Nurs 112-C (ATI) Final

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

the caregiver insists on remaining in the room

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? A. "Support the majority of your weight on the axillae." B. "Keep your elbows extended." C. "Bear weight on both of your legs." D. "Move both crutches forward at the same time."

"Bear weight on both of your legs."

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

"Client found lying on floor"

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

Assist the client to an upright position.

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

Compare prescriptions with medications the client received while at the facility.

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

"All of this equipment can be frightening."

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?

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

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

"The pain is like a dull ache in my stomach."

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

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

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr

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 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. Does this sound indicate which of the following?

Narrowed arterial lumen

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)

Narrowed arterial lumen (Bruit)

A nurse is caring for a client who requires bed rest and has a prescription for anti embolic stockings. Which of the following actions should the nurse take?

Remove the stockings at least once per shift.

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

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

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?

Semi-Fowler's

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

Sit at the bedside while feeding the client.

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

a client who smokes one pack of cigarettes each day

Indwelling urinary catheter A. remove catheter B. bladder scan C. pull on the catheter D. all of the above

bladder scan

The ethical principle of veracity

nurse tells client she has cancer

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

evacuate the client

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

Airborne

A nurse on a surgical unit is receiving a client who had abdominal surgery from the post-anesthesia care unit. Which of the following assessments should the nurse make first? A. Pain level B. Hydration status C. Airway D. Urinary output

Airway

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions.

A nurse is preparing to delegate client care tasks to an assistive personnel (ap). which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Auscultate lung sounds.

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b. a nurse asks a nurse from another unit to assist with documentation for a client c. a nurse who is caring for a client returns a call to a person appointed in the health care proxy to discuss the client's care d. a nurse discussed a client's status with the physical therapist who is caring for the client.

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

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

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

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with her documentation.

A nurse is admitting a client who has active TB to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for this client?

A room with air exhaust directly to the outdoor environment

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

A) Place the client in a room with negative-pressure airflow. B) Wear gloves when assisting the client with oral care. E) Use antimicrobial sanitizer for hand hygiene.

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

Calf swelling

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?

Check the client for injuries.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process. a. seal unused medications from the facility in a plastic bag b. evaluate the client's ability to self-administer medications c. report an identified discrepancy to The Joint Commission. d. compare prescriptions with medications the client received while at the facility

Compare prescriptions with medications the client received while at the facility.

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?

Contact precautions

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

Eggs

A nurse is assessing a client who is receiving TPN. Which of the following findings should the nurse recognize as a complication to this therapy?

Hyperglycemia

A nurse is caring for a client who is 48 hr. postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? A. Blood loss B. NPO status after surgery C. Nasogastric tube suctioning D. Impaired peristalsis of the intestines

Impaired peristalsis of the intestines

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. inserts an implanted port b. closes a laceration with sutures c. places an endotracheal tube d. initiates an enteral feeding through a gastrostomy tube

Initiate an enteral feeding through a gastrostomy tube

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

Medication dose

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." b. "Beginning at age 60, you should have a colonoscopy." c. "You should have a fecal occult blood test every year." d. "The recommendation is to have a sigmoidoscopy every 10 years."

"You should have a fecal occult blood test every year."

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

"You should receive a pneumococcal immunization every 10 years."

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? a. "You should have an eye exam every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should have a fecal occult blood test every 2 years" d. "You should receive a pneumococcal immunization every 10 years"

"You should receive a pneumococcal immunization every 10 years."

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

8 oz of ice chips

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

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

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

0.3 mg

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oil is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?

A client who has asthma.

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 is the nurse's priority action?

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

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 his condition is a contraindication for which of the following therapies?

Acupuncture

A nurse is preparing to delegate client care tasks to a assistive personnel (ap). which of the following tasks should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic

Ambulating a client who is postoperative

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension.

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.)

B) Pupil clarity D) Visual fields E) Visual acuity

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

Have family members wear a gown and gloves when visiting.

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

Press gently on the tragus of the client's ear.

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? A. Sunken eye balls B. Hypotension C. Poor skin turgor D. Bounding pulse

Bounding pulse

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply)

Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouth piece with an alcohol swab after each use D. Use the spirometer every 8 hr.

Cough deeply after each use.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

Cover the incision with a moist sterile dressing.

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decrease calcium B. Decreased potassium C. Increased potassium D. Increased calcium

Decreased calcium

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

Droplet

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment

Droplet

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

Edema at the infusion site

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?

Erythema on pressure points

A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? A. Activate the emergency fire alarm. B. Extinguish the fire. C. Evacuate the client. D. Confine the fire.

Evacuate the client

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

Fidelity

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

Have the client stand with her arms at her side and her feet together.

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

Have the client stand with her arms at her side and her feet together.

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?

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

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

Have the client use a trapeze bar when changing position.

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

Loss

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

Rapid heart rate

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

Rapid heart rate

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body.

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Ventrogluteal

Ventrogluteal

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? A. WBC 15,000 mm3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063

WBC 15,000 mm3

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

Walking briskly

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

apply an ankle-foot orthotic device to the client's feet

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

current medications

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

distended neck veins

the ethical principle of veracity nurse tells client she has cancer

nurse tells client she has cancer

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

practice sessions

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. Advanced directives.

we can talk about advanced directives brochures

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

"Client found lying on floor"

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

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

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

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

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you."

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this."

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?

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

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

"What could I have done to deserve this illness?"

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"When descending stairs, I will first shift my weight to my right leg."

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "When descending stairs, I will first shift my weight to my right leg." b. "I should place my crutches 12 inches in front and to the side of each foot." c. "As I sit down, I will hold one crutch in each hand." d. "I will make sure the shoulder rests are snug against my armpits.

"When descending stairs, I will first shift my weight to my right leg."

A nurse at an extended-care facility is instructing a class of APs about the use of assistive devices during ambulation. Which of the following should the nurse give the APs about the client's use of a cane?

"When the client moves, he should move the cane forward first."

A nurse is preparing a heparin solution infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr

A nurse is preparing a heparin solution A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr.

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

Wrap monitoring cords with stockinette and tape them in place.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

Daily weight

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min. B. Fill the bag two-thirds full of ice. C. Place the ice bag uncovered on the client's ankle. D. Tell the client that it is expected to feel numbness when the ice bag is in place.

Fill the bag two-thirds full of ice.

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

Flush the tube with 15 mL of sterile water.

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

Gently shake the container of medication prior to administration.

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

Hemolytic

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

Initiate an enteral feeding through a gastrostomy tube.

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

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

The nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? a. instruct the family to refrain from pushing the button for the client while she is asleep b. inform the client that because she is on PCA, vital signs will be taken every 8 hours c. teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10 d. increase the basal rate and shorten the lock-out interval time if the client's pain level is too high

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

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

N95 respirator

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

Place the client's arm in a dependent position.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pin from the extinguisher D. Sweep the hose from side to side to dispense material

Remove the safety pin from the extinguisher

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

Role overload

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. Two-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg Test

Romberg test

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A.Sit at the bedside while feeding the client. B. Order pureed foods. C. Make sure feeding are at room temperature. D. Offer the client a drink of fluid after every bite.

Sit at the bedside while feeding the client.

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

Skin blanching

The nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? a. purulent exudate b. warmth c. skin blanching d. bleeding

Skin blanching

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

Skin blanching

A 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?

Stand close to the cabinet when lifting it.

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia

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

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

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

Use a clock pattern to describe food on the client's plate.

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

Use progressive relaxation techniques at bedtime.

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes

Washing dishes

A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown.

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

When lifting an object, spread your feet apart to provide a wide base of support.

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

Withhold the blood transfusion

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

Witness the client's signature on the consent form.

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed

A nurse is caring for a client who has a terminal diagnosis and who's health is declining. Advanced directives. A)"We can talk about advance directives, and I can also give you some brochures about them." B)"You should set up a time to talk with your provider about that." C)"Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." D)"Why do you want to discuss this without your partner here to plan this with you?"

we can talk about advanced directives brochures, and I can also give you some brochures about them

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? A. "You won't need the equipment very long." B. "All of this equipment can be frightening." C. "Why does the equipment bother you?" D. "Let me tell you about what each machine does."

"All of this equipment can be frightening."

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? A. "I would try to get it over with because you won't get better without this tube." B. "You should talk to your provider about it." C. "Why don't you want the tube inserted?" D. "I can see that this is upsetting you."

"I can see that this is upsetting you."

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? a. "most people are happy when their children grow up and leave home" b. "you should be proud that your children are becoming independent" c. "maybe you should consider why you are feeling useless" d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

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

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply) a. check the cord routinely for frays and tearing b. keep the unit at least 1.2 m (4 feet) away from a gas stove c. consider purchasing a generator for power backupd. observe for signs of hypoxia d. select synthetic clothing and bedding

-Check the cord routinely for frays or tearing -Consider purchasing a generator for power backup -Observe for signs of hypoxia

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations. C. Prepare to administer oxygen. D. Give the client a back rub to help her relax.

-Observe the rate -depth -character of the client's respirations.

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Set the suction machine at 120 mm HG B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares.

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

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg

0.3 mg

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Inject 5 units of air into the bottle of regular insulin 2) Withdraw the correct dose of NPH insulin from the bottle 3) Inject 10 units of air into the bottle of NPH insulin 4) Withdraw the correct dose of regular insulin from the bottle

3) Inject 10 units of air into the bottle of NPH insulin 1) Inject 5 units of air into the bottle of regular insulin 4) Withdraw the correct dose of regular insulin from the bottle 2) Withdraw the correct dose of NPH insulin from the bottle

A nurse is calculating a client's fluid intake over the past 8 hour. Which of the following items should the nurse plan to document on the client's intake and output record as 120ml of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea

8 oz of ice chips

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells. B. A client who is being transported for a radiography of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization

A client who has a prescription for a transfusion of packed red blood cells

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oil is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? a. A client who has a history of physical abuse b. A client who has a permanent pacemaker c. A client who has ulcerative colitis d. A client who has asthma

A client who has asthma.

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream

Gelatin

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation

Assessment

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound.

Cleanse the wound from the center outward

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia

Cold extremities

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the client's provider and verify the prescription D. Ask the client if she takes this medication at home.

Consult the medication reference book available on the unit.

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles. B. Educating clients about the recommended immunization schedule for adults. C. Teaching clients who have type 1 diabetes mellitus about care of the feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually

Educating clients about the recommended immunization schedule for adults

A nurse is giving a change of shift report about a client admitted earlier who has pneumonia

breath sounds

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? A. Ask the client if he want to self-administer his insulin. B. Have the client list the steps of the procedure. C. Have the client demonstrates the procedure. D. Ask the client if he understands the purpose of insulin.

Have the client demonstrates the procedure.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a. place the client in high-Fowler's position. b. increase the client's intake of carbohydrates c. massage reddened areas with unscented lotion d. have the client use a trapeze bar when changing position

Have the client use a trapeze bar when changing position.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

Hemolytic

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? A. Inspection B. Auscultation C. Percussion D. Palpation

Inspection

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric ulcers C. Respiratory depression D. Liver damage

Liver Damage

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A. Loss B. Trust C. Self-disclosure D. Risk-taking

Loss

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? A. Place a padded tongue blade in the client's head. B. Lower the client to the floor and place a pad under the client's head. C. Seek the help of a coworker and life the client back to bed. D. Use an oropharyngeal airway to keep upper airway passages open.

Lower the client to the floor and place a pad under the client's head.

A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A. Carminative B. Hypertonic C. Oil retention D. Sodium polystyrene sulfate

Oil retention

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? A. BT for bedtime B. SC for subcutaneously C. PC for after meals D. HS for half-strength

PC for after meals

A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? A. "People who practice the Islamic faith pray over the decreased for a period of 5 days before burial." B. "People who practice the Hindu faith bury the deceased with their head facing north." C. "People who practice Judaism stay with the body of the deceased until burial." D. "People who are practicing the Buddhist faith have the female family members prepare the body following death."

People who practice Judaism stay with the body of the deceased until burial.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in Trendelenburg's position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain

Place the client in Trendelenburg's position.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the client's mouth open. C. Rinse the client's mouth with an alcohol-based mouth wash following the procedure D. Cleanse the client's mucous membranes with lemon-glycerin sponges

Place the client in a lateral position with the head turned to the side before beginning the procedure.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6in.) B. Wear sterile gloves to insert the tubing. C. Position the client on his left side. D. Hold the solution bag 91 cm (36 in) above the client's rectum.

Position the client on his left side.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500 mg/day of vitamin E C. Limit fluid intake to 20 ml/kg of body weight per day D. Provide a protein intake to 1.5g/kg of the body weight per day

Provide a protein intake of 1.5 g/kg of body weight per day.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion five times during each session B. Move the joint to the point of considerable resistance C. Sit approximately 2 feet from the side of the bed closest to the joint being exercised D. Exercise the smaller joints first.

Repeat each joint motion five times during each session.

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea

Tachycardia

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. rinse the feeding bag with water between feedings b. tell the client to keep the head of the bed elevated at least 30 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol

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

1. A assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures that there are no kinks in the drainage tubing.

The AP hangs the collection bag at the level of the bladder.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? a. the nurse opens the sterile field on a wet surface b. the nurse opens the first fold away from his body c.the nurse holds sterile objects above the waist d. the outer edge of the sterile field is touching the bottle

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

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

The situation, background, assessment, and recommendation (SBAR)

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? A. Use battery-operated equipment for personal care B. Apply mineral oil to protect the facial skin from irritation C. Remove the television set from the client's bedroom D. Wear cotton clothing to avoid static electricity

Wear cotton clothing to avoid static electricity.

A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest.

Wear gloves when changing the client's gown.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. client flow sheet b. acuity ranges c. current medications d. incident reports

current medications

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. Hypotension (FVD) b. Weak thread pulse (FVD) c. Slow capillary refill (FVD) d. Distended neck veins

distended neck veins

A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. Activate the emergency fire alarm. b. Extinguish the fire. c. Evacuate the client. d. Confine the fire.

evacuate the client

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? a. medication name b. route of administration c. medication dose d. frequency of administration

medication dose (The dose because Mg missing)

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions

practice sessions

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. "what could I have done to deserve this illness?" b. "I blame medical science for not curing me" c. "where is my daughter at a time like this? d. "will I ever begin to feel in charge of my life again?"

"What could I have done to deserve this illness?"

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg

Rapid heart rate

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

Reassure the client that this is an expected response to grief.

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed B. Tie the restraint with a quick-release knot C. Allow one finger's breadth between the restraint and the client's chest. D. Place the restraint under the client's clothing

Tie the restraint with a quick-release knot.

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? A. This image does not show the correct pressure reading. B. This image does not show the correct pressure reading. C. This image does not show the correct pressure reading. D.To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff

To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? A. Stand 3 feet from the client when assisting with lifting B. Lock your knees when standing for long periods C. Lift up to 22.6 kg (50lbs) without the use of assistive devices D. When lifting an object, spread your feet apart to provide a wide base of support.

When lifting an object, spread your feet apart to provide a wide base of support.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? a. ask the client to consider a direct donation b. withhold the blood transfusion c. request a consultation with the ethics committee d. ask the client's family to intervene

Withhold the blood transfusion

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. describe the procedure to the client b. witness the client's signature on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure

Witness the client's signature on the consent form.

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a. "this type of hearing aid does not allow for fine tuning of volume" b. "I shouldn't have trouble keeping the hearing aid in place during exercise c. "I expect to hear a whistling sound when I first insert the hearing aid" d. "I will be sure to remove my hearing aid before taking a shower"

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

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? A. "I can take echinacea to improve my immune system." B. "I can take feverfew to reduce my level of anxiety." C. "I can take ginger to improve my memory." D. "I can take ginkgo Biloba to relieve nausea"

"I can take echinacea to improve my immune system."

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good working order."

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A. " A lot of clients who are cared for at home have the same problem." B. "Don't worry about it. He will get a bath, and that will tae care of the odor." C. It must be difficult to care for someone who is confined to bed." D. "When was the last time that he has a bath?"

"It must be difficult to care for someone who is confined to bed."

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? A. "Don't worry, teenagers often have friends who give them bad advice." B. "I think you should stop seeing those friends since they discourage you from following your treatment plan." C. "Tell me more about how your friends discourage you." D. "Tell me where you met these friends."

"Tell me more about how your friends discourage you."

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild pain" b. "the pain is like a dull ache in my stomach" c. "I notice that the pain gets worse after I eat" d. "the pain makes me feel nauseous"

"The pain is like a dull ache in my stomach."

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Ask the client if he can bear weight 2) Use the stand-and-pivot technique to move the client to the chair 3) Position the chair on the left side of the bed 4) Have the client sit and dangle his feet at the bedside

1) Ask the client if he can bear weight 3) Position the chair on the left side of the bed 4) Have the client sit and dangle his feet at the bedside 2) Use the stand-and-pivot technique to move the client to the chair

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle

1- Inject 10 units of air into the bottle of NPH insulin1) 2- Inject 5 units of air into the bottle of regular insulin4) 3- Withdraw the correct dose of regular insulin from the bottle2) 4- Withdraw the correct dose of NPH insulin from the bottle

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? A. A 2-month-old can turn from his abdomen to his back B. A 10-month-old infant can pull up to a standing position C. A 4-month-old infant can sit up without support D. A 6-month-old infant can crawl on his hands and knees.

A 10-month-old infant can pull up to a standing position.

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

an x-ray

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a. wrap blankets around all 4 sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside

Wrap blankets around all four sides of the bed

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Wrap monitoring cords with stockinette and tape them in place. B. test patients with a latex bandage to see if they are really allergic C. use latex products anyways because the patient will be under general anesthesia D. place a latex sign on the patient's room door

Wrap monitoring cords with stockinette and tape them in place.