of urinary tract

A nurse is educating a client who has paraplegia about urinary catheter use. Which of the following catheter types should the nurse include in the teaching to help facilitate urinary elimination for this client? a. Suprapubic catheter b. Indwelling catheter c. Condom catheter d. Intermittent catheter

d, intermittent catheter

what position for enema in adult? a. prone b. dorsal recumbent c. right lateral with both knees at chest d. left lateral with right leg flexed

d, left lateral w right leg flexed

A nurse is preparing to administer albuterol 4 mg PO every 6 hr. Available is albuterol syrup 2 mg/ 5 mL. How many mL should the nurse administer per dose?

10 mL

The nurse caring for an older patient who is becoming increasing immobile teaches the family caregiver how about preventing pressure injuries. Which statement from the family members should indicate to the nurse that teaching was effective? "We will help the patient to move at least every 4 hours." "We will monitor the diet to ensure adequate daily intake of proteins and calories." "We will use an alcohol-based sanitizer to clean the skin after incidences of incontinence." "We will massage the bony prominences daily."

"We will monitor the diet to ensure adequate daily intake of proteins and calories."

During an assessment, the nurse notices skin excoriation around a ring on the patient's finger. Which question should the nurse ask this patient? "Have you made any changes to your diet recently?" "How often is your skin exposed to direct sunlight?" "When did you start to see this problem?" "Are you experiencing any associated symptoms, such as itching?"

"When did you start to see this problem?"

A nurse is preparing to administer methadone 2.5 mg PO every 8 hr. Available is methadone 5 mg tablets. How many tablets should the nurse administer per dose?

0.5 tablets

A nurse is preparing to administer lithium 600 mg PO every 8 hr. Available is lithium carbonate 300 mg capsules. How many capsules should the nurse administer?

2 capsules

A nurse is preparing to administer digoxin 250 mcg PO daily. Available is digoxin 0.125 mg tablets. How many tablets should the nurse administer?

2 tablets

A nurse is preparing to administer zolpidem 10 mg PO at bedtime. Available is zolpidem 5 mg tablets. How many tablets should the nurse administer per dose?

2 tablets

A nurse is preparing to administer rifampin 0.6 g PO daily. Available is rifampin 150 mg capsules. How many capsules should the nurse administer?

4 capsules

A nurse is preparing to administer 650 mg of acetaminophen syrup to a client. The amount available is acetaminophen syrup 160mg/5mL. How many tsp should the nurse administer per dose?

4 tsp

Which patient should the nurse identify as having the greatest risk for hypothermia? A 45-year-old A 3-day-old infant A 3-year-old A 15-year-old

A 3-day-old infant

Identify the factors that may have an effect on an 82-year-old patient's temperature: (Select all that apply.) A) Drinking a cold glass of water. B) Participation in strenuous physical therapy exercises. C) Infection. D) Room temperature. E) Patient's body weight.

A B C D

The nurse is working at a summer camp when the heat index is predicted to be over 100°F (37.8°C). Which child should remain indoors? A child with cerebral palsy A child with a fractured arm A child with seasonal allergies A child with asthma

A child with asthma

A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? A. An infant who has an apical pulse rate of 132/min B. A preschooler who has an apical pulse rate of 108/min C. A young adult who has an apical pulse rate of 104/min D. An older adult who has an apical pulse rate of 96/min

A young adult who has an apical pulse rate of 104/min

A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective? a) an older adult client who has pneumonia and a RR of 26/min after a position change b) an adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesics c) a young adult who is experiencing an asthma attack and has a BP of 116/72 mm Hg after using an inhaler d) an older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques

A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? a. A client who has a Braden Scale score of 9 b. A client who has a Braden Scale score of 23 c. A client who has a Braden Scale score of 12 d. A client who has a Braden Scale score of 15

A. A client who has a Braden Scale score of 9

A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective? (Select all that apply.) A. A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min B. An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min C. A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg D. A toddler who was febrile 2 hr ago due to a viral infection and has a temporal temperature of 38.2° C (100.8° F)E. An adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min

A. A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min B. An older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min C. A young adult who had hypotension after receiving an opioid analgesic and now has a blood pressure of 98/68 mm Hg

A nurse is teaching a class about error - prone abbreviations in medication prescriptions. The nurse should include that which of the following prescriptions has acceptable abbreviations? A. Metoclopramide 10 mg IM Q6H PRN nausea B. Desipramine 100 mg PO QD C. Enoxaparin 30 mg sub q 2 hr before surgery D. MSO4 10 mg IM Q3H PRN pain

A. Metoclopramide 10 mg IM Q6H PRN nausea

The nurse determines the following nursing diagnosis for a patient: Impaired Urinary Elimination related to retention secondary to enlarged prostate. Which portion represents Axis 3 in the nursing diagnosis? Urinary Retention Enlarged prostate Impaired

Impaired

The nurse is caring for a 17-year-old patient with hypothermia and frostbite who spent the night outside in the elements after passing out from binge drinking. The nurse should recognize that which process increased the risk of hypothermia for this patient? Alcohol increases the viscosity of the blood, increasing the risk of ice crystals. Alcohol increases the intracellular sodium content, lowering the freezing point of the tissues. Alcohol causes peripheral vasoconstriction, causing decreased blood flow to the extremities. Alcohol causes peripheral vasodilation, causing a faster drop in body temperature.

Alcohol causes peripheral vasodilation, causing a faster drop in body temperature.

Which intervention does the nurse include in the bowel-training program for a patient with chronic constipation secondary to cognitive impairment? Using a diet that is low in bulk Allowing ample time for evacuation Decreasing fluid intake to 1000 mL/day Administering an enema once a day to stimulate peristalsis

Allowing ample time for evacuation

After reviewing a patient's laboratory reports, the nurse suspects the patient has pancreatitis based on increased levels of which component? Bilirubin Amylase Alkaline phosphatase Carcinoembryonic antigen

Amylase

A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? A. A 17-year-old who has a respiratory rate of 16/min B. A young adult who has a pulse rate of 98/min C. An 11-year-old child who has a respiratory rate of 34/min D. An older adult who has a pulse rate of 62/min

An 11-year-old child who has a respiratory rate of 34/min

A patient with a body temperature of 39.0°C (102.2°F) asks the nurse, "Can you do something about my mouth being so dry?" Which intervention should the nurse implement to maximize the patient's comfort? Assisting the patient in performing oral hygiene Giving the patient lemon glycerin swabs to swab lips Suggesting that the healthcare provider order a fluid restriction Allowing the patient to go outside to smoke once per shift

Assessing the patient in performing oral hygiene

A nurse is preparing to administer medication to a client who has a prescription for docusate sodium 50 mg capsule PO twice daily. The client refuses to take the medication because of nausea. Which of the following actions should the nurse take? A. Administer a docusate sodium capsule rectally. B. Withhold the medication. C. Administer 100 mg docusate sodium with the next scheduled administration. D. Encourage the client to take the medication as the provider prescribed.

B. Withhold the medication

A nurse is preparing to administer insulin subcutaneously to a client. The nurse should document the administration of the medication immediately after which of the following actions? A. Taking the insulin from the automated dispensing machine B. Injecting the insulin C. Checking the client's blood glucose level D. Checking the correct dosage of the insulin

B. injecting the insulin

The nurse is reviewing a list of patients who are all at risk for a pressure injury. Which patient should the nurse identify that would benefit the most from a kinetic bed? Bedridden patient with limited mobility A patient with left-sided weakness following a stroke YOU WERE SURE AND INCORRECT A patient with paraplegia confined to a wheelchair A patient admitted to the obstetrical unit on bedrest

Bedridden patient with limited mobility

The nurse is caring for a patient with a suspicious lesion. For which test should the nurse prepare teaching for this patient? Biopsy IgE antibody test Tzanck test Intradermal test

Biopsy

A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include? A. Diastolic blood pressure reflects the pressure exerted during contraction of the heart. B. Blood pressure is measured and documented in millimeters of mercury. C. Blood pressure decreases when the blood viscosity increases. D. Systolic blood pressure reflects the pressure when the heart is relaxed.

Blood pressure is measured and documented in millimeters of mercury

Which assessment finding that increases a patient's risk for impaired tissue perfusion should the nurse identify? Mechanical devices used for transfer Body Position Poor nutrition Increased mobility

Body position

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? A. Positioning the chair slightly behind the nurse so that the seat faces the client's bed B. Placing the client's left leg in front of the right leg just prior to the transfer C. Aligning the nurse's knees with the client's knees just before the transfer D. Grasping the client under the axillae to assist them to their feet

C. Aligning the nurse's knees with the client's knees just before the transfer. Rationale: This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position.

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take? a. Ask the client to bear down and cough b. Ask another nurse to bring icepacks to apply to the wound c. Cover the client's wound with sterile saline dressing d. Place the client in high-Fowler's position

C. Cover the client's wound with a sterile saline dressing.

a charge nurse is reviewing the types of prescriptions with a newly licensed nurse. Which of the following prescriptions should the nurse include as an example of a standing prescription? A. Oxycodone 5 mg by mouth every 4 hr as needed for pain B. Furosemide 20 mg IV stat C. Acetaminophen 650 mg by mouth every 6 hr for temperature greater than 38.4° C (101.2° F) D. Diazepam 10 mg IV 30 min prior to procedure

C. acetaminophen 650 mg by mouth every 6 hr for temperature greater than 38.4 c (101.2 F)

a nurse discovers a medication error in which the client received twice the prescribed amount of medication. Which of the following actions should the nurse take first? A. Notify the provider. B. Complete an incident report. C. Assess the client. D. Report the error to the nurse manager.

C. assess the client

The nurse notes that a patient has a rash and areas of inflammation on the skin. Which should the nurse consider as the reason for this skin change? Immobility Poor nutrition Poor tissue perfusion Immune response

Immune response

Which bowel elimination problem is most likely the result of improper diet, reduced fluid intake, and lack of exercise? Diarrhea Flatulence Constipation Incontinence

Constipation

The nurse is caring for a patient diagnosed with hypothermia. Which assessment finding should the nurse expect? Bounding pulse Flushed skin Cyanotic nail beds Capillary refill of 2 seconds or less

Cyanotic nail beds

For which patient would a tympanic thermometer be the preferred thermometer to use? A) A marathon runner who developed weakness during the race. B) A newborn in the intensive care unit who requires continuous temperature monitoring. C) A child who had tubes surgically placed in the ears. D) A tachypneic patient who is receiving oxygen by nasal cannula.

D

a nurse is transcribing a provider's prescription for a client. The prescription reads morphine 2 mg IV bolus at 1400. The nurse should recognize this as which of the following types of medication orders? A. Routine order B. Stat order C. PRN order D. Single order

D. single order

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor? COPD Diabetes mellitus Anemia Osteoporosis

Diabetes mellitus Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.

A patient presents with abdominal pain, history of chronic constipation, and possible fecal impaction. Which diagnostic test should the nurse anticipate will be ordered? Digital rectal examination (DRE) Abdominal ultrasound Upper endoscopy Chest x-ray

Digital rectal examination (DRE)

Which collaborative therapy should the nurse expect to be utilized in the management of a fecal impaction? Digital removal of the impaction Saline enemas Intake of high-residue foods with decreased fluids Intake of cold drinks, especially before the usual time of defecation

Digital removal of the impaction

A patient recovering from a foot wound is resting comfortably in bed. During the last vital signs assessment, the patient's temperature was 37.5°C (101.7°F). Which action should the nurse implement? Document the assessment results. Provide a cooling blanket. Give the patient a tepid sponge bath. Apply an ice pack to the groin.

Document the assessment results.

How would the nurse position a female patient for examining the genitalia for inflammation and infection related to urinary elimination problems? Supine Fowler's Squatting Dorsal recumbent

Dorsal recumbent

A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? Urge incontinence Dribbling of urine Weight gain Rectal distention

Dribbling of urine Dribbling of urine, or overflow incontinence, is an indicator of bladder distention. The nurse should perform intermittent catheterization when this occurs to prevent bladder trauma or infection. A regular schedule to drain the flaccid bladder should be established, with no longer than 8 hr. between catheterizations.

The nurse is teaching a patient on how to prevent fluid imbalance while experiencing an elevated temperature. Which instruction should the nurse include in the teaching? Ingest at least 1 L of hot fluids each day. Wear sufficient clothing to encourage sweating. Drink at least 2 L of cool fluids each day. Take a hot shower after spending time outdoors.

Drink at least 2 L of cool fluids each day.

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? a. direct contact b. droplet c. airborne d. indirect contact

Droplet

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take? Assist the client to the bathroom every 2 hr. Restrict oral fluid intake during waking hours. Encourage the client to hold her breath when feeling the urge to urinate. Provide adult diapers until bladder retraining is successful.

Encourage the client to hold her breath when feeling the urge to urinate. The nurse should encourage the client to take deep, slow breaths to help diminish the urge to urinate.

A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first? a. mask b. gloves c. goggles d. face shield

Gloves

A patient with impaired mobility needs assistance with completing activities of daily living (ADLs). The nurse should request a referral for which collaborative rehabilitation service? Physical therapy Speech therapy Occupational therapy Music therapy

Occupational therapy

A nurse should use which units when measuring weight?

Gram

A patient reports abdominal cramping, pain, and constipation. Which question should the nurse ask the patient during the health history? "Are you taking protein supplements?" "Are you taking anything for your allergies?" "Are you taking any pain medication?" "Are you eating a diet high in fats?"

"Are you taking any pain medication?"

he nurse provided discharge teaching to a patient with frostbite of their nose. Which patient response indicates the teaching was successful? "I will rub the skin of my nose with a washcloth daily." "I will not touch my nose until it is fully healed." "I will gently message my nose several times a day." "If blisters occur, I will keep them covered with a bandage."

"I will not touch my nose until it is fully healed."

Which health promotion instruction should the nurse give a patient regarding constipation? "Monitor bowel habits." "Limit exercise." "Follow a low-fiber diet." "Increase potassium intake."

"Monitor bowel habits."

A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching? "You should limit fluids for 12 hr following the procedure." "You may have pink-tinged urine after this procedure." "You can eat a full liquid meal up to 1 hour before the procedure." "You will be placed on your right side during the procedure."

"You may have pink-tinged urine after this procedure." The client might have blood-tinged, or pink, urine after the procedure. The client should report dark red urine because it is an indication of bleeding.

The parents of a child with a fever call the nurse and report purple spots on the child's extremities. Which response by the nurse is appropriate? "You should bring the child to the emergency department for evaluation." "Give your child aspirin as directed on the bottle for the fever symptoms." "Those spots will go away in a few days after the fever subsides." "Come see the healthcare provider if the fever lasts 4 or more days."

"You should bring the child to the emergency department for evaluation."

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Perform hand hygiene Place package on work surface. Open outermost flap away from self, Open innermost flap toward self. Open side flap, pulling to the side. Use inner surface of package as sterile field.

- perform hand hygiene - place package on work surface - open outermost flap away from self - side flaps moving to the side - open the innermost flap, toward self - use innermost surface of package as sterile field

A nurse is preparing a medication and calculates the dosage as 0.547 mL. Rounding this amount to the nearest hundredth, the nurse should administer how many mL?

0.55 mL

The nurse is caring for an older adult patient who requires an assistive device for ambulation. Which device should the nurse recommend for the patient? Cane Crutches Wheelchair Walker

Walker

You are validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? A) When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. B) When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. C) When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. D) After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing.

A

A nurse is reviewing the vital signs of four clients. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range? A. A 52-year-old client who has a fever due to a wound infection and a pulse rate of 100/min B. A 76-year-old client who reports moderate pain and has a respiratory rate of 20/min C. A 46-year-old client who is postoperative following a hysterectomy and has an SaO2 of 95% D. A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg

A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg

A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention? a) a 1 month old infant who has a RR of 58/min b) a 3 year old preschooler who has an apical pulse of 144/min c) an 8 year old child who has a RR of 25/min d) an 18 month old toddler who has an apical pulse rate of 120/min

A 3-year-old preschooler who has an apical pulse rate of 144/min

Which patient is most likely to exhibit symptoms such as dysuria, urgency, frequency, and nocturia? A patient with kidney failure A patient receiving diuretic therapy A patient with a urinary tract infection A patient with uncontrolled diabetes mellitus

A patient with a urinary tract infection

a charge nurse is teaching a newly licensed nurse about medication reconciliation. Which of the following information should the charge nurse include in the teaching? A) Perform medication reconciliation daily during a client's hospitalization. B) Only newly prescribed medications need to be reviewed during a medication reconciliation. C) Vitamins, supplements, and over-the-counter (OTC) medications should be included in a medication reconciliation. D) The goal of medication reconciliation is to minimize the financial impact of prescription medications to the client.

C) Vitamins, supplements, and OTC medications should be included in a medication reconciliation

The nurse is caring for a newly admitted patient. Which skills should the nurse use to build rapport and trust with the patient? Cognitive Interpersonal Multidisciplinary Technical

Interpersonal

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? a. open the first flap on the sterile package away from their body b. place objects on the sterile field at least 1.3cm (0.5in) from the edge c. unwrap both sides of the sterile package at the same time d. set up the sterile field next to a wall in the clients room

Open the first flap on the sterile package away from their body.

The nurse presents genetic factors that might affect mobility to a community group. Which genetic factor listed by a community member should lead the nurse to provide further teaching? Muscular dystrophy Marfan syndrome Sickle cell disease Amyotrophic lateral sclerosis

Sickle cell disease

A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse? A. The AP uses a cuff width that is 40% of the circumference of the client's arm. B. The AP provides support for the client's arm while taking the BP. C. The AP waits to take the client's BP 45 min after the client ambulates in the hallway. D. The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.

The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second.

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? a. The AP places the client in high-Fowler's position b. The AP places pillow under the client's lower extremities c. The AP feeds the client 80% of each meal d. The AP cleans and tires the client's perineum after each episode of incontinence

The AP places the client in high-Fowler's position.

The nurse caring for a 6-year-old patient suspects that the child's intravenous (IV) site may be infected. Which clinical manifestation would support the nurse's finding? The IV site is warm and puffy. The IV site is cool to the touch. The IV site is red and painful. The IV tape is lifted on one side.

The IV site is red and painful. An IV site that is red and painful may be infected. The nurse should mark the redness near the IV site to make sure it does not extend beyond the initial assessment. If further redness is noted, the healthcare provider should be notified. If an IV site is warm and puffy, the line may be infiltrated and need adjustments. An IV site that is cool to the touch is not an indication of possible infection. Lifted tape puts the site at risk for infection.

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include? a. the door to the AIIR should remain closed b. clients who are on contact precautions require AIIR c. an AIIR has at least 4 air exchanges each hr. d. a mask is not needed to care for clients who are in an AIIR

The door to the AIIR should remain closed.

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? The nurse separates the client's labia with her dominant hand. The nurse coats the indwelling urinary catheter with lubricant. The nurse provides perineal care prior to inserting the urinary catheter. The nurse applies the sterile drape prior to inserting the urinary catheter.

The nurse separates the client's labia with her dominant hand. The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.

The nurse is talking with a hospitalized older adult patient who reports "feeling chilly." The nurse suggests walking in the halls. What is the nurse's rationale for making the suggestion? Walking can distract the patient from their discomfort. The hallways are warmer than the patient's room. Walking uses the muscles, which produces heat and can help to warm the patient. Walking helps to strengthen muscles, which, over time, will increase thermoregulation.

Walking uses the muscles, which produces heat and can help to warm the patient.

A patient presents with superficial frostbite on the nose, ears, and hands. Which assessment finding should the nurse consider consistent with superficial frostbite? Presence of gangrene Stiffness of affected areas White appearance of affected areas Yellow appearance of affected areas

White appearance of affected areas

nurse assessing catheter and finds it in place and functioning properly. nurse should expect what finding? a. dark yellow, cloudy urine b. pale yellow, clear urine c. urine w strong odor d. urine w slight red tint

b, pale yellow, clear urine

nurse is caring for a client who has a history of IBS and reports last bowel. movement (BM) was 5 days ago. this is an example of which of the following elimination patterns? a. encopresis b. diarrhea c. fecal incontinence d. constipation

d, constipation

nurse caring for older adult client with urinary leakage. what age-related change can cause this a. reduced blood supply b. loss of kidney tissue c. loss of nephrons d. loss of bladder tone

d, loss of bladder tone

A nurse is providing postoperative instructions for a client who had kidney stone removal and placement of a nephrostomy tube. Which of the following statements by the client indicates an understanding of the instructions? a. "This tube will keep my ureters open in case of another stone." b. "This tube will remain permanently because I can't empty my bladder." c. "This tube goes directly into my bladder." d. "This tube is only temporary."

d, tube is temporary

nurse is applying a condom catheter for a client who is uncircumcised. which of the following actions should the nurse take? a. Stretch the sheath portion of the condom catheter along the length of the penis. b. Secure the sheath portion with adhesive tape. c. Leave a space between the penis and sheath portion tip. d. Reposition the foreskin after application.

c, leave space

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Measure the client's vital signs. b. Notify the primary care provider. c. Lower the enema fluid container. d. Stop the enema instillation

c, lower container

which med classification increases risk of constipation? a. magnesium-containing supplements b. antibiotics c. narcotic pain meds d. beta blockers

c, narcotics

A nurse is caring for a client who has a stone in the right ureter that is obstructing the flow of urine. Which of the following urinary diversions should the nurse anticipate the client will need? a. urostomy b. continent cutaneous reservoir c. urethral stent d. neobladder

c, urethral stent

nurse is planning to obtain a urinary specimen from a client's closed urinary system. identify the correct sequence of steps that the nurse should take a. Attach a syringe to the collection port of the indwelling catheter. b. Transfer the urine to a sterile specimen container. c. Withdraw 3 to 30 mL of urine. d. Wipe the port with an alcohol swab or agency specified antiseptic. e. Transport the specimen to the laboratory.

d, a, c, b, e

nurse is preparing to administer an oil retention enema to a client who has constipation. nurse should instruct the client to retain the solution for which of the following durations? a. The duration of the procedure b. 10 to 15 min c. Until the client feels the urge to defecate d. At least 30 min

d, at least 30 min

nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. which of the following actions should the nurse take first? a. Irrigate the catheter. b. Assess for peripheral edema. c. Palpate for bladder distention. d. Check the catheter for kinks.

d, check for kinks

nurse is preparing to insert a nasogastric tube into a client for decompression. which of the following actions should the nurse perform first? a. Measure the tube from the client's ear to the xiphoid. b. Insert the tube while the client takes sips of water. c. Connect the nasogastric tube to suction. d. Ensure the client is in a sitting position.

d, client sitting

A parent tells the nurse, "My infant who is breastfed passes stools an average of 5 times per day." How does the nurse respond? "It would benefit the child to increase the maternal intake of dietary fiber." "You should supplement breastfeeding with bottle-feeding." "Administer a dose of antidiarrheal medication each day to your child." "This is a normal finding for the infant."

"This is a normal finding for the infant."

A patient scheduled for a joint aspiration study asks the nurse what this test will show? Which response by the nurse is accurate? "This test is done to determine the electrical activity of the muscle." "This test is done to determine if you possibly have a fracture." "This test is done to analyze the electrical activity of the joint." "This test is done to see if you have carpal tunnel syndrome."

"This test is done to determine if you possibly have a fracture."

The nurse is caring for four patients. Which patient should the nurse assess as having the highest risk for developing hyperthermia? A 20-year-old adult with an asthma exacerbation A 45-year-old adult with uncontrolled diabetes mellitus A 4-month-old child with respiratory syncytial virus A 60-year-old adult with congestive heart failure

A 4-month-old child with respiratory syncytial virus

The nurse is caring for multiple patients with mobility issues. Which patient should the nurse identify that is most at risk for a pressure injury? An 86-year-old male admitted to the step down unit recovering from pneumonia A 96-year-old female who is dependent on staff to move into and out of a wheelchair A 32-year-old female admitted to the obstetrical unit at 33 weeks' gestation and on bedrest A 54-year-old male who experienced a stroke 6 months ago with residual left-sided weakness

A 96 year-old-female who is dependent on staff to move into and out of a wheelchair

Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) A) The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. B) The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. C) The NAP waits until a tone sounds to read the tympanic thermometer. D) The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. E) The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer.

A B

What should you do if you observe your patient taking more than 20 breaths per minute? (Select all that apply.) A) Count again for a full 60 seconds (1 minute). B) Tell the patient that you are counting breaths so the patient will slow the rate of breathing. C) Assess physiologic factors that may be causing the patient to breathe so fast. D) Administer a bronchodilator that will decrease the respiratory rate.

A C

Which of the following situations may affect a patient's vital signs? (Select all that apply.) A) Time of day. B) Occupation. C) Moving from lying to standing position. D) Pain rated as a 7 on 1-10 pain scale. E) Isolation precautions.

A C D

Which of the following patients would you expect to have to monitor their temperature more frequently? (Select all that apply.) A) A patient receiving a blood transfusion for chronic anemia. B) An elderly patient who needs assistance with feeding and dressing. C) A 43-year-old female who has undergone a hysterectomy. D) A child who is small for his age. E) A 19-year-old with a white blood count of 15,000.

A C E

a nurse is preparing to administer a medication to a newly admitted client. The nurse should identify which of the following actions as part of the assessment phase of the nursing process? A. Asking the client about a history of medication allergies B. Instructing the client about the medication's adverse effects C. Determining whether the medication should be administered with or without meals D.Monitoring the client's response to the medication

A. asking the client about a history of medication allergies

Which event may occur because of vagus nerve stimulation during removal of a fecal impaction? Atelectasis Bradycardia Hypertension Cardiac tamponade

Bradycardia

The supervisor of the materials management department asks the nurse to recommend a method of standardization that will improve efficiency and reduce costs. Which recommendation should the nurse suggest? An electronic system that uses a bar-code scanning system. A computerized system that features a dashboard. A Global Trade Item Number instead of an account number. A Global Location Number instead of a custom item number.

An electronic system that uses a bar-code scanning system.

A patient has an area of eschar within a healing wound. Which type of debridement should the nurse expect to be ordered because it does not damage healthy and healing tissue within a pressure injury? Chemical Autolytic Sharp Mechanical

Autolytic

A patient presents with frostbite to the left ear, nose, and feet. Which intervention should the nurse implement? Protect and cover any blisters. Avoid handling affected areas after rewarming. Place affected areas in the dependent position. Massage affected areas to increase blood flow.

Avoid handling affected areas after rewarming.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 7/10 (0 to 10 scale) abdominal pain. c. The patient has absent breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

C

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Absent bowel sounds b. Complaints of incisional pain c. Temperature 102.1° F (38.9° C) d. Scant nasogastric (NG) tube drainage

C

The NAP reports that the patient's temperature is 39° C. Which of the following are appropriate nursing actions? (Select all that apply.) A) Place the patient's feet in a tub of cool water with ice. B) Apply a hyperthermia blanket as ordered. C) Remove the patient's blankets. D) Limit the patient's fluid intake. E) Administer an antipyretic to the patient as ordered.

C E

A nurse manager is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse manager take first? A) Complete an incident report. B) Notify the provider about the medication error. C) Assess the client for adverse effects. D) Report the error to the risk manager.

C) assess the client for adverse effects

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use? a. A hydrogel dressing b. A wet gauze dressing c. A transparent film d. An alginate dressing

C. A transparent film

A nurse is caring for a client who reports severe back pain at 1400. The client's prescriptions include oxycodone XR 20 mg PO every 12 hr (last dose received at 0600) and oxycodone immediate-release 5 mg PO every 4 hr PRN (last dose received at 2300 the day before). Which of the following actions should the nurse take? A. Contact the provider to request an order for a different pain medication. B. Administer oxycodone immediate-release 5 mg PO at 1600. C. Administer oxycodone immediate-release 5 mg PO now. D. Contact the provider to request an increase in the oxycodone extended-release dose.

C. Administer oxycodone immediate-release 5 mg PO now

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? a. Be sure to keep the skin moist b. Do not use pillows to support extremities c. Flex the client's knees while in bed d. Provide a firm mattress for client

C. Flex the client's knees while in bed.

A patient was admitted with a persistent body temperature averaging around 38.8°C (102°F) for several weeks. Testing has ruled out an infection, autoimmune disease, and malignancy. Which condition should the nurse suspect as the source of the fever? Medication-induced fever Hypothalamic dysfunction Fever of unknown origin Febrile seizures

Fever of unknown origin

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Notify the provider. Check the tubing for kinks. Adjust the rate of the bladder irrigant. Irrigate the catheter.

Check the tubing for kinks. When providing client care, the nurse should first use the least restrictive intervention; nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage therefore, the nurse should check the catheter tubing for kinks. The from the catheter to prevent clotting, which could occlude the catheter lumen.

How can you best obtain an accurate measurement of a patient's respiratory rate? A) Inform the patient that you are monitoring his or her respirations. B) Assess the respirations while the patient is talking. C) Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. D) Continue to act as though you are taking the patient's pulse while discretely observing the rise and fall of the patient's chest.

D

You are taking a patient's vital signs. When you assess the respiratory rate, you are having difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is your best action? A) Have someone else assess the patient's respiratory rate. B) Remove the patient's gown so you have better visualization of the patient's chest for assessment. C) Document the inability to visualize inspiration and expiration. D) While holding the patient's wrist, move the patient's arm over the chest or abdomen, then feel the rise and fall of inspiration and expiration and assess the rate.

D

The nurse notes a milky exudate from the surgical wound of an older adult patient. For which health problem should the nurse plan care for this patient? Delayed wound healing Insufficient perfusion Poor nutrition Altered oxygenation

Delayed wound healing

A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include? A. Instruct the client to increase exercise. B. Instruct the client to consume no more than four caffeinated beverages per day. C. Encourage the client to practice relaxation techniques each day. D. Encourage the client to engage in pattern paced breathing by panting.

Encourage the client to practice relaxation techniques each day.

A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate? A. Encourage the client to reduce intake of caffeinated soft drinks. B. Inform the client to ambulate in the hallway for 10 min prior to taking vital signs .C. Increase the room temperature and add blankets to warm the client. D. Withhold the client's antianxiety medication.

Encourage the client to reduce intake of caffeinated soft drinks.

The nurse is teaching a patient and the family about nutritional interventions to decrease the risk of developing pressure injuries. Which dietary instruction should the nurse include in the teaching? Ensure adequate intake of carbohydrates, fluids, and vitamin C. Decrease the intake of protein. Eat larger meals three times per day and avoid snacking. Decrease the intake of carbohydrates and fats.

Ensure adequate intake of carbohydrates, fluids, and vitamin C.

A patient with full-thickness burns has a significant amount of eschar. Which treatment should the nurse anticipate will be prescribed for this patient? Wound debridement Covering with a procoagulant bandage Drain insertion Escharotomy

Escharotomy

The nurse is assessing a patient who is critically ill with suspected hypothermia. Which site should the nurse use to take the temperature? Rectum Esophagus Tympanic membrane Temporal artery

Esophagus

The parents of a child with a fever of 39.0°C (102.2°F) report giving acetaminophen to their child with little success in bringing down the fever. Which instruction should the nurse provide the parents about adding ibuprofen to the treatment? "Acetaminophen can be administered every 4 hours, and then give ibuprofen every 6 hours." "You should refrain from using ibuprofen along with acetaminophen because it can cause Reye syndrome." "Alternating ibuprofen with acetaminophen helps provide comfort, but research does not support this." "I would only use acetaminophen, because this has been proven the best medication to treat a fever."

"Alternating ibuprofen with acetaminophen helps provide comfort, but research does not support this."

The nurse is teaching a patient about the antibiotic prescribed to treat their infection. Which information should the nurse include? "Monitor your levels of pain." "Be aware of the nature of parasitic infections to decrease the possibility of reinfection." "Be certain to take all the prescribed amount of the medication." "Remember pharmacotherapy, the disease process, and the prevention of contaminating others."

"Be certain to take all of the prescribed amount of the medication." It is important to teach patients receiving antibiotics to take the entire amount prescribed. Monitoring pain levels is important in teaching patients about analgesics. Instructions regarding parasitic reinfestations are necessary when prescribing antihelminthics. Extensive teaching regarding pharmacotherapy, disease process, and prevention of contaminating others is important when prescribing antiretrovirals.

The nurse is caring for a 5-year-old child with a fever, nausea, vomiting, and seizures. Which information should the nurse provide the parents to alleviate their fears? "Because of your child's age, it is less likely that your child will have additional seizures." "An electroencephalogram (EEG) can be done to determine brain damage." "Have you or anyone in your family, including your child, ever had seizures before?" "Research shows children who experience febrile seizures will develop a seizure disorder."

"Because of your child's age, it is less likely that your child will have additional seizures."

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include? a) cardiac output is the amount of blood flow through the heart in 1 minute b) cardiac output is the amount of blood ejected from the atria c) cardiac output is the ability of the muscle fibers in the ventricles to stretch d) cardiac output is the resistance of the ventricles to pump blood through the heart

"Cardiac output is the amount of blood flow through the heart in 1 minute."

A pregnant patient visits the office for a routine monthly checkup and shares that their 4-year-old child is going to daycare and there seems to be an outbreak of chickenpox. The patient asks whether the fetus will be harmed if she contracts chickenpox. Which is the nurse's accurate response? "Chickenpox is not harmful during pregnancy." "Chickenpox will not be transferred to the fetus." "Chickenpox can cause birth defects in an unborn fetus." "Chickenpox causes hydrocephalus in the fetus."

"Chickenpox can cause birth defects in an unborn fetus." Pregnant women need special considerations if they contract an infection that may cause birth defects, such as rubella, cytomegalovirus (CMV), parvovirus, and chickenpox. CMV is the most common infection that causes birth defects. Pregnant women should be educated about the risks of infection and ways to prevent infection during pregnancy. If a pregnant woman has an infection, it can be transmitted to the newborn. Infections that can be transmitted from the mother to the newborn include HIV, group B Streptococcus, CMV, and listeriosis.

A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include? A. "Clients will exhibit an increase in their respiratory rate after using a bronchodilator." B. "Count the respiratory rate for 1 minute for clients who have a respiratory infection." C. "Expect clients who have a brainstem injury to exhibit rapid respirations. "D. "Clients who are experiencing acute pain will have slow, deep respirations."

"Count the respiratory rate for 1 minute for clients who have a respiratory infection."

The nurse is teaching the parents of a child about fever management. The parents ask about alternating acetaminophen with ibuprofen. Which response by the nurse is accurate? "That is a good idea. Make sure you follow the recommended dosing on the drug insert." "I hope you do not want to alternate these medications to get the child back to school faster." "You should try using aspirin for fever and pain relief for your child." "Evidence shows that there is no improvement in condition with alternating acetaminophen and ibuprofen."

"Evidence shows that there is no improvement in condition with alternating acetaminophen and ibuprofen."

A patient being treated for a stage 1 pressure injury asks why Granulex is being used. Which statement should the nurse say in response? "Granulex will increase blood supply to the skin." "Granulex softens intact skin." "Granulex creates a negative pressure to reduce edema." "Granulex removes moisture to aid in removal of necrotic tissue."

"Granulex will increase blood supply to the skin."

The nurse is teaching a patient about a newly prescribed antibiotic. Which patient statement demonstrates the teaching has been effective? "I should take the pills until they are gone." "I can stop taking the medication once I stop coughing." "I can only take my medication in the morning." "I should take my medication with milk."

"I should take the pills until they are gone." Nurses should encourage patients to take the full regimen of antibiotics as prescribed. Bacterial resistance often results from incomplete antibiotic therapy, which can lead to more serious and resistant infections in the future. Lack of adherence to the antibiotic regimen may also increase the risk of recurrent infections, producing further complications. In addition, patients who have leftover antibiotics from one infection may tend to self-medicate, using those antibiotics for another infection, even if the infection is caused by a different organism. Using antibiotics for nonsusceptible organisms is another major cause of bacterial resistance.

The nurse is cleaning up vomitus. Which statement by the nurse demonstrates following the practice of medical asepsis? "I will wipe the vomitus up with paper towels." "I will call housekeeping to clean up the vomitus." "I will put up isolation signs." "I will cover the vomitus with granules and allow them to absorb."

"I will cover the vomitus with granules and allow them to absorb." Waste cleanup kits contain granules that absorb the vomit and then the absorbed substance is swept up and disposed of in a red biohazard bag. Each individual is trained in cleaning up biohazardous waste, so waiting for housekeeping to clean it up is not an option. Placing wet floor signs would be appropriate, but using isolation signs would not be.

A patient tells a nurse "I lose small amounts of urine while coughing, laughing, exercising, and walking but not at night while sleeping." Which response by the nurse is most appropriate? "You may require intermittent catheterization." "You should avoid caffeine, artificial sweeteners, and alcohol." "I'll teach you pelvic muscle exercises that you can perform regularly to address the problem." "You can perform urge-inhibition exercises to obtain relief from symptoms of urinary incontinence."

"I'll teach you pelvic muscle exercises that you can perform regularly to address the problem."

The preceptor is explaining to a new nurse the differences between a local infection and a systemic infection. Which statement by the new nurse demonstrates understanding? "If a patient has otitis media, that is an example of a local infection." "If a patient has pneumonia, that is considered a systemic infection." "If a patient has a urinary tract infection, that is an example of a systemic infection." "If a patient has sepsis, they have a local infection."

"If a patient has otitis media, that is an example of a local infection." Infections can be local or systemic. A local infection is limited to the specific part of the body where the microorganisms remain. Examples of local infections include otitis media, urinary tract infection (UTI), and pneumonia. If the microorganisms spread and damage different parts of the body, the result is a systemic infection. Sepsis is a systemic infection. When a culture of the individual's blood reveals bacteria, the condition is called bacteremia.

The nurse is meeting with a patient who reports feeling fatigued and is coughing yellow sputum. The patient is confused about what led to the sickness because no one in their home has been ill. Which response from the nurse would provide the patient an adequate explanation? "You must have picked it up from some allergens in your home left over from the fall season and the falling leaves." "If you were in public and someone coughed, you could breathe in the droplets that cause infection." "You do not need to be exposed to microorganisms to get sick." "You may be having a reaction to your medication."

"If you were in public and someone coughed, you could breathe in the droplets that cause infection." Before an individual can become infected, microorganisms must enter the body. The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry. Often, microorganisms enter the body of a host by the same route they used to leave the source. For example, an airborne infection escapes its host, or carrier, via sneezing or coughing and is transmitted to a new host who inhales the microorganism through the nose or mouth. The mouth, throat, nose, ears, eyes, and genitalia are open to outside exposure and thus are the most frequent portals of entry for microorganisms. There are many kinds of reservoirs (sources of microorganisms). Common sources are other humans, the patient's own microorganisms, plants, animals, and the general environment. Patients with allergen contact and medication reactions do not present with the manifestations identified.

A patient states to the nurse, "I am worried about having this fecal impaction. What is it?" Which response by the nurse is most accurate? "I understand your concern, but it is really nothing to worry about." "I can see why you are worried; it is a painful condition." "This condition is a loss of voluntary control of defecation." "It is a collection of hardened feces in the rectum or colon."

"It is a collection of hardened feces in the rectum or colon."

Which statement by the nurse describes an isometric exercise that may be helpful in decreasing the occurrence of constipation? "Lift a 5-pound weight from the floor to your waist." "Lie flat on your back and tighten the abdominal muscles for 10 seconds and then release them." "Run on the treadmill for 20 minutes." "Stretch your legs for 10 repetitions in the morning and 10 repetitions at bedtime."

"Lie flat on your back and tighten the abdominal muscles for 10 seconds and then release them."

The nurse is teaching the parents of a preschool-age child about the causes of nocturnal enuresis. Which statement is appropriate for the nurse to include in the teaching session with the parents? "Many children wet the bed due to difficulties in arousal from sleep." "Bedwetting is more common in girls than in boys." "Your child knows she can get away with this and is just being lazy." "It is common for children to develop incontinence when stressed."

"Many children wet the bed due to difficulties in arousal from sleep."

Which statement by the nurse explains the difference between medical and surgical asepsis? "Medical and surgical asepsis are basically the same, only the location is different." "Medical asepsis confines a microorganism to a specific area, while surgical asepsis attempts to keep an area free of microorganisms." "Medical asepsis is keeping the area free of microorganisms, and surgical asepsis is containing the organisms present." "Medical asepsis is cleaning and sanitizing mechanical equipment and surgical asepsis entails the cleaning of just surgical tools."

"Medical asepsis confines a microorganism to a specific area, while surgical asepsis attempts to keep an area free of microorganisms." Medical and surgical asepsis are not the same. Medical asepsis includes all practices intended to confine a specific microorganism to a specific area, thus limiting the number, growth, and transmission of microorganisms. In medical asepsis, objects are referred to as clean, which means that almost all microorganisms are absent, or dirty (soiled, contaminated), which means that microorganisms are likely to be present, some of which may be capable of causing infection. Surgical asepsis, or sterile technique, refers to practices that keep an area or object free of all microorganisms; it includes practices that destroy all microorganisms and spores (microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques). Surgical asepsis is used for all procedures involving sterile areas of the body, which may include both mechanical equipment and surgical tools.

Which statement by a student nurse regarding urinary incontinence requires correction? "Urinary incontinence is common in older adults." "Urge incontinence and stress incontinence are common forms of urinary incontinence." "Urinary incontinence is characterized by an involuntary loss of urine." "Mixed incontinence is a combination of stress and functional incontinence."

"Mixed incontinence is a combination of stress and functional incontinence."

A patient with urinary incontinence is scheduled for urodynamic testing. The patient's family asks the nurse, "What is this test for?" Which response by the nurse is accurate? "This test will determine how completely the bladder empties with voiding." "This test will identify structural disorders contributing to incontinence." "This test will evaluate detrusor muscle function." "This test will measure bladder strength and urinary sphincter health."

"This test will measure bladder strength and urinary sphincter health."

The nurse taught the parents about the possible causes of constipation the toddler has experienced. Which statement made by the parent demonstrates effective teaching? "My child may be holding it in because the bathroom is unfamiliar." "My child is not eating enough protein." "My child is drinking too many fluids." "My child has encopresis."

"My child may be holding it in because the bathroom is unfamiliar."

The parents of a newborn tell the nurse they are concerned about bringing the baby home to a household of relatives with various illnesses. Which response by the nurse is accurate? "Newborns have naturally acquired immunity from the mother, but it is good only for 24 hours." "Newborns may not be able to respond to infections due to an underdeveloped immune system." "Infants do not begin to synthesize their own immunoglobulins until after 6 months." "Newborns have a heightened response to infections and respond quickly with high fevers."

"Newborns may not be able to respond to infections due to an underdeveloped immune system." Although newborns have some naturally acquired immunity that is transferred from the mother across the placenta at birth, they may not be able to respond to infections due to an underdeveloped immune system. As a result, in the first few months of life, newborns may not exhibit the signs/symptoms typically associated with infection (may not present with fever). Infants begin to produce their own immunoglobulins between 1 and 3 months of age.

A 5-year-old is brought to the emergency department by their parents after experiencing a seizure. The mother asks, "Does this mean that my child has epilepsy?" Which response by the nurse is accurate? "Yes. Most children who have a seizure from fever have epilepsy." "No. High temperatures can cause seizures in young children." "No, but your child will have seizures with a high fever." "Yes. Having any seizure means the child has a seizure disorder."

"No. High temperatures can cause seizures in young children."

Which instruction regarding bladder training would be included in the teaching plan for the family of a patient who is incontinent because of a stroke? "Use an indwelling catheter at night to prevent accidents." "Offer the patient the commode or urinal every 2 hours." "Decrease the patient's oral fluid intake to 1 L per day." "Instruct the patient to hold the urine as long as possible to restore bladder tone."

"Offer the patient the commode or urinal every 2 hours."

The nurse is planning care for an older adult patient with muscle atrophy and limited mobility. The nurse pads the patient's joints. Which explanation for this action should the nurse provide to the patient? "This will encourage you to ambulate more." "These pads are necessary for you to do isometric exercises." "These pads will help you with range-of motion exercises." "Padding your joints should increase your comfort."

"Padding your joints should increase your comfort."

The public health nurse is training a class about first aid methods. The nurse talks about the activity of pathogens in each stage of the infectious process, including one stage that could last for years. Which is a correct statement about the pathogens during this extended stage? "Early clinical manifestations appear." "Pathogens proliferate and cause symptoms." "Pathogens do not come in contact with the host." "Pathogens replicate but do not cause manifestations."

"Pathogens replicate but do not cause manifestations." It is the incubation period in which pathogens replicate but do not cause manifestations. It can last for years. Early clinical manifestations appear during the prodromal stage. Pathogens proliferate and cause symptoms during the illness stage. If pathogens do not come in contact with the host, there is no infection.

A registered nurse is educating nursing students about the factors that influence urination. Which statement by a student nurse indicates a need for further education? "Patients with anxiety and stress may have increased frequency of voiding." "Patients who take atropine may have an increased risk of urinary retention." "Patients who undergo lower abdominal surgery may require the temporary use of an indwelling urinary catheter." "Patients with pathological conditions such as arthritis and dementia may experience either bladder overactivity or deficient bladder emptying."

"Patients with pathological conditions such as arthritis and dementia may experience either bladder overactivity or deficient bladder emptying."

The nurse is providing discharge teaching for a patient with an alteration of mobility. The family asks the nurse, "What is the best thing we can do to keep our father free from injury?" Which response by the nurse is appropriate? "Keep the lights turned down low." "Pick up all the throw rugs you have so your father doesn't fall." "Avoid helping your father with things he can do for himself." "Encourage your father to learn something new."

"Pick up all the throw rugs you have so your father doesn't fall."

A patient with pressure injuries has dementia, limited mobility, and lives with an adult daughter. Which should the nurse suggest to the patient's daughter to help reduce the patient's risk for pressure injuries? "Reposition in the chair every 3 hours." "Keep in bed instead of sitting in a chair." "Place a memory foam pad on the chair." "Use a more comfortable chair."

"Place a memory foam pad on the chair."

Which statement by the nurse indicates an accurate understanding of primary encopresis? "Primary encopresis occurs when a child has not achieved toilet training." "Primary encopresis occurs when, after a child was trained, they resort back to having toileting accidents daily." "Primary encopresis refers to a child who wets the bed at night." "Primary encopresis refers to a child who is not potty trained."

"Primary encopresis occurs when a child has not achieved toilet training."

A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? A. "Convection is the loss of body heat when a client is in contact with a cooler surface." B. "Conduction is the loss of body heat when sweat dries from a client's skin." C. "Evaporation is the loss of body heat when a client is near a current of cool air." D. "Radiation is the loss of body heat when a client is in close proximity to a cooler surface."

"Radiation is the loss of body heat when a client is in close proximity to a cooler surface."

A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make? a. "you can wear artificial fingernails if they are kept short" b. "leave rings on your fingers when performing surgical hand sepsis" c. "keep your fingernails less than half an inch in length" d. "remove nail polish on your fingernails if it is chipped"

"Remove nail polish on your fingernails if it is chipped."

The nurse is providing the rationale to support the purchase of an electronic health record system that allows the use of multiple nursing language terminologies in a standardized format. Which statement should the nurse include? "The use of uniform language reduces the steps in the nursing research process." "Most computerized systems use uniform language to integrate nursing terminologies into the health record." "Retrieval of evidence-based information about patient care is easier with uniform language." "The use of uniform language only applies to communication between nurses."

"Retrieval of evidence-based information about patient care is easier with uniform language."

An older adult patient presents with symptoms that appear to be influenza. The patient does not know what led to the sickness. Which statement by the nurse explains the term reservoir as it applies to this patient's condition? "The flu virus is present in your home." "You can only get the flu by touching someone who has it." "The flu is spread on airborne pathogens." "Someone you were near at the grocery store had the flu."

"Someone you were near at the grocery store had the flu." There are many reservoirs, or sources, of microorganisms. Common sources are other humans—the other shopper in the grocery store, the patient's own microorganisms, plants, animals, and the general environment. People are the most common source of infection for others and for themselves. For example, an individual with an influenza virus frequently spreads it to others. Stating that the flu is airborne or present in the patient's home doesn't explain the concept of reservoir. Nor does stating that the patient can only get the flu by touch explain the concept of a reservoir.

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury? a. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue." b. "Stage 3 pressure injury to the coccyx observed with non-blanchable area of erythema." c. "Stage 3 pressure injury to the coccyx observed with partial-thickness skin loss, wound bed pink and moist." d. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss, muscle and bones visible."

"Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

Which statement by the nurse demonstrates understanding of standard precautions? "Standard precautions are designed for EMTs on the scene of an accident." "Standard precautions are not regulated." "Standard precautions are relative to the patient." "Standard precautions are designed for hospital-based care."

"Standard precautions are designed for hospital-based care." The following facts are related to standard precautions. 1. These precautions are designed for all patients in the hospital. 2. They apply to: Blood. All body fluids, excretions, and secretions except sweat. Nonintact (broken) skin. Mucous membranes. They are designed to reduce the risk of transmission of microorganisms from recognized and unrecognized sources.

The nurse informaticist is summarizing the function and findings of the Technology Informatics Guiding Educational Reform (TIGER) summit for a group of staff nurses. Which statement should the nurse include in the presentation? "TIGER is developing plans to include informatics in all baccalaureate nursing programs." "TIGER concluded that knowledge of informatics is important for certain healthcare professionals." "TIGER was attended mainly by nurse administrators from major healthcare institutions." "TIGER is examining ways to reach out to nurses who lack informatics skills needed to practice."

"TIGER is examining ways to reach out to nurses who lack informatics skills needed to practice."

The nurse is explaining the benefits and limitations of using the electronic health record (EHR). Which statement should the nurse include? "The use of EHRs often increases patient readmission rates." "The EHR promotes observation of quality metrics." "EHRs increase the challenges related to care coordination." "Trending patients' progress is not a function of EHRs."

"The EHR promotes observation of quality metrics."

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching? A. "The body lowers body temperature through sweating." B. "The body loses heat through shivering." C. "The body increases body temperature through the process known as vasodilation." D. "The body generates heat through evaporation."

"The body lowers body temperature through sweating."

During a meeting with hospital administrators, the nurse is using the Surgical Care Improvement Project to illustrate the use of informatics in quality care. Which statement should the nurse include in the presentation? "The study objectives include identifying nurses who make medication errors." "The study will not affect reimbursement for hospital stays or surgical procedures." "The goals of the study include reducing complications among surgical patients." "The study's target population is all nurses who work in the surgical setting."

"The goals of the study include reducing complications among surgical patients."

The nurse suggests a consult with a medical social worker for an older adult patient who is reporting to the clinic for the third time in a month with signs of hypothermia. The patient asks, "Why are you suggesting this?" Which response by the nurse is correct? "The medical social worker will work with your utility company to eliminate your heating bills." "The medical social worker will determine if adult protective services needs to be called." "The medical social worker will assess the safety of your home environment." "The medical social worker will be able to assist with your hospital finances."

"The medical social worker will assess the safety of your home environment."

The nurse is caring for a child with constipation. Which statement by the nurse reflects an understanding of dietary changes that should be suggested to the child's parents? "The parents should remove all fruit from the diet temporarily." "The parents should remove fruit juices from the diet temporarily." "The parents should limit the amount of grains consumed in the diet." "The parents should remove cow's milk from the diet temporarily."

"The parents should remove cow's milk from the diet temporarily."

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "The skin is strongest during early childhood." b. "The epidermis pads internal organs and structures." c. "The subcutaneous layer of the skin contains cells that contribute to skin and hair color." d. "The skin assists in the regulation of body temperature."

"The skin assists in the regulation of body temperature."

The healthcare provider orders a creatine kinase level analysis for a patient who has moderate hypothermia. The patient asks why this test is needed. Which response by the nurse is accurate? "The test is to monitor for muscle breakdown, which may lead to kidney injury or failure." "The test will tell us if your kidneys are failing." "The test will tell us how much oxygen is circulating in your bloodstream." "The test detects the presence of bacteria in the urine."

"The test is to monitor for muscle breakdown, which may lead to kidney injury or failure."

The nurse is developing a presentation that describes the benefits of using a clinical decision support system in the electronic health record. Which statement should the nurse include? "There is a decreased need for critical thinking at the point of care." "It has no impact on errors and adverse events." "It has an inability to function as a stand-alone system." "There are fewer challenges when incorporating current nursing research."

"There are fewer challenges when incorporating current nursing research."

Which statement describes the makeup of viruses? "They include yeasts and molds." "There are several hundred species." "They consist of mainly nucleic acid." "They include protozoa."

"They consist of mainly nucleic acid." Four major categories of microorganisms cause infection in humans: bacteria, viruses, fungi, and parasites. Bacteria are by far the most common infection-causing microorganisms. Several hundred species of bacteria can cause disease in humans and can live and be transported through air, water, food, soil, body tissues and fluids, and inanimate objects. Viruses consist primarily of nucleic acid and therefore must enter living cells to reproduce. Common virus families include the rhinovirus (causes the common cold), hepatitis, herpes, and HIV. Fungi include yeasts and molds. Candida albicans is a yeast considered normal flora in the human vagina. Parasites live on other organisms. They include protozoa, such as the one that causes malaria, helminths (worms), and arthropods (mites, fleas, and ticks).

A patient tells the nurse, "I have been taking magnesium hydroxide daily to help with the constipation I've had from my prescriptions." Which response by the nurse is correct? "This type of laxative should not cause any abdominal cramping." "This type of laxative may lead to electrolyte disturbances that might affect your heart and lungs." "This laxative may result in hypermagnesemia." "This type of laxative should produce a bowel movement within 12-18 hours."

"This type of laxative may lead to electrolyte disturbances that might affect your heart and lungs."

After rewarming the feet, the nurse elevated the feet on pillows. The patient asks, "Why are you putting my legs on pillows?" Which statement by the nurse is correct? "This will promote better circulation to your legs and feet." "You will be more comfortable with your legs on a pillow." "The pillows will help keep your legs warm." "This will prevent cold blood from returning to the rest of your body."

"This will promote better circulation to your legs and feet."

The nurse attends class regarding statewide tracking mechanisms that identify providers who are not practicing sound medicine. Which statement by the nurse indicates that learning occurred? "Law enforcement can run periodic surveillance of patient records." "Tracking helps identify healthcare providers who are writing opioid prescriptions for financial kickback." "Tracking helps remind a healthcare provider to write a prescription for opioids for pain management." "A financial incentive is given to healthcare providers who refrain from prescribing opioids."

"Tracking helps identify healthcare providers who are writing opioid prescriptions for financial kickback."

A patient states, "I have been taking herbs for my upper respiratory infection." Which question by the nurse would be appropriate? "What herbs are you currently taking?" "Why are you doing that?" "Who told you to do such a thing?" "Are you aware that these are not monitored by the Food and Drug Administration (FDA)?"

"What herbs are you currently taking?" Over-the-counter (OTC) Echinacea and goldenseal, which are herbal supplements purported to eliminate upper respiratory infections, have been used for many years by the general public. Their use is often based on traditions and beliefs of the patient's particular cultural group. It is important that the nurse respond in a nonjudgmental manner when asking what other therapies the patient may be using.

The nurse is teaching a patient how to treat mild hyperthermia. Which nonpharmacologic action should the nurse include? "You should eat warm foods, like chicken broth." "You should remove any extra clothing or blankets." "You can take a cold bath every 4 hours to cool down." "Avoid turning on a fan, because it could spread germs."

"You should remove any extra clothing or blankets."

The nurse is teaching the parents of young children about the signs and symptoms of infection. Which statement by the nurse should be included? "You will find a rapid onset of symptoms in a child." "They will always have a fever." "You will see a rash develop associated with the infection." "The child will be in a great deal of pain."

"You will find a rapid onset of symptoms in a child." In children, acute otitis media or other viral infections may be associated with a rapid onset of symptoms and poor feeding. A fever will not always accompany an illness, and the child may even have a fever of unknown origin. A rash and pain may not accompany an infection.

Which of the following may increase respiration rate and depth? (Select all that apply.) A) Walking 1 mile briskly. B) Having a pain level rating at 7 on a scale of 1-10. C) Feeling anxious when taking a test. D) Smoking a cigarette. E) Taking an opioid to relieve pain. F) Having an addiction problem with amphetamines/cocaine. G) Using a bronchodilator prior to exercise. H) Incurring a head injury from a motor vehicle accident.

A C F

The nurse is planning to teach a class about device integration. Which example should the nurse use? A blood pressure monitor transferring vital signs to the electronic medical record Linking a policy to a particular communication with a colleague Forwarding a desk phone to a cell phone Manually entering blood glucose values into an electronic medical record

A blood pressure monitor transferring vital signs to the electronic medical record

A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include? A. A client is diagnosed with an elevated blood pressure when the measurement is greater than 130/80 mm Hg. B. A client is experiencing a hypertensive crisis when their blood pressure is greater than 150/90 mm Hg. C. A client who has a blood pressure of 128/86 mm Hg has stage I hypertension. D. A client who has a blood pressure of 162/102 mm Hg has stage II hypertension.

A client who has a blood pressure of 162/102 mm Hg has stage II hypertension.

A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provider A. A client who has an apical pulse rate of 120/min B. A client who has a blood pressure of 100/74 mm Hg C. A client who has an apical pulse rate of 84/min D. A client who has a blood pressure of 110/68 mm Hg

A client who has an apical pulse rate of 120/min

A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? A. A client who has a BP lower than the expected reference range B. A school-age child C. A client recovering from extensive abdominal surgery D. A client who has stabilized BP measurements

A client who has stabilized BP measurements

A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature? A. A toddler who has diarrhea B. A client who is 1 day postoperative following a hemorrhoidectomy and receiving pain medications via PCA pump C. An infant who is receiving intravenous fluids D. A client who is diaphoretic and frequently chewing ice to relieve dry mouth

A client who is diaphoretic and frequently chewing ice to relieve dry mouth

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? a. A client who is incontinent and is taking a prescribed diuretic b. A client who has a lower extremity fracture and uses the overhead bed trapeze to move c. A client who is NPO for surgery and receiving IV fluids d. A client who has lung cancer and will be receiving their first radiation treatment

A client who is incontinent and is taking a prescribed diuretic.

A client who has an elevated BUN is most likely to have a manifestation of A client who reports painful urination of a A client who reports urinary frequency A client who has glucose in his urine

A client who reports urinary frequency Voiding a small amount of urine (less than 100 mL) frequently (2 to 3 times per hr), and dribbling of urine are manifestations of urinary retention.

A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP? A. A client who just received the fourth dose of an antibiotic for an infection B. A client who has heart failure and is scheduled for discharge later in the day C. A client who is 24 hr postoperative and is visiting with friends D. A client who was recently admitted and reports chest pain

A client who was recently admitted and reports chest pain

While performing continuous bladder irrigation, a nurse assesses the patient's urine for color, amount, clarity, and the presence of mucus, blood clots, or sediment. What is the nurse looking for? Bladder spasms A need for further patient instruction Accurate urine output measurements A need for increased irrigation rate to prevent bleeding

A need for increased irrigation rate to prevent bleeding

The nurse is taking report for a group of patients. The nurse anticipates that which patient will need surgical debridement? A hyperthermic athlete who passed out at practice yesterday A patient who is hypothermic and has black tissue on the tip of their nose A young child who has had a fever of 104.5°F (40.3°C) for 3 days An older adult patient who has a fever of unknown origin

A patient who is hypothermic and has black tissue on the tip of their nose

A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia? A. Adult male who has a respiratory rate of 18/min B. Toddler who has a respiratory rate of 44/min C. Infant who has a respiratory rate of 56/min D. Adolescent female who has a respiratory rate of 16/min

A young adult who has a radial pulse rate of 56/min

Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? A) Temp 96.8° F, P-60, R-18, BP 160/90, O2 sat 93%. B) Temp 97.0° F, P-60, R-16, BP 116/78, O2 sat 95%. C) Temp 98.6 °F, P-56, R-20, BP 120/80, O2 sat 91%. D) Temp 98.0 °F, P-76, R-22, BP 110/70, O2 sat 88%.

B

Who would you expect to have the lowest body temperature? A) A 16-year-old who ran 1 mile. B) An 80-year-old who walked half a mile. C) A toddler who is febrile. D) A child playing softball.

B

A nurse working in a med-surg unit is preparing to administer medications to a client. The nurse plans to use two forms of id to verify that she has the right client. Which of the following actions can the nurse take to identify the client? select all that apply. A. Compare the name on the client's wristband with the name in the medication administration record (MAR). B. Ask the client to state his date of birth. C. Check the room number in the medication administration record (MAR) with the room number of the client. D. Ask the client to state his name. E. Use the bar code scan to identify the client.

A. Compare the name on the client's wristband with the name in the MAR B. ask the client to state DOB D. ask client to state name E. use the bar code scan

The nurse is conducting a teaching session with a group of college students regarding alcohol consumption and the risk of hypothermia. Which information should the nurse include in the teaching? Alcohol causes peripheral vasoconstriction, which increases the rate of cooling. Alcohol impacts respiratory function, which contributes to hypothermia. Alcohol causes peripheral vasodilation, which increases the rate of cooling. Alcohol impacts sensory perception and the individual's ability to sense cold.

Alcohol causes peripheral vasodilation, which increases the rate of cooling.

A case manager is reviewing a patient's record. Which situation is an example of decision support? An EHR issuing an alert when a patient has met the criteria for discharge The case manager reviewing a medication that has been prescribed and realizing that there is a less costly alternative, recommending it to the provider The case manager documenting that a message has been sent to the provider The case manager sending clinical documentation of the patient's care to the insurance company through an encrypted email

An EHR issuing an alert when a patient has met the criteria for discharge

The patient asks the nurse, "How did I get this urinary tract infection (UTI)?" Which common causative factor should the nurse include in the response? An ascending infection from the urethra An infection elsewhere in the body Congenital strictures in the urethra Urinary stasis in the urinary bladder

An ascending infection from the urethra The most common cause of a UTI is an ascending infection from the urethra. Congenital strictures and urinary retention can lead to infection, but these are not the most common causes. Systemic infections are rarely causes of UTIs.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should plan to administer the client's PRN bethanechol when the client reports which of the following manifestations? Bladder spasms Severe pain. An inability to void Frequent episodes of painful urination

An inability to void Bethanechol is a cholinergic medication that stimulates the parasympathetic nervous system, thus improving the tone and motility of the smooth muscles of the urinary tract enough to initiate urination.

A patient has been having multiple episodes of fecal incontinence. Which disagnostic test should the nurse anticipate to evaluate anal spincter function? Colonoscopy Anorectal manometry Barium enema Upper GI

Anorectal manometry

Which type of laxative acts by causing the stool to absorb water and swell? Emollient Stimulant Lubricant Bulk-forming

Bulk-forming

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? Apply a moisture barrier ointment to the client's skin. Clean the client's skin and perineum with hot water after each episode of incontinence. Check the client's skin every 8 hr for signs of breakdown. Request a prescription for the insertion of an indwelling urinary catheter.

Apply a moisture barrier ointment to the client's skin. Skin that remains in contact with urine for prolonged periods is at risk for maceration and should apply a moisture barrier ointment to prevent further contact of the skin with urine. breakdown. After cleansing and drying the client's skin, the nurse

A parent of an 8-year-old child with a viral infection says, "I've been giving my child acetaminophen. What else can I do to make my child more comfortable?" Which additional intervention should the nurse instruct the parent to provide? Draw a cool bath and have the child sit in the tub for a while. Apply cool washcloths or ice bags to the axilla, groin, and forehead. Bundle the child up with more warm clothes and blankets. Encourage the child to drink 1000 mL of fluid per day.

Apply cool washcloths or ice bags to the axilla, groin, and forehead.

The nurse identifies that a patient with decreased mental status is at risk for a pressure injury. Which action should the nurse take to maintain skin hygiene and prevent a pressure injury? Applying lotion to moist skin after bathing Monitoring the skin once a week during bathing Massaging bony prominences during bathing Using hot water and mild soap during bathing

Applying lotion to moist skin after bathing

The nurse is providing care to a patient who recently had back surgery. Which nursing action is a collaborative nursing activity? Assessing the patient's surgical wound site Arranging for physical therapy to ambulate the patient Assisting the patient with bathing Adjusting the head of the patient's bed for comfort

Arranging for physical therapy to ambulate the patient

A nurse is caring for an elderly patient who has recently started taking an antimuscarinic medication to treat urinary incontinence. Which nursing intervention is most important in the situation? Teaching pelvic muscle exercises Assessing the patient for mental status changes Reminding the patient to drink adequate amounts of water Instructing the patient to restrict fluid intake 2 hours before bedtime

Assessing the patient for mental status changes

An 82-year-old female patient is admitted to a long-term care facility because the family found it too difficult to perform care in the home to meet toileting needs. Which nursing action is appropriate when providing care for the patient? Limiting the patient's fluid intake to less than 1.5 L per day to reduce the number of times she will need to void Performing intermittent catheterization on a schedule to keep the patient's clothing and skin dry Assessing the patient for physical and mental abilities and limitations, usual voiding pattern, and ability to assist with toileting Reviewing the patient's daily medications and holding those that cause diuresis

Assessing the patient for physical and mental abilities and limitations, usual voiding pattern, and ability to assist with toileting

The nurse is teaching a pregnant woman in the first trimester strategies to prevent neural tube defects. Which instruction should the nurse include? Avoid lukewarm showers. Avoid hot tubs and saunas. Avoid summer heat during weeks 20 to 25 of pregnancy. Avoid sitting by a space heater.

Avoid hot tubs and saunas.

A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

B

For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? A) A patient without arms. B) A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). C) A patient with a history of a CVA (stroke). D) A patient who has an arteriovenous shunt located in the forearm for hemodialysis.

B

The student nurse is unsure of the BP measurement. What should the student nurse do first? A) Repeat the measurement on the same arm within 30 seconds. B) Measure the BP in the other arm. C) Get the RN to assess the BP. D) Determine whether the patient has had is or her BP medication.

B

Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? A) An African-American patient with a systolic BP of 100. B) A football player with a diastolic BP of 94. C) An elderly patient with a systolic BP of 88. D) A pregnant woman with a diastolic BP of 67.

B

Which of the following would be appropriate to delegate the task of pulse assessment? (Select all that apply.) A) An apical pulse of a patient who is going to receive digoxin (Lanoxin). B) A radial pulse on a patient with a 1200 mL fluid restriction. C) A radial pulse of a patient in the emergency room with chest pain. D) A femoral pulse following a lower leg amputation. E) The temporal pulse of a child.

B E

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? A. Adducting the arm so that it lies next to the client's side B. Flexing the shoulder by raising the arm from a side position to a 180° angle C. Abducting the arm to a 90° angle from the side of the body D. Circumducting the shoulder in a 180° half circle

B. Flexing the shoulder by raising the arm from a side position to a 180° angle Rationale: This demonstrates full ROM of shoulder. The client's fingers should be pointing directly upward. circumduct = 360* circle

A nurse is observing an assistive personnel (AP) who is using a mechanical lift w/ 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? A. Places a removable cover over the sling B. Leaves the bed in the lowest position throughout the procedure C. Locks the hydraulic valve before attaching the sling to the lift D. Raises the head of the bed to a sitting position just before transfer

B. Leaves the bed in the lowest position throughout the procedure Rationale: The bed should be raised to a comfortable working position in order to prevent injury to nursing staff and to properly position the lift under the client's bed.

A nurse is planning care for an older adult client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown? a. Firmly massage lotion into the client's skin b. Tilt the client on their side at 30 degrees c. Slide the client to the edge of the bed to transfer d. Keep the head of the bed at 45 degrees when in supine position

B. Tilt the client on their side at 30°.

A nurse is preparing to administer a high-alert pain medication for a client. Which of the following actions should the nurse perform during the planning stage of medication administration? A. Assess the effectiveness of the pain medication. B. Verify the dosage calculation with another nurse. C. Teach the client about the action of the medication. D. Ask the client to state their name and birthdate.

B. Verify the dosage calculation with another nurse

A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? A. Anxiety can cause a decrease in respiratory rate. B. Body temperature is typically lower in older adults. C. Caffeine can cause a temporary decrease in pulse rate in adolescents. D. Blood pressure slightly decreases immediately following the use of nicotine.

Body temperature is typically lower in older adults.

In which order will the nurse take the following actions when caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

D, B, A, C

a nurse caring for a client who states that his provider told him he is at risk for anaphylaxis following administration of amoxicillin and that he does not understand what this means. Which of the following is an appropriate response by the nurse? A. "Anaphylaxis is a predictable and often unavoidable secondary effect that can occur at a usual therapeutic dose." B. "Anaphylaxis will cause you to experience withdrawal symptoms when you discontinue taking the medication." C. "Anaphylaxis is an unusual response that can occur due to an inherited predisposition." D."Anaphylaxis is a severe hypersensitivity or allergic reaction that is life-threatening."

D. Anaphylaxis is a severe hypersensitivity or allergic reaction that is life-threatening

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? A. Wrap both arms around the client's arms and shoulders. B. Move both feet together when the client begins to fall. C. Protect the client's extremities while lowering them to the floor. D. Extend one leg and allow the client to slide down the leg to the floor.

D. Extend one leg and allow the client to slide down the leg to the floor. Rationale: This action helps prevent injury to the client. As the client gets close to the floor, the nurse should bend both legs to continue supporting the client.

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? A. Place the stockings on the client after the client ambulates to the restroom. B. Ensure the client's toes are visible after placing the stockings on the client. C. After applying the stockings, place two fingers between the client's leg and stocking to check the fit. D. Measure the client's calf circumference and leg length from heel to knee.

D. Measure the client's calf circumference and leg length from heel to knee. Rationale: To ensure proper fit, the nurse should measure the widest part of the client's calf as well as the length of client's leg from heel to knee. Antiembolic stockings that are too large will not apply the pressure needed to prevent DVT. Antiembolic stockings that are too small could impair circulation in the client's legs.

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster? a. The epidermis contains cells that assist in systemic immune responses b. Collagen and elastin fibers increase with age c. The skin consists of 4 distinct layers d. The dermis contains blood vessels that help nourish the epidermis

D. The dermis contains blood vessels that help nourish the epidermis.

A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes? a. droplet b. indirect contact c. airborne d. direct contact

Droplet

The nurse has developed a plan of care for a patient with a specific goal. The patient was unable to meet the goal by the stated time frame. Before revising the goal, which step must the nurse perform? Ask the healthcare provider for a more reasonable goal. Evaluate factors impeding goal attainment. Document noncompliance with the plan. Compare patient progress with that of other patients.

Evaluate factors impeding goal attainment.

The nurse is caring for a patient who has difficulty breathing. Which nursing action would be considered independent? Sitting the patient up in bed Ordering chest physiotherapy Administering medication to relax breathing Prescribing oxygen therapy

Sitting the patient up in bed

The nurse evaluates the plan of care for a patient admitted with pneumonia who still has difficulty breathing related to an ineffective breathing pattern. Which step should the nurse include to select new interventions for the plan of care? Evaluating the current interventions and patient needs Setting more realistic patient goals and easier interventions Delegating the selection of the new interventions to another nurse Deleting the current nursing diagnosis because it was not meeting the patient's needs

Evaluating the current interventions and patient needs

Which statement describes the evaluation phase of the nursing process? Evaluation focuses on determining changes and preventing complications. Evaluation is performed throughout all phases of the nursing process. Evaluation is performed only after nursing interventions are performed. Evaluation is determined based on gathering subjective and objective data.

Evaluation is performed throughout all phases of the nursing process.

The nurse plans care to reduce a patient's risk for pressure injuries. Which factor should the nurse recall that contributes to the increase in the cell's need for oxygen? Diminished sensation Immobility Inadequate nutrition Excessive body heat

Excessive body heat

The body's surface temperature changes continuously in response to the environment. When considering the ways in which heat transfer occurs in the development of hypothermia, which situation is the most likely cause of excessive heat loss through convection? Falling into a partially frozen lake Standing outside in a sunny area Sweating after completing a workout session Placing an infant on a metal examination table

Falling into a partially frozen lake

A patient reports severe abdominal cramping and foul-smelling diarrhea. Which condition should the nurse suspect as the cause of these symptoms? Fecal impaction Constipation Stomach cancer Diverticulitis

Fecal impaction

During a home health visit after a patient's recent surgery, the nurse assesses that a patient is experiencing acute pain related to constipation. The nurse reviews the potential causes of the pain and recognizes that the patient is at risk of intestinal obstruction if which condition is unresolved? Incisional pain Fecal impaction Use of opioid medication Impaired physical mobility related to surgery

Fecal impaction

An 83-year-old man lives alone on a limited income. Which assessment should the nurse perform to determine if the man is at increased risk for hypothermia? Hyperthyroidism Decreased immune response Giant cell arteritis Financial

Financial

The nurse is developing a plan of care for a child admitted to the hospital for a fever. Which nursing intervention should the nurse include in the plan of care? Applying warm washcloths or ice bags to the axilla, groin, and forehead Providing 1000 mL of fluid intake within a 24-hour period Giving a tepid sponge bath after administering fever medication Having the child wear an extra layer of clothing

Giving a tepid sponge bath after administering fever medication

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include? a. gowns can be reused on the same client b. masks should be removed after leaving a client's room c. gloves should be removed from the inside out d. eyeglasses can be used in place of goggles

Gloves should be removed from the inside out.

The nurse is reviewing the laboratory report of a patient. The presence of which substance in the urine hints at the possibility of an abnormality? Protein, 6 mg/mL Glucose, 2+ Red blood cells, 2 White blood cells, 4

Glucose, 2+

The nurse is presenting how to differentiate between patient goals and outcomes. Which statement by the nurse is accurate? "Goals evaluate the patient's response to the plan of care developed by the nurse." "Goals are established by the nurse and used to evaluate patient outcomes." "Goals are patient responses, whereas outcomes are the patient's response to care." "Goals include the subjective and objective data observed by the nurse."

Goals are patient responses, whereas outcomes are the patient's response to care."

The nurse is caring for a patient with a stage 1 pressure injury to the sacrum. Which product should the nurse suggest to help increase the blood supply to the skin of this pressure injury? Vacuum-assisted closure Transparent dressing Granulex Hydrogel dressing

Granulex

A patient who has undergone urological surgery is prescribed urinary catheterization. Which diameter of catheter does the nurse anticipate will be used for this patient? 5 to 6 Fr 8 to 10 Fr 12 Fr Greater than 16 Fr

Greater than 16 Fr

The nurse is concerned that a patient who has been in isolation for several days in the hospital may be experiencing sensory deprivation. Which clinical sign should the nurse assess? Hallucinations Incontinence Diarrhea Hypertension Hallucinations

Hallucinations Two of the most common issues associated with isolation are sensory deprivation and decreased self-esteem related to feelings of inferiority. Sensory deprivation occurs when the environment lacks normal stimuli for the patient, such as communication with others. Nurses should be alert to common clinical signs of sensory deprivation, such as boredom, inactivity, slowness of thought, daydreaming, increased sleeping, thought disorganization, anxiety, hallucinations, and panic. Hypertension, diarrhea, and incontinence are negative symptoms that are not associated with being isolated.

A patient who presents with dribbling of urine is diagnosed with stress incontinence. Which datum would the nurse include in the assessment of this patient? Select all that apply. Height & weight History of osteoarthritis Menopausal status Number of live births Alcohol use

Height & weight Menopausal status Number of live births

What should the nurse include in the plan of care for a patient with urge urinary incontinence? Helping the patient learn efficient and safe toilet transfers Helping the patient with leg-strengthening exercises Helping the patient strengthen the pelvic floor muscles and learn fluid and food modifications Helping the patient obtain assistive devices for the home that are covered by insurance

Helping the patient strengthen the pelvic floor muscles and learn fluid and food modifications

Which sign manifests in infants and young children who are dehydrated? Select all that apply. Dizziness High fever Sunken eyes Light-headedness Dry eyes when crying Listlessness or irritability

High fever Sunken eyes Dry eyes when crying Listlessness or irritability

The nurse is discussing nonpharmacological treatments with the patient who has urinary incontinence. Which information in the patient's history would indicate that the use of a pessary could benefit this patient? History of multiparity Functional incontinence Benign prostatic hypertrophy Spinal cord injury

History of multiparity

The nurse is teaching a class about the role of infection in the development of cancer. Which infection that increases the likelihood of developing cancer should the nurse include in teaching? Varicella zoster virus Tinea fungus Streptococcus Human papilloma virus (HPV)

Human papilloma virus (HPV)

A patient presents with abdominal discomfort, and the nurse auscultates 40 bowel sounds in 1 minute. Which pattern of bowel sounds does the nurse document? Normal Hypoactive Hyperactive Tympanic note

Hyperactive

The nurse is planning care for a patient who has a baseline body temperature of 38.7°C (101.6°F). After assessment, the nurse assigns the nursing diagnosis of Fluid Volume: Deficient, Risk for. Which rationale explains the selection of this nursing diagnosis? Vasoconstriction from hyperthermia causes fluid losses to occur. Hyperthermia increases metabolism, which results in the need for fluid. Tachycardia causes a decrease in blood volume, leading to dehydration. Febrile seizures due to severe hyperthermia can cause fluid losses.

Hyperthermia increases metabolism, which results in the need for fluid.

The nurse is caring for a patient who is undergoing core rewarming after extreme cold exposure. The patient is still hypothermic, despite efforts to warm them up. The nurse should ask the patient's relatives about a history of which medical condition? Hypothyroidism Heart disease Diabetes Hyperthyroidism

Hypothyroidism

The nurse is caring for a patient who believes in the hot and cold theory. Which food should the nurse offer the patient? Chicken soup Hot chocolate Grilled cheese sandwich Ice cream

Ice cream

A patient who is recovering from a motor vehicle crash has been ordered complete bedrest for 3 months. The patient presents with skin breakdown. Which nursing diagnosis statement is correct? ANSWER Impaired Skin Integrity related to motor vehicle crash Impaired Skin Integrity related to time in bed Impaired Skin Integrity related to immobility Impaired Skin Integrity related to skin breakdown

Impaired Skin Integrity related to immobility

Which factor should the nurse consider as a contributing cause of urinary incontinence in older adult patients? Urine concentration Internal sphincter Impaired mobility Micturition

Impaired mobility

The nurse is assessing a child with a history of febrile seizures and notes that the child has a temperature of 101.2°F (38.4°C). How should the nurse proceed? Implement seizure precautions. Monitor temperature every 4 hours. Prepare to administer acetaminophen once the temperature reaches 102°F (38.4°C). Insert a Foley catheter to monitor urine output.

Implement seizure precautions.

The nurse is outlining strategies through which informatics can address the increasing national problem with prescription opioid addiction and overdose. Which strategy should the nurse include? Enhancing electronic tracking of opioid prescriptions at the community level Monitoring data to identify patients who sell opioids and their buyers Linking computerized written orders with patient records to identify prescribers of opioids Improving the ability to identify individuals who engage in "doctor shopping"

Improving the ability to identify individuals who engage in "doctor shopping"

A patient phones the clinic and states, "I've been sweating and have a temperature of 101.5°F (40.1°C)." Which instruction should the nurse provide until the patient can be seen by the healthcare provider? Stay under a blanket. Take an antipyretic every hour. Increase fluids. Alternate doses of an antipyretic and anti-inflammatory.

Increase fluids.

A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect? a) increase in BP b) decrease in RR c) decrease in HR d) increase in stroke volume

Increase in blood pressure

A patient with alcoholism develops chronic pancreatitis. Which laboratory parameter is helpful in diagnosing pancreatitis? Increased bilirubin Increased serum amylase Elevated carcinoembryonic antigen Elevated alkaline phosphatase levels

Increase serum amylase

A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action? A. Teach the client how to take their pulse so they can keep the provider informed of variations. B. Inform the client to ask for assistance with getting out of bed. C. Educate the client on medications, including therapeutic effects and potential adverse effects. D. Ensure the client has been taking medications as prescribed.

Inform the client to ask for assistance with getting out of bed.

The nurse receives a prescription to obtain a postvoid residual for a patient via catheterization. Which method to obtain this measurement is best? Intermittent catheterization Long-term indwelling catheterization Short-term indwelling catheterization Medium-term indwelling catheterization

Intermittent catheterization

The nurse is assessing a patient with a history of urinary retention who is diagnosed with a urinary tract infection. When reviewing the patient's health history, which finding would most likely be the causative agent? Lack of performing Kegel exercises Decreased functional mobility Alzheimer disease Intermittent self-catheterization

Intermittent self-catheterization

When collecting a guaiac fecal occult blood test (gFOBT), the nurse should take which action? Interpret the color of the guaiac paper after 30-60 seconds. Open the flat of the slide and, using a cotton applicator, thinly smear stool in the first box of the guaiac paper. After waiting 10-15 minutes, open the cardboard flap and apply two drops of developing solution on each box of guaiac paper. Recognize that a green color indicates it is positive for guaiac or presence of fecal occult blood.

Interpret the color of the guaiac paper after 30-60 seconds.

When a patient reports passing black and tarry stools, the nurse identifies that a patient should be evaluated for which condition? Select all that apply. Iron ingestion Ingestion of beeds Gastrointestinal (GI) bleeding Spastic constipation Malabsorption of fat

Iron ingestion Gastrointestinal (GI) bleeding

The nurse cares for a patient with a nasogastric tube for gastric decompression in place. Which action does the nurse include in the plan of care to prevent adverse effects related to the tube? Select all that apply. Irrigate the tube with saline Administer frequent oral hygiene Measure the length of the exposed tube Measure the pH of the aspirated tube contents Frequently lubricate the nares to minimize discomfort

Irrigate the tube with saline Administer frequent oral hygiene Measure the length of the exposed tube Measure the pH of the aspirated tube contents Frequently lubricate the nares to minimize discomfort

A nurse is caring for a patient with an indwelling catheter. Which nursing action may increase the risk of a catheter-associated urinary tract infection? Collecting specimens via a port in the tubing. Keeping the drainage bag above the level of the bladder. Allowing the patient to wear a leg bag while ambulating. Monitoring the drainage system to prevent backflow of urine.

Keeping the drainage bag above the level of the bladder.

A patient who is confined to bed is at risk for developing a pressure injury. Which support surface should the nurse request for this patient? Memory foam mattress Alternating pressure mattress Gel flotation pads Kinetic bed

Kinetic bed

Which symptom would the nurse anticipate in a patient with urge urinary incontinence? Select all that apply. Distended bladder on palpation Leaks on the way to the bathroom Leaks without awareness Strong urge or leaks upon hearing water running Loss of a small volume of urine while coughing or laughing

Leaks on the way to the bathroom Strong urge or leaks upon hearing water running

A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse? a) pulse deficit of 0 b) left radial pulse is nonpalpable c) peripheral pulse +2 bilateral d) brachial pulses are symmetrical

Left radial pulse is nonpalpable

A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse? - Lubricates the first 2.5 to 5 cm (2 in) of the catheter. - Dons sterile gloves before cleaning the client's meatus. - Secures the tubing to the client's upper thigh. - Pulls gently on the catheter to check for resistance after inflating the balloon.

Lubricates the first 2.5 to 5 cm (2 in) of the catheter. The nurse should lubricate the first 2.5 to 5 cm (1 to 2 in) of the catheter when inserting a catheter into a female client. The nurse should lubricate the first 15 to 17.5 cm (6 to 7 in) when inserting a catheter into a male client. cleaning the client's meatus.

A patient is admitted to the emergency department after the ingestion of a poison. The nurse anticipates a prescription for which type of cathartic? Bisacodyl Castor oil Docusate calcium Magnesium citrate

Magnesium citrate

Which substance may cause complications for a patient who has kidney dysfunction? Castor oil Mineral oil Docusate sodium Magnesium hydroxide

Magnesium hydroxide

A patient is suspected of having a spinal cord injury. The nurse tells the patient, "Your healthcare provider has ordered a diagnostic test that measures how your nerves respond to stimulation." The nurse is referring to which test? Spinal x-rays Magnetic evoked potentials MRI of the spine CT of the spine

Magnetic evoked potentials

The nurse is caring for a newborn that has a temperature of 96.9°F (36.05°C). How should the nurse help the newborn regulate its temperature? Maintain a very warm thermal environment. Maintain a neutral thermal environment. Undress the newborn and place them in a radiant warmer. Rapidly rewarm the child when necessary.

Maintain a neutral thermal environment.

The nurse is providing home care instructions for a patient with fecal incontinence. Which information should the nurse include? Eat a low-fiber diet. Maintain good skin care. Reduce fluid intake. Decrease usage of bulk-forming laxatives.

Maintain good skin care.

The nurse is completing the health history for a newly admitted patient diagnosed with hypothermia. Which should the nurse identify as the most important health history data to assess? Blood pressure Heart rate Medications Skin color

Medications

Which drug acts by increasing stool bulk and promoting the passage of stool? Bisacodyl Milk of Magnesia Bismuth subsalicylate (Kaopectate) Methylcellulose (Citrucel)

Methylcellulose (Citrucel)

The nurse is assessing a patient who has a core body temperature of 35°C (95°F) after being found outside in the cold. How should the nurse document this finding? Normothermia Hyperthermia Mild hypothermia Severe hypothermia

Mild hypothermia

The nurse is providing teaching to the family caregiver of an older patient who has become increasingly immobile at home. Which instruction should the nurse provide to reduce the patient's risk of developing a pressure injury? Massage the bony prominences daily. Monitor the diet to ensure adequate intake of proteins and calories. Use an alcohol-based sanitizer to clean the skin after incidences of incontinence. Help the patient to move at least every 4 hours.

Monitor the diet to ensure adequate intake of proteins and calories.

A nurse is caring for a patient with a spinal cord injury who reports an absence of awareness of bladder filling and the urge to void. A family member adds that the patient also sometimes has leakage of urine without awareness. Which nursing intervention is most important for the patient? Placing an indwelling catheter. Monitoring for autonomic dysreflexia. Encouraging the patient to perform pelvic muscle exercises. Monitoring the postvoid residual volume according to the health care provider's direction.

Monitoring for autonomic dysreflexia.

The parents call the clinic to report that their 5-year-old child has a temperature of 40.1°C (104.2°F). In which instance should the nurse instruct the parents to take their child to the emergency department? Intermittent crying Increased sleeping Nasal congestion Neck stiffness

Neck stiffness

A patient has a pressure injury over the sacrum. Which assessment finding should indicate to the nurse indicates that this injury is in stage 3? Skin loss to the dermis Nonblanchable erythema of intact skin Necrosis of subcutaneous tissue Damage identified to muscle and bone

Necrosis of subcutaneous tissue

A nurse in a clinic is assessing a client who has a new diagnosis of interstitial cystitis. The nurse should expect which of the following Negative urine culture Denies urgency Denies pain with urination Fever

Negative urine culture A laboratory finding of a negative urine culture is consistent with a diagnosis of interstitial cystitis since it is a non-infectious process.

A nurse instructs an elderly patient to restrict fluid intake 2 hours before bedtime. Which complication is the nurse trying to reduce? Nocturia Urinary retention Urinary tract infection Stress urinary incontinence

Nocturia

Which admission assessment is most appropriate for the nurse to perform for a patient with altered mobility? Observe the patient eat a meal. Observe the patient interact with family. Observe as the patient walks across the room. Observe the patient get undressed.

Observe as the patient walks across the room.

A patient reports passing narrow, pencil-shaped stools over the past few days. The nurse suspects which cause for the assessment finding? Select all that apply. Pancreatitis Obstruction Malabsorption Absence of bile Increased peristalsis

Obstruction Increased peristalsis

A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next? A. Obtain a manual blood pressure reading from the client. B. Notify the charge nurse of the client's blood pressure reading. C. Reinforce client education on measures to decrease blood pressure. D. Reinforce client teaching regarding medications to control blood pressure.

Obtain a manual blood pressure reading from the client.

The nurse is caring for an older adult patient with poor dietary intake and decreased mobility. Which action is least effective in diminishing the risk of pressure injuries? Offer the patient nutritional supplements high in protein and iron. Offer the patient water before each meal. Sit with the patient during mealtimes to encourage eating. Assess the patient's ability to swallow.

Offer the patient water before each meal.

The nurse is caring for an older adult patient with poor dietary intake and decreased mobility. Which action is least effective in diminishing the risk of pressure injuries? Offer the patient nutritional supplements high in protein and iron. Sit with the patient during mealtimes to encourage eating. Offer the patient water before each meal. Assess the patient's ability to swallow.

Offer the patient water before each meal.

The nurse is teaching an older adult patient about the importance of using sunscreen. Which statement should the nurse include in this teaching? Older adults have decreased eccrine and apocrine activity. Older adults have fewer active melanocytes. The dermal-epidermal junction in older adults is flattened. The subcutaneous tissue layer in older adults is thinner.

Older adults have fewer melanocytes.

A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record? Enuresis Anuria Nocturia Oliguria

Oliguria The nurse should document the client has oliguria, which is urine output between 100 mL and 400 mL of urine in 24 hr.

The nurse preceptor is demonstrating how to don sterile gloves prior to an open wound dressing change. Which method should be demonstrated to use outside the operating suite? Closed method Open method Slide method Open-handed method

Open method Sterile gloves may be donned by the open method or the closed method. The open method is most frequently used outside the operating room because the closed method requires that the nurse wear a sterile gown. Gloves are worn during many procedures to maintain the sterility of equipment and protect a patient's wound. Sterile gloves are packaged with a cuff of approximately 5 cm (2 in) and with the palms facing upward when the package is opened. The package usually indicates the size of the glove.

A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature? A. Tympanic temperature can be affected by environmental temperature. B. Temporal temperature is inaccurate in children under 3 years of age. C. Axillary temperature reflects rapid changes in a client's core body temperature. D. Oral temperature is easily accessible despite a client's position.

Oral temperature is easily accessible despite a client's position.

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? Stress incontinence Urge incontinence Overfiow incontinence Reflex incontinence

Overflow incontinence These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.

A nurse is caring for an elderly patient who is receiving treatment for urinary incontinence. After reviewing the patient's prescription, the nurse knows to observe the patient for cognitive impairment. Which medication is the patient most likely taking? Atropine Diuretics Oxybutinin Phenazopyridine

Oxybutinin

The nurse is planning care for an older adult patient with muscle atrophy and limited mobility. The nurse assigns a goal to promote comfort for the patient. Which action is most important for the nurse to include in the plan of care? Encourage ambulation Coach about isometric exercises Pad joints Teach range-of-motion exercises

Pad joints

The nurse is caring for a patient with malabsorption syndrome. Which change in bowel elimination is the patient likely to report? Select all that apply. Pale stools Black, tarry stools Clay-colored stools Increased flatulence Oily stools

Pale stools Oily stools

A patient reports severe abdominal cramping, constipation, and some bowel leakage. Which action should be a part of the nurse's initial assessment plan? Giving a cleansing enema Providing prune juice Increasing fluid intake Palpating the abdomen

Palpating the abdomen

The nurse inspects the skin of a patient with contact dermatitis. Which other assessment technique should the nurse use? Auscultation Percussion Palpation Culture

Palpation

The nurse is examining the following nursing diagnosis statement: Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. The use of "secondary to" in this diagnosis reflects which component? Axis 2 of the nursing diagnosis Primary identifiable nursing problem Subjective data obtained Pathophysiological disease process

Pathophysiological disease process

The nurse is designing an online course about the use of patient portals for consumer and patient e-health. Which item should the nurse include? Prescription refill requests are not permitted when using a portal. Protected health information is encrypted and securely transmitted via the portal. Patients must provide user identification and a password for each portal visit. To use the portal, the patient must first register in person at the healthcare facility.

Patients must provide user identification and a password for each portal visit.

Which is the cause of fecal incontinence in a pregnant woman who is 21 weeks' gestation? Extremely large fetus Obesity Movement of the fetus Pelvic floor dysfunction

Pelvic floor dysfunction

The nurse is reviewing the medication record of a patient admitted with an alteration in mobility. Which class of medications should lead the nurse to carefully observe the patient for central nervous system (CNS) effects? Nonsteroidal anti-inflammatory drugs (NSAIDs) Bisphosphonates Hormones Skeletal muscle relaxants

Skeletal muscle relaxants

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? Increase fluids. Perform a bladder scan. Insert a straight catheter. Provide assistance to bathroom,

Perform a bladder scan. The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.

The nurse is caring for a patient with impaired mobility who is not able to move on their own. Which independent intervention is important for the nurse to implement? Perform passive range-of-motion exercises. Instruct the patient about following a low-salt diet. Prepare the patient for an electrocardiaogram (ECG). Prepare the patient for arterial blood gas (ABG) testing.

Perform passive range-of-motion exercises.

During a checkup, a pregnant patient reports urinary incontinence. Which instruction is appropriate for the nurse to provide for this patient? Increasing fluid intake Consuming more fiber Performing Kegel exercises Avoiding alcohol

Performing Kegel exercises

The nurse is caring for an older adult patient who has a fever and is on bedrest. Which is the priority nursing intervention for this patient? Administering an antipyretic according to the prn order Performing a full skin assessment Applying ice packs to the patient's groin Monitoring the patient's temperature every 30 minutes

Performing a full skin assessment

The nurse preceptor is observing a new graduate nurse who is caring for a patient with limited mobility and fecal incontinence. For which action by the graduate nurse should the preceptor intervene? Skin cleaned well and dried completely before reapplying an adult diaper Dimethicone-based cream applied to the skin Petroleum-based ointment applied to the skin Skin washed with soap and warm water

Petroleum-based ointment applied to the skin

The nurse is caring for a patient who has a colostomy. When assessing the stoma, which color indicates that the stoma is healthy? Select all that apply. Pink Red Blue Brown Black

Pink Red

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take? a. wear an N95 respirator when caring for the client b. place the client in a private room c. place a mask on the client when they leave their room d. place the client in a negative airflow room

Place the client in a private room.

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? Shakes the soiled linen to remove any toilet paper remnants Places the soiled linen on the floor before bagging it Holds the solled linen against her body while carrying it to the linen bag Places clean linen that touched the floor in the soiled linen bag

Places clean linen that touched the floor in the soiled linen bag Linen that touches the floor or the AP drops requires laundering.

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? Deflate the catheter balloon using a sterile syringe. Measure and document the urine in the drainage bag. Remove the tape or device securing the catheter to the client's thigh Position the client supine.

Position the client supine. The first action the nurse should take using the nursing process is to place the client in a supine position. This permits adequate visualization and assessment of the perineal area and promotes client comfort and relaxation.

A parent reports that their 5-year-old child has never been able to achieve bowel control. Which condition should the nurse suspect? Secondary encopresis Pyschosocial issues Primary encopresis Growth retardation

Primary encopresis

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing? a. incubation b. convalescence c. acute illness d. prodromal

Prodromal

The nurse is discussing how electronic health records improve mortality rates related to sepsis in an acute care hospital. Which feature should the nurse include? Tracks and trends occurrences of sepsis Calculates percentages of in-facility deaths from sepsis Creates a monthly report of occurrence of sepsis Produces an alert when criteria for sepsis is met

Produces an alert when criteria for sepsis is met

he mother of a preschool-age child is concerned because the child became normothermic after receiving a dose of acetaminophen but, 4 hours later, is febrile again. Which instruction should the nurse give the mother? Give a dose of aspirin. Give the child a cold bath. Take the child to the nearest emergency department. Provide another dose of acetaminophen.

Provide another dose of acetaminophen.

A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching? A. Record vital signs at the end of each shift. B. Recording vital signs provide critical information regarding a client's condition .C. Obtaining and documenting baseline vital signs is the responsibility of the AP. D. It is not necessary to record electronic blood pressure measurements.

Recording vital signs provides critical information regarding a client's condition.

The nurse is developing a plan of care for a patient with the nursing diagnosis Impaired Physical Mobility related to inactivity secondary to arthritis. The nurse and patient develop a goal of ambulating the hall three times a day with a wheeled walker. Which purpose should this goal help achieve? Evaluate the patient's response to the plan of care. Identify a time frame for an action to occur. Provide direction for nursing interventions. Measure the end result of nursing action.

Provide direction for nursing interventions.

A 7-year-old child presents with decreased pulse and respirations, severe shivering, and chills. The child's parent states the child has been playing outside in the snow without a coat. Which intervention should the nurse implement first? Administer warm whirlpool therapy. Immediately administer anti-inflammatories. Remove clothing and assess for frostbite. Provide dry clothing and warm blankets.

Provide dry clothing and warm blankets.

The parent of a 6-year-old child with a fever calls the nurse to report that the child will not drink water to replace fluid losses. Which instruction should the nurse give the mother? Bring the child to the emergency department for intravenous fluids. Explain to the child the need for drinking a lot of water. Provide extra fluids with popsicles and flavored gelatin. Encourage the consumption of milk and milk products with ice cream and yogurt.

Provide extra fluids with popsicles and flavored gelatin.

Which intervention is most appropriate for a patient with a functional urinary incontinence? Insert an indwelling catheter. Increase fluid intake to flush the kidneys. Provide normal fluid intake and establish a toilet schedule. Restrict fluid intake to decrease the episodes of incontinence.

Provide normal fluid intake and establish a toilet schedule.

The nurse is implementing care for patients in an acute care facility and asks a patient about dietary restrictions related to religion or ethnicity. Which nursing goal is the nurse meeting with this question? Provide culturally competent care. Follow prescribed dietary needs. Promote contentment in the patient. Determine need for special services.

Providing culturally competent care.

The nurse is discussing how the HITECH Act promotes the use of electronic health records (EHRs). Which information should the nurse include? Imposing penalties on providers who do not utilize EHRs Providing monetary incentives to providers who promote the use of EHRs Promoting a specific brand of EHR with the intention of having all providers use the same system Mandating the use of electronic medical records in the sharing of information

Providing monetary incentives to providers who promote the use of EHRs

A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? A. Tricuspid valve B. Pulmonary artery C. Right atrium D. Vena cava

Pulmonary artery

A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following? a) pulse deficit less than 10 b) radial pulse irregular c) apical pulse greater than radial d) pulse deficit of 13/min

Pulse deficit of 13/min

A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse? A. An older adult client who has pneumonia and a respiratory rate of 26/min after a position change B. An adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesic C. A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 mm Hg after using an inhaler D. An older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques

Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall.

A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take? Raise the side rail on the working side of the bed. Use the non-dominant hand to insert the catheter. Stand on the left side of the bed. Raise the bed to a comfortable height.

Raise the bed to a comfortable height. The nurse should raise the bed to a comfortable height to prevent personal musculoskeletal injury.

The nurse is assessing a 2-year-old patient for signs and symptoms that may be associated with an infection. Which assessment finding most reflects the manifestation of acute infection? Sharp increase in appetite Rapid onset of symptoms Pearly-gray tympanic membrane Sweaty, moist skin

Rapid onset of symptoms In children, acute otitis media or other viral infections may be associated with a rapid onset of symptoms and poor feeding. A nonbulging, nonretracted, pearly-gray tympanic membrane is a normal assessment finding that is not associated with an infection. Pallor, mottled, or flushed dry skin may be associated with an infection, not sweaty, moist skin.

The nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, Impaired because the wound has not healed within the time frame specified. The nurse chooses to revise the plan of care. Which step should the nurse perform first? Talk to the healthcare provider. Reassess the wound. Change the interventions. Set a new, reachable goal.

Reassess the wound.

A patient reports urine leakage. The nurse notes the following medical history: obesity, ambulation difficulty, smoking, and hypertension treated with diuretics. Which lifestyle intervention should the nurse suggest to the patient to reduce urinary incontinence? Decreasing activity Switching from cigarette smoking to chewing tobacco Reducing physical barriers to toileting Stopping all diuretics

Reducing physical barriers to toileting

After assessing a patient with urinary incontinence, the health care provider confirms that the patient is at risk of a life-threatening condition that causes severe elevation of the blood pressure and pulse rate as well as diaphoresis. Which type of of urinary incontinence does this patient have? Transient incontinence Stress urinary incontinence Reflex urinary incontinence Urgency urinary incontinence

Reflex urinary incontinence

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? Select all that apply. Relief of urinary retention Convenience for the nursing staff or the client's family Measurement of residual urine after urination Routine acquisition of a urine specimen An open perineal wound

Relief of urinary retention Measurement of residual urine after urination An open perineal wound Valid indications for urinary catheterization include urinary retention, bladder distention, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery.

The nurse is planning to suggest a dietary change to the mother of a 4-year-old child who has constipation. Which temporary change should the nurse suggest to see what is causing the constipation? Removing all fruit from the diet Removing cow's milk from the diet Removing vegetables from the diet Limiting the amount of grains consumed in the diet

Removing cow's milk from the diet

A patient is admitted to a clinic with urinary retention caused by a mechanical obstruction. The nurse should suspect which condition as the likely cause of the patient's condition? Repeated urinary tract infections Benign prostatic hyperplasia Anticholinergic medications Fecal impaction

Repeated urinary tract infections

The nurse notices pus in the catheter of a patient who had an indwelling catheter inserted 4 days ago. Which nursing measure is appropriate for this patient? Irrigating the catheter with 10 mL of water Replacing the catheter with a new one Irrigating the catheter with antiseptic solution Milking the catheter from proximal end to distal end

Replacing the catheter with a new one

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) Report of feeling pressure Tenderness over the symphysis pubis Distended bladder Voiding 30 ml frequently - Dysuria

Report of feeling pressure Distended bladder Dysuria Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. Tenderness over the symphysis pubis is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis. Distended bladder is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder, Voiding 30 ml frequently is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine. Dysuria is incorrect. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Dysuria, or painful burning with urination, is not a finding associated with urinary retention.

The nurse identifies the diagnosis Imbalanced Nutrition: Less than Body Requirements related to poor nutrition, as evidenced by low serum albumin level, for a 65-year-old patient with osteoporosis. Which format should the nurse use to write goals for this patient? SBAR PIE SMART CBE

SMART

A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? A. Pulse 52/min B. Respiratory rate 24 C. SaO2 97% right index finger, room air D. Blood pressure 132/86 mm Hg

SaO2 97% right index finger, room air

A patient reports having the urge to void, but urine starts leaking before the patient reaches the bathroom. Which treatment strategy would be helpful for this patient? Select all that apply. Scheduled toileting Absorbent products Electrical stimulation Clothing modification Antomuscarinic agents

Scheduled toileting Absorbent products Clothing modification

A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Apply the sensor probe on the chose site. B. Select the site for obtaining the measurement. C. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse. D. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter.

Select the site for obtaining the measurement is the first step. Apply the sensor probe on the chosen site is the second step. Confirm the pulse rate displayed on the oximeter by palpating the radial pulse is the third step. Wait 15 seconds and observe the SaO2 percentage displayed on the pulse oximeter is the fourth step.

Which diagnostic test is used to detect antibodies to infecting respiratory organisms? Serology testing Blood cultures Chest x-ray Pulse oximetry

Serology testing Serology testing is used to detect antibodies to respiratory pathogens. Blood cultures are used to identify possible bacteremia. A chest x-ray is used to determine interstitial infiltrates or consolidation. Pulse oximetry is used to determine oxygen saturation.

A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? A. Atrioventricular (AV) node B. Left ventricle C. Sinoatrial (SA) node D. Right ventricle

Sinoatrial (SA) node

The nurse is preparing a patient to ambulate for the first time after a prolonged period of bedrest. The patient reports dizziness when first standing. Which action should the nurse take first? Immediately return the patient to bed. Sit the patient on the edge of the bed until the dizziness passes. Call the healthcare provider. Immediately call for an ECG.

Sit the patient on the edge of the bed until the dizziness passes.

A patient develops paraplegia after a motor vehicle crash. Which information should the nurse include when teaching the patient to prevent pressure injuries? Slight weight shifts of only 10 to 15 degrees every 15-30 minutes can help promote circulation Use the trapeze to help slide up to the head of the bed Baby powder can be applied to bony prominences to prevent skin breakdown Reposition every 4 hours if using a special mattress

Slight weight shifts of only 10 to 15 degrees every 15-30 minutes can help promote circulation

Which result can occur from excess manipulation when performing a digital rectal examination to determine the presence of fecal impaction? Slowing heart rate Severe cramping Fluid and electrolyte imbalance Toxic buildup of magnesium

Slowing heart rate

Upon auscultating the abdomen of a patient with a stethoscope, the nurse hears high-pitched and hyperactive bowel sounds. The nurse identifies that the assessment findings correspond with which condition? Small intestine obstruction Normal bowel activity Fluid or gas within the abdomen Effects of abdominal surgery

Small intestine obstruction

A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response? A. Hypothermia B. Smoking C. Sleeping D. Aging

Smoking

A patient who is a smoker complains of involuntary passage of urine after a strong sense of urgency to void. Which nursing intervention would be helpful to this patient? Select all that apply. Crede method Smoking cessation Intermittent catheterization Antimuscarinic agents Behavioral interventions

Smoking cessation Antimuscarinic agents Behavioral interventions

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use? a. alcohol-based sanitizer b. soap and water c. iodine solution d. chlorhexidine solution

Soap and water

A patient with type 1 diabetes mellitus has a blister on the left heel caused by ill-fitting shoes. Which stage should the nurse document this injury to be? Stage 1 Stage 4 Stage 2 Stage 3

Stage 2

A patient with a pressure injury on the sacrum has obvious necrosis of subcutaneous tissue. For which pressure stage should the nurse plan care for this patient? Stage 1 Stage 2 Stage 3 Stage 4

Stage 3

The patient's urine specific gravity is 1.05. The urine tests positive for ketone bodies. Which condition is a possible cause? Select all that apply. Starvation Dilute urine Dehydration Overhydration Diabetes mellitus

Starvation Dehydration Diabetes mellitus

The nurse is reviewing laboratory results for patient and notices the urine tested positive for ketones. Which underlying factor may lead to the presence of urinary ketone bodies? Select all that apply. Epilepsy Starvation Dehydration Hyperthyroidism Uncontrolled diabetes mellitus

Starvation Dehydration Uncontrolled diabetes mellitus

While administering an enema to a patient, the nurse notes blood in the return fluid and rectal bleeding. Which action does the nurse take? Administer pain medication Slow down the rate of instillation Tell the patient to breathe slowly and relax Stop the instillation and obtain vital signs

Stop the instillation and obtain vital signs

The nurse is preparing a teaching session about use of a pessary device for a patient with urinary incontinence. Which type of urinary incontinence should the nurse suspect? Urge incontinence Stress incontinence Reflex incontinence Overflow incontinence

Stress incontinence

A patient presents to the emergency department with high fever and coughing. Which information should the nurse collect for analysis? Opinions Judgments Subjective data Inferences

Subjective data

A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be most beneficial in assisting the patient to void? Suggest that he stand at the bedside. Stay with the patient. Give him the urinal to use in bed. Tell him that if he does not urinate he will be catheterized.

Suggest that he stand at the bedside.

The nurse is caring for a pregnant patient diagnosed with cauda equina syndrome. Which procedure should the nurse expect to prepare the patient to undergo? X-rays Surgery CT scan MRI

Surgery

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection? a. reservoir b. susceptible host c. portal of entry d. portal of exit

Susceptible host

A nurse is performing a throat culture on a client. Which of the following actions should the nurse take? a. swab the back of the clients pharyngeal wall b. place the swab in a clean container after obtaining the culture c. insert the swab in the culture medium within 1 hours of obtaining the sample d. don sterile gloves to obtain the culture from the client

Swab the back of the client's pharyngeal wall.

The nurse is assessing a patient with a fever. Which other clinical manifestation should the nurse expect to find? Bradypnea Hyperglycemia Hypotension Tachycardia

Tachycardia

The nurse is teaching a patient how to take a nonsterioidal anti-inflammatory drug (NSAID). Which instruction should the nurse provide Take it on an empty stomach first thing in the morning. Take it with food or a full glass of water. Take it 2 hours after each meal. Take it 1 hour before checking temperature at home.

Take it with food or a full glass of water.

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? Remind the client to tell the nurse when he has to urinate. Use adult diapers to prevent frequent clothing changes. Take the client to the bathroom every 2 hr. Request a prescription for an indwelling urinary catheter.

Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

The nurse is reviewing the medication list with a pregnant patient who is complaining of painful incidences of constipation. Which should the nurse suggest as the cause of the patient's symptoms? Following a high-fiber diet Drinking 6-8 glasses of water daily Taking ibuprophen for discomfort Taking guaifenesin in the morning

Taking ibuprofen for discomfort

A patient who is bedridden with pressure injuries caused by frequent incontinence feels ignored by their family and is depressed about the situation. Which action should the nurse take to address the patient's situational low self-esteem? Teach the family how to conduct skin hygiene Teach the patient how to perform skin hygiene Encourage the family to bring the patient to the healthcare provider more often Encourage the family to spend more time with the patient

Teach the family how to conduct skin hygiene

A 70-year-old woman complains about involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when she coughs. The nursing assessment reveals that the patient is obese, has had three pregnancies, and has already gone through menopause. Which nursing interventions would help this patient reduce incontinence? Advise the patient to suppress coughs. Teach the patient Kegel exercises. Advise the patient to avoid caffeinated drinks. Stress the importance of losing eight. Encourage lifting heavy weight to increase muscle strength.

Teach the patient Kegel exercises. Advise the patient to avoid caffeinated drinks. Stress the importance of losing weight.

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? Temporary urinary retention Urinary frequency for several days Blood-tinged urine Highly concentrated urine

Temporary urinary retention Until the bladder regains its full tone, it is common for clients to develop urinary retention, If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.

A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? A. The AP pulls the pinna up and back when obtaining a tympanic temperature. B. The AP informs the client when they are counting the respirations. C. The AP gently presses down with the pads of two to three fingers over the radial pulse site. D. The AP selects a blood pressure cuff width that is 40% the circumference of the client's arm.

The AP informs the client when they are counting the respirations.

The nurse is caring for a patient with an infection who has been prescribed an intravenous antibiotic. Thirty minutes after administering the antibiotic, the nurse has the lab technician draw a blood sample. What is this test measuring? The minimum level of the antibiotic The trough blood level of the antibiotic The maximum blood level of the antibiotic The therapeutic range of the antibiotic

The maximum blood level of the antibiotic Blood is drawn at specific intervals after administration of antibiotics to measure antibiotic peak and trough levels. The peak level (maximum blood level of the antibiotic) is measured 30 minutes after the antibiotic is administered intravenously. The trough level (minimum blood level of the antibiotic) is measured about 15 minutes prior to the next dose. The therapeutic range refers to the minimum and maximum blood levels at which the drug is effective.

An older adult patient presents with hypothermia. The nurse should consider which process as contributing to the risk for this patient? The normal aging process decreases metabolism. The normal aging process decreases pain tolerance. The normal aging process decreases safety awareness. The normal aging process decreases the ability to shiver.

The normal aging process decreases metabolism.

The nurse is caring for a patient recovering from hypothermia. Which outcome should the nurse expect? The patient develops piloerection. The patient states the need to take antipyretics at the first sign of a fever. The patient is able to list early signs and symptoms of hypothermia. The patient's core temperature rises to 101.8°F (38.8°C).

The patient is able to list early signs and symptoms of hypothermia.

While assessing a patient for posture and gait, the nurse identifies a concave cervical spine, a convex thoracic spine, and a flattened lumbar spine. Which reason should concern the nurse in the light of these findings? The patient may have a herniated lumbar disc. The findings are suggestive of a bulging cervical disc. The patient may have a displaced thoracic disc. The findings are suggestive of lordosis.

The patient may have a herniated lumbar disc.

A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis. Which goal includes all elements of a goal statement? The patient will be given bronchodilators as prescribed. The patient will be instructed in use of the incentive spirometer every hour. The patient will be given supplemental oxygen to use via nasal cannula. The patient will demonstrate correct use of the incentive spirometer after the teaching session.

The patient will demonstrate correct use of the incentive spirometer after the teaching session.

The nurse is caring for a patient with malnutrition and identifies a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to poor oral intake secondary to cancer treatment. Which goal set by the nurse is an example of a specific and measurable goal? The patient will take in 80 grams of protein per day. The patient will experience no further nausea and vomiting. The patient will gain weight over the next few months. The patient will verbalize foods that are needed to gain weight.

The patient will take in 80 grams of protein per day.

Which short-term goal should the nurse view as appropriate for a patient with the nursing diagnosis Deficient Knowledge related to disease process secondary to diabetes? The patient will follow a diabetic diet with 90% compliance within 3 months. The patient will maintain blood sugars between 80 and 120 mg/dL within 1 month. The patient will identify ways to prevent complications from diabetes within 2 months. The patient will verbalize understanding of how insulin affects blood sugar by the end of the day.

The patient will verbalize understanding of how insulin affects blood sugar by the end of the day.

The nurse is evaluating the outcome of care provided to a patient who developed a postoperative fever. Which outcome indicates that care has been successful? The patient's heart rate is 100 beats/min, and respirations are 28 breaths/min. The patient's body temperature is 98.4°F (36.9°C) without the use of antipyretics. The patient's temperature spikes occur only during the night. The patient appears flushed and the skin is warm to the touch.

The patient's body temperature is 98.4°F (36.9°C) without the use of antipyretics.

A patient with abdominal pain is scheduled for a barium enema with air contrast. Which information does the nurse give to the patient before the procedure? Select all that apply. The procedure will help in the examination of the lower gastrointestinal (GI) tract The patient will need to take laxatives the day before the procedure No metallic objects should be worn during the procedure Light sedation is required The patient needs to lie very still

The procedure will help in the examination of the lower gastrointestinal (GI) tract The patient will need to take laxatives the day before the procedure

The nurse is caring for a patient with urinary incontinence who has been prescribed bladder-training behavior modification. Which goal of therapy should the nurse include in the teaching session with the patient? To improve pelvic floor muscle strength by stopping the urine flow during voiding and holding for a few seconds To toilet on a schedule that corresponds with the normal pattern To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times To toilet at regular intervals (e.g., every 2-4 hours)

To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times

While caring for a female patient with altered urinary elimination, the nurse instructs the patient to assume a squatting position when voiding. Which rationale is the reason behind the recommendation? To prevent infections To promote normal micturition To promote complete bladder emptying To help relieve stress urinary incontinence

To promote complete bladder emptying

A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene? A. Adult male who has a respiratory rate of 18/min B. Toddler who has a respiratory rate of 44/min C. Infant who has a respiratory rate of 56/min D. Adolescent female who has a respiratory rate of 16/min

Toddler who has a respiratory rate of 44/min

A patient who is taking opioids to control cancer-related pain develops constipation. On assessment, the nurse finds that the patient has abdominal distention and hypoactive bowel sounds. The nurse anticipates that the treatment plan will include which intervention? Select all that apply. Using laxatives Promoting water intake Withholding the opioids Encouraging high-fiber diet Training for relaxation techniques

Using laxatives Promoting water intake Encouraging high-fiber diet

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle? a. try to use alternatives before inserting indwelling urinary catheters b. use clean technique for insertion of indwelling urinary catheters c. check client every 2 days to evaluate the need for indwelling catheters d. disconnect the system to obtain urine samples from indwelling urinary catheters

Try to use alternatives before inserting indwelling urinary catheters.

A postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action would the nurse implement first? Encourage fluid intake. Administer pain medication. Catheterize the patient. Turn on the bathroom faucet as the patient tries to void.

Turn on the bathroom faucet as the patient tries to void.

The nurse is developing a plan of care for an immobile patient and is concerned about skin integrity. Which intervention is appropriate for the nurse to include? Turn the patient every 2 hours. Give the patient's skin a brisk rubdown daily. Reposition the patient every 4 hours. Allow the patient to sit up in a chair for as long as possible.

Turn the patient every 2 hours.

Which nonpharmacologic intervention should the nurse include in the plan of care to promote normal body temperature in a patient with a fever? Turning on a fan or the air-conditioning system Placing multiple blankets on the patient's bed Administering intravenous and oral fluids Providing warm chicken noodle soup

Turning on a fan or the air-conditioning system

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a. washes their hands for 10 seconds b. turns off the faucet with a towel c. uses hot water to wash their hands d. holds their hands above their elbows while rinsing off the soap

Turns off the faucet with a towel

While the nurse is preparing to assess a child's temperature, the parents report that the child had ear tubes placed last year. Which site should the nurse understand is contraindicated in this patient? Tympanic membrane Oral Rectal Axillary

Tympanic membrane

A patient reports feeling as if their bladder is always full, requiring frequent trips to the bathroom. The patient also reports difficulty starting their urine stream and a weak urine flow. After a postvoiding catheterization obtained 250 mL of urine, the patient was diagnosed with chronic urinary retention. Which clinical therapy should the nurse anticipate being ordered? Urethral dilation Radiation therapy Lithotripsy A vaginal device

Urethral dilation

The nurse is caring for a patient with urinary incontinence related to a urinary tract infection. Which diagnostic test would indicate if a urinary tract infection is contributing to urinary incontinence? Bladder diary 24-hour urine sample Postvoid residual Urinalysis

Urinalysis

A patient reports hematuria along with the pain. After reviewing the patient's chart and assessing the patient, the nurse documented the following nursing diagnosis: Acute Pain related to urinary obstruction secondary to prostate cancer. Which part of the nursing diagnosis statement reflects the etiology? Urinary obstruction Hematuria Prostate cancer Acute Pain

Urinary obstruction

The nurse is assessing an 80-year-old patient admitted with delirium and hyperthermia. Which medical diagnosis should the nurse expect to find in the medical record as the most likely cause? Autoimmune disorder Skin breakdown Malignant tumor Urinary tract infection

Urinary tract infection

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? Urinary tract infection Urinary incontinence Urinary frequency Urinary retention

Urinary tract infection A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCS, RBCS and bacteria, The urine often has an unpleasant odor.

Which statement provides the best description of telehealth? The ability of a patient to call a nurse to obtain medical advice over the phone The ability of a patient to access their medical record from a home computer Use of telecommunication technology to allow patients access to care otherwise inaccessible Use of a personal computer to research medical conditions to better self-diagnose

Use of telecommunication technology to allow patients access to care otherwise inaccessible

The nurse assesses that the patient has a full bladder, and the patient states that he/she is having difficulty voiding. Which instruction would the nurse provide the patient? Use the double voiding technique. Perform Kegel exercises. Use the Crede method. Keep a voiding diary.

Use the Crede method.

A nurse is discussing the use of a client's thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include? A. Select a blood pressure cuff width that is 25% of the circumference of the client's thigh. B. Palpate the femoral pulse when obtaining blood pressure in the thigh. C. Expect blood pressure in the thigh to be 10 to 15 mm Hg less than in the arm. D. Use the thigh to obtain blood pressure when a client has severe edema in their arms.

Use the thigh to obtain blood pressure when a client has severe edema in their arms.

The nurse is reviewing a patient's medical orders that include an electrocardiogram (ECG). Which is the most appropriate action by the nurse in light of the point-of-care model? Using a portable ECG machine to complete the patient's testing Notifying the patient that there may be a delay in obtaining the ECG test results Obtaining prior authorization from the patient's insurance company for the ECG Documenting completion of the ECG results in the patient's paper chart

Using a portable ECG machine to complete the patient's testing

A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? Omeprazole Vancomycin Ondansetron Diphenhydramine

Vancomycin The nurse should identify that vancomycin, an antibiotic, to be associated with nephrotoxic adverse effects.

The nurse is caring for a patient with hypothermia who is confused and disoriented. Which factor should the nurse identify as the primary reason for the patient's disorientation? Vasodilation of cerebral blood vessels Decreased levels of serum carbon dioxide Vasoconstriction of cerebral blood vessels Effects secondary to respiratory alkalosis

Vasoconstriction of cerebral blood vessels

The nurse is caring for a patient with severe frostbite of the feet. Which is the most common cardiac dysrhythmia that occurs with excessive handling of the patient's frostbitten extremities? Atrial tachycardia Ventricular fibrillation Premature atrial contractions (PACs) Premature ventricular contractions (PVCs)

Ventricular fibrillation

Which intervention would be most appropriate for the nurse to include in the plan of care for a child with nocturnal enuresis? Wake the child up during the night to use the bathroom. Use absorbent bed pads to prevent skin excoriation. Recommend counseling for the child to determine the cause. Administer medications for overactive bladder.

Wake the child up during the night to use the bathroom.

The nurse is teaching a group of hikers about the signs of heatstroke. Which signs should the nurse include? Warm, flushed skin without sweating and a temperature of 41.1°C (106°F) or higher Paleness, dizziness, nausea, vomiting, fainting, with a temperature of 38.5°C (101.3°F) Fluctuating temperatures of more than 2°C (5.3°F) above normal within 24 hours Body temperature alternating between periods of fever and periods of normal or subnormal temperatures

Warm, flushed skin without sweating and a temperature of 41.1°C (106°F) or higher

The nurse is caring for a child after a sledding injury. The nurse suspects the child has superficial frostbite. Which assessment finding supports the nurse's suspicion? Yellow appearance of the tip of the nose White appearance of the tip of the nose Hallucinations Presence of gangrene

White appearance of the tip of the nose

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? Insert the needle into the neediess port at a 60° angle. Withdraw 3 to 5 ml of urine from the port. Wipe the area of needleless port with sterile water. Don sterile gloves.

Withdraw 3 to 5 ml of urine from the port. The nurse should withdraw the required amount of urine which would be approximately 3 to 5ml for a urine culture or 30 mL for a routine urinalysis.

nurse is providing information to a client about what may happen if their urinary tract infection (UTI) is not treated. which of the following statements by the client indicates an understanding of the information? a. "I can develop a kidney infection called pyelonephritis. b. "I might have urinary retention." c. "I might become incontinent." d. "I can develop functional incontinence.

a, can develop kidney infection, pyelonephritis

nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. which of the following actions should the nurse take? a. Place the client in the dorsal recumbent position on a bedpan. b. Administer the enema while the client sits on the toilet. c. Administer an antidiarrheal medication 3 hr prior to the enema. d. Instill 200 mL of fluid over an hour at 15-min intervals.

a, client in dorsal recumbent on a bedpan

A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors? (Select all that apply.) a. History of irritable bowel syndrome b. A shortened urethra c. Cardiovascular disease d. Consumes large amounts of dairy in their diet e. Currently taking antibiotics for an infection

a, d, e

nurse prepping to collect urine sample for urinalysis using a reagent strip. this strip detects substances consistent with which condition? a. diabetes b. colon cancer c. pancreatitis d. pregnancy

a, diabetes

A nurse is planning care for a client who reports blood in their stool. Which of the following tests should the nurse anticipate the provider ordering? a. fecal occult blood test b. stool culture c. flexible sigmoidoscopy d. endoscopic retrograde cholangiopancreatography (ERCP)

a, fecal occult blood test

nurse is caring for a female client who has a prescription for a clean catch urine specimen. which of the following statements by the client demonstrates an understanding of how to provide a urine specimen? a. "I need to wipe from front to back with a sanitary wipe." b. "I should place the urine sample cup in the refrigerator." c. "I will begin the urination process in the specimen cup." d. "I will urinate in the urine tray for the nurse to collect."

a, front to back w wipe

nurse is teaching a client about diagnostic urinary testing. which of the following should the nurse include in the teaching about cystometric testing? a. Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins. b. Cystometric testing measures urine speed and volume. c. Cystometric testing measures bladder pressure when urinary leakage occurs. d. Cystometric testing measures electrical activity of the muscles and nerves of the bladder and sphincters.

a, measures bladder capacity, pressure, final capacity when urge begins

which test should nurse anticipate being ordered if presence of WBC is detected on urinalysis? a. urine culture b. bladder scan c. 24-hr urine d. stool culture

a, urine culture

nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. which of the following actions should the nurse take? a. Warm the enema solution prior to instillation. b. Prepare 1,500 mL of enema fluid. c. Use tap water as the enema fluid. d. Hang the enema container 24 inches above the anus

a, warm first

nurse is preparing to remove a client's indwelling urinary catheter. which of the following actions should the nurse take? a. Pull the catheter out as quickly as possible b. Deflate the balloon completely before removal. c. Cut the inflation port to deflate the balloon. d. Tell the client to expect to feel a tugging sensation on removal.

b, deflate balloon completely

nurse is caring for a client who has constipation and requires an enema. which of the following actions should the nurse take when administering the enema solution? a. Instruct the client to lie on their right side with their left leg pulled up to their chest. b. Instruct the client to lie on their left side with their right leg pulled up to their chest. c. Instruct the client to lie on their left side with both legs pulled up to their chest. d. Instruct the client to lie on their right side with both legs pulled up to their chest.

b, lie on left side with right leg pulled up to chest (For enema use, clients are instructed to lie on their left side and place their right leg up to their chest. The enema is inserted through the anus and into the rectum and sigmoid colon. The plastic container is then squeezed until all of its contents have been emptied.)

client who is postoperative is experiencing abdominal distention and is having difficulty expelling flats. nurse should expect the provider to prescribe which of the following types of enemas? a. Cleansing b. Return-flow c. Medicated d. Oil-retention

b, return-flow

A nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and is experiencing diarrhea. Which of the following should the nurse identify as a potential cause of the diarrhea? a. The antibiotic dose is not correct, and the provider should be alerted. b. The antibiotic interferes with the client's ability to absorb nutrients. c. The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow. d. The antibiotic decreases a client's immunity level, resulting in diarrhea.

c, antibiotic eliminates healthy GI bacteria, so harmful bacteria can grow

nurse is caring for a group of newly admitted clients. for which of the following clients should the nurse expect to receive a prescription for urinary catheterization? a. A client who has a persistent urinary tract infection. b. A client who has urge incontinence. c. A client who is in the ICU for a gastrointestinal bleed. d. A client who has incontinence due to cognitive decline.

c, client in ICU

nurse caring for client who has a colostomy and doesn't wear a pouch. which action should nurse anticipate performing on client to maintain expected bowel function? a. administer an enema b. administer a laxative c. perform colostomy irrigation d. insert rectal tube

c, colostomy irrigation

nurse caring for client with suspected dehydration. which of the findings should the nurse monitor for this client? a. oral temp of 36.4ºC (97.5ºF) b. light yellow urine c. dry mucus membranes d. diaphoresis

c, dry mucus membranes

nurse caring for client w constipation. which diet should nurse instruct client to follow? a. low fat b. high protein c. high fiber d. low carb

c, high fiber