NIC semester 3, ATI fundamentals

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

A, B, D These are within the AP's range of function all others require a nurse.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 ml of the medication from a 2ml vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

A. Ask another nurse to observe the medication wastage.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries B. Move hazardous objects away from the client. C. Notify the provider D. Ask the client to describe how she felt prior to the fall.

A. Check the client for injuries. The other options are not the first action.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. Press gently on the tragus of the client's ear. B. Pack a small piece of cotton deep into the client's ear canal. C. Move the client's auricle down and back toward her head. D. Tilt the clients head backward for 5 min.

A. Press gently on the traugus of the ear will help the medication get into the inner ear. Pushing in cotton could damage the ear, the auricle should be moved upward and back to straighten canal, and the client should lie on their side with ear upward for 2-5 minutes to let gravity move the medication.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. which of the following actions should the nurse take? A. Turn the client every 2 hr. B. Administer an entiemetic every 6 hr. C. Hold oral care D. Increase the room's temperature.

A. Turn the client every 2 hr. Turning the cient at least once every 2 hrs will break up the secretions in the clients lungs and prevent noisy respirations. Antiemetics are for nausea and vomiting, to keep mouth moist provide frequent oral care, keeping it cool with decrease clients air hunger and increase comfort.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. A. place a name tag on the body. B. obtain the pronouncement of death from the provider C. Remove tubes and indwelling lines. D. Wash the client's body E. Ask the client's family members if they would like to view the body.

B, C, D, E, A

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? Select all that apply A. Lacrimal apparatus B. pupil clarity C. Appearance of bulbar conjuctivae D. Visual fields E. Visual acuity

B,D,E

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? A. "I can place an extension cord across my living room to plug in my television." B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." C. " I will place my alarm clock on my bedroom dresser across the room." D. "I will replace the old throw rug in my kitchen with a new one."

B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." Extension cords should be fastened to the floor, frequently used items like an alarm clock, glasses, or disposable tissues should be within reach, throw rugs increase risk and should be removed.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? A. request that a respiratory therapist discuss the technique for incentive spirometry with the client B. Determine the reasons why the client is refusing to use the incentive spirometer C. Document the client's refusal to participate in health restorative activities D. Administer a pain medication to the client

B. Determine the reasons why the client is refusing to use the incentive spirometer.

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

B. Use tracheostomy covers when outdoors. The out cannula should not be removed, in home care is asepsis, and hydrogen peroxide can irritate the skin. It is better toclean with 0.9% sodium chloride to irrigate and cleans the site.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A. The client uses a wool blanket on their bed. B. the client uses nonacetone nail polish remover. C. the client stores and extra oxygen tank on its side under their bed. D. the client has a weekly inspection checklist for exygen equipment.

B. the client uses nonacetone nail polish remover. client should use nonflammable materials around supplemental oxygen. Cotton should be used instead of wool, oxygen tanks should be stored upright, and caregivers should inspect oxygen equipment daily.

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

C. Make sure two fingers can fit under the sleeve to prevent inhibition of circulation. The client should be in dorsal recumbent or semi-fowler's. The nurse should place the sleeve under each leg with an opening. The pressure should be between 35-65.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? A. Role ambiguity B.. Sick role C. Role overload D. Role Conflict

C. Role overload. Sick role refers to expectations placed on the individual who as health issues, Role conflict develops when a person must assume multiple roles that conflict.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Instill the 15ml of irrigation fluid into the catheter with each flush. C. Subtract the amount of irrigant used from the client's urine output. D. Perform the irrigation using a 20ml syringe

C. Subtract the amount of irrigant used from the client's urine output. The client should be supine or dorsal recumbent for maximum access, the open irrigation requires 30-40ml of fluid, and the nurse will need a 30-50ml syringe to perform the irrigation.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. Combine client care tasks when caring for multiple clients. B. Wait until the end of the shift to document client care. C. Use the planning step of the nursing process to prioritize client care delivery. D. Allow for interruptions in tasks to discuss client care issues with colleagues.

C. Use the planning step of the nursing process to prioritize client care delivery. The nurse should complete tasks for one patient before beginning another client. Documentation should be done timely throughout care, and controlling interruptions is a time management principle.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A. insert the needle at a 15 degree angle B. Aspirate for blood return prior to administration. C. administer the medication into the abdomen. D. massage the site following the injection.

C. administer the medication into the abdomen. The nurse should instruct the client to insert the needle at 90 to 45 degrees sc. The nurse should not aspirate for blood return as this will cause tissue damage, and so would massaging the site after injection.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. the top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 46cm forward C. the client holds the cane on the stronger side of her body. D. the client moves her stronger limb forward with the cane.

C. the client should hold the cane on the stronger side of her body to increase support and maintain alignment. The top of the cane should be parallel to the greater trochanter, the client should only advance the cane 14-30cm at a time, the client should move the weak leg with the cane for support.

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings, and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? A. the client is receiving formula at room temperature B. the feedings infuse at a slow, continuous drip over 8 hr each night C. the client's caregiver washes out the feeding bag with warm water once every 24hr D. the client's caregiver flushes the tubing with water before and after administering medications.

C. the client's caregiver washes out the feeding bag with warm water once every 24hr. Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination.

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

D. Abdominal cramping. low sodium level manifests as cramping, weakness, confusion, and lethargy. Chvosteks sign is a manifestation of hypomagnesemia and hypocalcemia. Tachycardia is a manifestation of hyponatremia along with hypovolemia.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer. B. focus teaching on what the client will need to do in the future to manage his illness. C. provide the client with written information about the phases of loss and grief D. Reassure the client that this is an expected response to grief.

D. Reassure the client that this is an expected response to grief. The client might perceive the discussion of risk factors as challenging or argumentative, the nurse should focus the teaching on the present psychosocial adaptation and not the future management, unless the client requests material this is not a good time, this is when the client needs to express their feelings.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A. Bend at the waist B. Keep his feet close together C. Use his back muscles for lifting D. Stand close to the cabinet when lifting it

D. Stand close to the cabinet when lifting it. The action keeps the cabinet close to the nurse's center of gravity and decreases back strain. You should bend at the knees, and use arms and legs to lift the cabinet.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A. Have the client wear a mask when receiving visitors B. Limit the client's time with visitors to no more than 30 min per day C. Assign the client to a room with a negative pressure airflow exchange D. Wear a gown when caring for the client

D. Wear a gown when caring for the client. Shigella is contact precautions.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? Select all that apply A. Lacrimal apparatus B. Pupil clarity C Appearance of bulbar conjuctivae D. Visual fields E. Visual activity

Pupil clarity, if it clouds over they may have cataracts The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and back in again. The nurse should use a Snellen chart to assess the distance vision, uses handheld cards to assess near vision.

A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many ml/hr? round to nearest whole number

107

A nurse is preparing to administer enoxaparin subcutaneously to a client. which of the following actions should the nurse take? A. Administer the medication with the needle at a 45 degree angle. B. Administer the medication into the client's non-dominant arm C. Pull the clients skin laterally or downward prior to administration D. massage the injection site after administration

A. Administer the medication with the needle at a 45 degree angle. Subcutaneous injections should be inserted at 45 to 90 degree angles. Enoxaparin is given in the abdomin, and the z track method is for IM injections. Massaging the site of an anticoagulant will increase bruising.

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

A. During the admission process. The initiation of discharge planning does not depend on the client's condition, and you can not consult with family unless the client gives permission to share that information.

A nurse is assessing a client's readiness to learn about insulin self administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. I can concentrate best in the morning B. It is difficult to read the instructions because my glasses are at home C. I'm wondering why I need to learn this D. You will have to talk to my wife about this.

A. I can concentrate best in the morning

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. Pad the client's wrist before applying the restraints. B. Evaluate the client's circulation every 8 hr after application C. Remove the restraints every 4 hr to evaluate the client's status D. Secure the restraint ties to the bed's side rails

A. Pad the client's wrist before applying the restraints. The nurse should evaluate the client's circulation ever 15min, the nurse should remove the restraints every 2 hr to reposition, the nurse should remove and assess needs for hygiene, the nurse should secure the restraint ties to a part of the bed frame that moves with the client.

A nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client? A. Use a bed exit alarm system B. Raise four side rails while the client is in bed C. Apply one soft wrist restraint. D. Dim the lights in the client's room

A. Use a bed exit alarm system

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? A. Use a bed exit alarm system B. Raise for side rails while the client is in bed C. Apply one soft wrist restraint D. Dim the lights in the client's room

A. Use a bed exit alarm system. Raising four side rails is a form of restraint, so is applying even one wrist band. Dimming the lights will decrease visibility and increase falls and risk for injury.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. Use the complete name of the medication magnesium sulfate B. Delete the space between the numerical dose and the unit of measure C. Write the letter U when noting the dosage of insulin D. Use the abbreviation SC when indicating an injection

A. Use the complete name of the medication magnesium sulfate.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A. advocacy ensures clients' safety, health and rights B. Advocacy ensures that nurses are able to explain their own actions C. Advocacy ensures that nurses follow through on their promises to clients D. Advocacy ensures fairness in client care delivery and use of resources.

A. advocacy ensures clients' safety, health and rights

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

A. examine personal values about the issue. Nurses should give care that is without bias. The nurse should provide information but not push care as "necessary", parents must give consent for blood transfusions, and the provider should give information about the procedure not a spiritual support person.

a nurse is caring for a client who has a respiratory infection. which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A. Insert the suction catheter while the client is swallowing B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with her clean, nondominant hand.

B. Apply intermittent suction when withdrawing the catheter. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. The nurse should insert the suction while the client is inhaling to avoid inserting into the esophagus, discard the suction catheter to eliminate the risk for infection, and the nurse should use her dominant hand with a sterile glove.

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

B. Droplet

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A. Use the Face, Legs, Activity, Cry, and Consolability pain rating scale for a client who is experiencing pain. B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum D. Palpate the client's abdomen before auscultating bowel sounds.

B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? A. I am not worried because I still have hope that he will be okay. B. I am relying on support from our family during this time C. We can plan our family reunion once he recovers and comes home. D. We don't see any reason to start discussing funeral arrangements right now

B. I am relying on support from our family during this time.

A nurse is initiating a protective enviornment for a client who has had an allogeneic stem cell transplant. which of the following precautions should the nurse plan for this client? A. make sure the client's room has atleast six air exchanges per hour. B. Make sure the client wears a mask when outsider her room if there is construction in the area C. Place the client in a private room with negative-pressure airflow. D. Wear and N95 respirator when giving the client direct care.

B. Make sure the client wears a mask when outsider her room if there is construction in the area. The client's immune system is compromised and needs protection from breathing in pathogens. The room should have atleast 12 air exchanges per hour, the room should have positive airflow, and an N95 is for airborne precautions not protective environment.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A. Carry a client's soiled linens out of the room in a mesh linen bag. B. Place a client who has tuberculosis in a room with negative pressure airflow C. Provide disposable plates and utensils for a client who is HIV positive D. Dispose of a client's blood saturated dressing in a trash bag inside a second trash bag

B. Place a client who has tuberculosis in a room with negative pressure airflow. A client with airborn precautions should be in a room with negative pressure airflow to reduce transmission.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45 degree angle B. Place the client's arm in a dependent position C. Shave excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand

B. Place the client's arm in a dependent position. This position will help the veins dilate due to gravity.

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

B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. The nursse should regulate the flow by aligning the middle of the ball, the reservoir bag of a partial rebreather should inflate one third to one half, and only use water-soluable lubricant to protect the client's skin.

A nurse is preparing a change of shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A. Critical pathway B. Situation, background, assessment, and recommendation C. Transfer report D. Medication administration record.

B. Situation, background, assessment, and recommendation

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A. they allow the court to oveerrule an adult client's refusal of medical treatment B. They indicate the form of treatment a client is willing to accept in the event of a serious illness C. They permit a client to withhold medical information from health care personnel D. They allow health care personnel in the emergency department to stabilize a client's condition

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

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. We would consult the person appointed by your health care proxy to make decisions B. We would give you oxygen through a tube in your nose C. You would give you oxygen through a tube in your nose. D. We would insert a breathing tube while we evaluate your condition

B. We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A. A lesion with uniform pigmentation B. New appearance of petechiae C. A mole with an asymmetrical appearance D. The presence of a papule

C. A mole with an asymmetrical appearance. An uneven or asymmetrical shape is a potential indication of a skin malignancy.

The nurse is assessing a client who has required bed rest for the past month. which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

C. Calf swelling. bladder distention is from urinary retention, bed rest can cause postural hypertension, and a decrease in bowel sounds is a sign of perstalisis which can lead to constipation.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location

C. Compare the client's home medications with the provider's prescriptions. Verify the client's name when administering medication, the nurse should call the pharmacy when medications are not available, and a client's home meds should be secured.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication the the treatment was successful? A. Increase in hematocrit B. Increase in respiratory rate C. Decrease in heart rate D. Decrease in capillary refill time

C. Decrease in heart rate. Fluid volume deficit causes an increase in RR with correction it should return to range, capillary refill will return, and hematocrit should decrease.

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

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

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

C. It might help me to listen to music while I'm lying in bed

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire". Which of the following responses should the nurse make? A. You would have so much more time to spend with your family B. You should consider getting a part-time job or doing volunteer work C. Lets talk about how the change in your job status will affect you D. Why wouldn't you want to retire and relax?

C. Lets talk about how the change in your job status will affect you.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? A. biofeedback B. Aloe C. Feverfew D. Acupuncture

D. Acupuncture The nurse should inform the client that any skin infection is a contraindication for acupuncture. An open portal in the skin could spread the infection. Feverfew is an alternative therapy that promotes wound healing. Aloe is complementary to wound healing. Biofeedback assists clients with stroke recovery.

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

D. Administer pain medication 45 min before changing the client's dressing.

A nurse receives report about a client who has NS infusing IV at 125ml/hr. When the nurse performs the initial assessment, he notes that the client has received only 80ml over the last 2 hr. Which of the following actions should the nurse take first? A. reposition the client B. Document the client's IV intake in the medical record. C. Request a new IV fluid prescription. D. Check the IV tubing for obstruction.

D. Check the IV tubing for obstruction. The nurse should reposition but this isn't the first step, the nurse should document but this too isn't the first step. The nurse should request new IV fluid prescription to compensate for lost fluid but this isn't the first step.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A. Protective environment B. Airborne precautions C. Droplet precautions D. Contact precautions

D. Contact precautions. Major wound infections require contact precautions.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. position the client with the head of the bed elecated to 30 degrees prior to insertion of the NG tube B. Remove the NG tube if the client begins to gag or choke. C. Apply suction to the NG tube prior to insertion D. Have the client take sips of water to promote insertion of the NG tube into the esophagus

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus. The client should be in high-fowlers position, the nurse shoud withdraw the NG tube slightly not remove it if the client gags, the nurse should not apply suction unless NG tube is verified by x-ray.

The nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D. Hydrocolloid promote healing in stage 2 by creating a moist wound bed. Alginate dressing are for stage 3 and 4 injuries to absorb drainage, moist guaze is for stage 4 or unstageable dressing that need debridement, transparent dressing are for stage 1 to prevent further friction.

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

D. Is your pain sharp or dull? Asking the pain scale determines intensity, asking constant or intermittent determines onset duration and pattern of pain, asking if it radiates determines the location.

The nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? A. Document the provider's statement in the medical record B. Complete an incident report C. Consult the facility's risk manager D. Notify the nursing manager.

D. Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status, therefore the next action is to activate the chain of command to ensure the client receives care.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dl B. Creatinine 0.8 mg/dl C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D. Potassium 5.4 mEq/L. Potassium should be 3.5-5. Bun is 10-20, Creatinine is 0.5 - 1.1, Sodium is 136-145