Nursing 111 Final Exam Review. ATI Questions

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? a) "I flavor my meat with lemon juice." b) "I eat two eggs for breakfast every morning." c) "I cook my food with canola oil." d) "I take an omega 3 supplement daily."

b) "I eat two eggs for breakfast every morning." Clients should limit eggs yolks to two to three per week.

A nurse is teaching an assistive personnel (AP) about using personal protective equipment whole caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? a) "I will wear gloves whenever I am in contact with clients." b) "I will wear gloves and a gown when bathing a client who has open skin lesions." c) "I will wear gloves to minimize the number of times I have to wash my hands." d) "I will wear gloves when measuring a client's blood pressure."

b) "I will wear gloves and a gown when bathing a client who has open skin lesions." The AP should wear personal protective equipment when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.

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

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

A nurse is providing dietary, teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods is the best source of protein to promote wound healing? a) one cup of brown rice b) one cup of orange juice c) one cup of puréed avocado d) one cup of lentils

e) one cup of lentils The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. 1 cup of lentils contain 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nothing legumes are good sources of protein to include in a plant-based diet such as a vegan diet.

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180 mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice-cream. How many mL should the nurse document as the client's total intake for the shift?

1,720 mL

A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide? a) "Crushing the medication might cause you to have a stomachache or indigestion." b) "Crushing the medication is a good idea, and I can mix it in some ice cream for you." c) "Crushing the medication would release all the medication at once, rather than over time." d) "Crushing is unsafe, as it destroys the ingredients in the medication."

a) "Crushing the medication might cause you to have a stomachache or indigestion." The pill is enteric-coated to prevent breakdown in the stomach and decrease the possibility of GI distress. Crushing the pill destroys that protection.

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? a) "I will call for pain medication before the previous dose wears off." b) "I will call for pain medication as my pain starts to increase again." c) "I will wait for you to evaluate my pain before asking for more medication." d) "I will ask for less pain medication to avoid addiction."

a) "I will call for pain medication before the previous dose wears off." The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe.

A nurse is teaching a client about how to use her hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? a) "I will clean the hearing aids with alcohol wipes." b) "I will not use hairspray if I am wearing the hearing aids." c) "I will change the batteries once a week." d) "I will expect the hearing aids to whistle when I cup my hand over them."

a) "I will clean the hearing aids with alcohol wipes." Alcohol use can break down the mechanism of the hearing aids. The client should follow the manufacturer's instructions, which usually include using a soft cloth to remove cerumen and other debris and never immersing them in water.

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching? a) "It might take up to 3 days for the medication to work." b) "I will take the medication for diarrhea." c) "I should drink 4 oz of water when I take the medication." d) "I can take this medication along with mineral oil."

a) "It might take up to 3 days for the medication to work." The client understands docusate sodium is a stool softener and the therapeutic effect might take up to 3 days to achieve.

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription or docusate sodium. Which of the following statements by the client indicates an understanding of the teaching? a) "It might take up to 3 days for the medication to work." b) "I will take the medication for diarrhea." c) "I should drink 4 oz of water when I take the medication." d) "I can take this medication along with mineral oil."

a) "It might take up to 3 days for the medication to work." The client understands docusate sodium is a stool softener and the therapeutic effect might take up to 3 days to achieve.

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching. a) "without treatment, glaucoma can cause blindness." b) "double vision is a common symptom of glaucoma." c) "glaucoma is caused by inadequate production of fluid within the eye." d) "use of eye drops will improve vision over time."

a) "without treatment, glaucoma can cause blindness." The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (SELECT ALL THAT APPLY) a) "your provider might prescribe anticholinergic medication" b) "you should limit fluids in the evening." c) "you should restrict your intake of caffeine." d) "you might require intermittent urinary catheterization." e) "you might require an anterior vaginal repair."

a) "your provider might prescribe anticholinergic medication" b) "you should limit fluids in the evening." c) "you should restrict your intake of caffeine."

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time? a) Check the client's medical record for the provider's prescription. b) Explain to the client that the provider prescribed the procedure. c) Assure the client that enemas are commonly prescribed for constipation. d) Inform the charge nurse that the client refused the enema.

a) Check the client's medical record for the provider's prescription. The nurse should use the client's medical record to verify the provider prescribed an enema for the client.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (SELECT ALL THAT APPLY) a) Excessive laxative use b) Ignoring the urge to defecate c) Inadequate fluid intake d) Increased fiber in the diet e) Increased activity

a) Excessive laxative use b) Ignoring the urge to defecate c) Inadequate fluid intake

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? a) Increases heart rate. b) Decreased respiratory rate. c) Hyperactive bowel sounds. d) Decreased blood pressure.

a) Increased heart rate Acute pain stimulates the sympathetic nervous system and can cause an increase in heart rate.

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain. a) Lower left quadrant b) Upper left quadrant c) Lower right quadrant d) Upper right quadrant

a) Lower left quadrant The nurse should expect the client to have abdominal pain in the lower left quadrant of the abdomen. The disease is usually found in the sigmoid colon, where high pressure to move fecal contents form the rectum causes pouch formation.

A nurse is completing an admission assessment on an adolescent client who is vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet? a) peanut butter and jelly sandwich b) baked potato topped with sour cream c) bagel with cream cheese d) fruit salad

a) PB&J a vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Peanut butter is an excellent source of protein. A peanut butter and jelly sandwich, especially if prepared on protein-enriched bread, can provide almost 20g of protein.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching a) protein b) calcium c) vitamin B1 d) vitamin D

a) Protein protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first? a) Provide the appropriate PPE to the AP. b) Notify the charge nurse about the AP's need for training. c) Volunteer to provide an inservice about infection control. d) Speak with the AP when he exits the room about the appropriate protocol.

a) Provide the appropriate PPE to the AP. Due to the potential for the spread of infectious organisms to other clients the AP cares for, the nurse should intervene by providing the appropriate PPE right away.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? a) apply a moisture barrier ointment to the client's skin b) clean the client's skin and perineum with hot water after each episode of incontinence. c) check the client's skin every 8 hr for signs and breakdown d) request a prescription for the insertion of an indwelling urinary catheter.

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

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? a) apply the bag 30 min at a time. b) reapply the bag 30 min after removing it. c) allow the room for some air inside the bag. d) place the bag directly on the skin.

a) apply the bag for 30 at a time. the nurse should leave the bag in place for 30 mins, but should check the client's skin after 15 min to make sure there are no adverse effects.

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use? a) ask the client's full name and date of birth b) verify the client's room number c) check the client's name on the medication administration record (MAR) d) ask a family member to verify the client's identity

a) ask the client's full name and date of birth The nurse must use two identifiers before administering medications. Acceptable identifiers include the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge.

A nurse is assessing a clients radial pulse and determines that the pulses irregular. Which of the following actions should the nurse take? a) assess the apical pulse for a full minute b) assess the apical pulse with a Doppler device c) assess the pedal pulses for a full minute d) assess the pedal pulses with a Doppler device

a) assess the apical pulse for a full minute for clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulse stations for 30 seconds and multiplied by two. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity and irregularity of the heart.

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check? a) at the client's bedside before administration b) in the area where the nurse obtained the medication c) at the time of documentation d) at the nurses' station while reviewing the provider's prescription

a) at the client's bedside before administration The nurse should perform the final medication check at the client's bedside while reviewing the package's label.

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (SELECT ALL THAT APPLY) a) Broth b) Grape Juice c) Nonfat milk d) Custard e) Lemon Gelatin

a) broth fat-free broth is an acceptable component of a clear liquid diet. Coffee and tea are also acceptable. b) grape juice grape juice is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice. e) lemon gelatin lemon gelatin is an acceptable component of a clear liquid diet, along with sugar, honey, hard candy, and ice pops.

A nurse is admitting a client who has prescribed antibiotic therapy and now has a C.Diff infection. Which of the following actions should the nurse take? a) disinfect equipment in the client's room daily b) place the client in a protective environment c) use alcohol hand sanitizer after completing tasks for the client d) have the client wear a mask when out of the room.

a) disinfect equipment in the client's room daily. The nurse should disinfect equipment in the client's room every day, or when visibly soiled, to minimize the C. difficile spores in the client's room. The nurse should choose a solution that is effective against spores.

A nurse is instructing a group of clients regarding nutrition. Which of the following is a good source of omega-3 fatty acids that the nurse should include in the teaching? a) fish b) corn oil c) dietary supplements d) leafy green vegetables

a) fish fish is an excellent source of omega-3 fatty acids.

A nurse has just finished a wound irrigation for a client ho requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? a) gloves b) gown c) face shield d) mask

a) gloves The greatest risk to safety is pathogen transmission. The gloves are the most contaminated item of PPE, so the nurse should remove them first. Failing to remove the most contaminated item first increases this risk.

A nurse is developing an education program for a community group about dietary intake of vitamins and minerals in the diet. The nurse should include which of the following foods as sources of vitamin C? (SELECT ALL THAT APPLY) a) green pepper b) orange c) cabbage d) strawberries e) milk

a) green pepper Green peppers are a source of vitamin C, and should be included as a source of vitamin C. b) orange oranges are a good source of vitamin C, and should be included as a source of vitamin C. c) cabbage cabbage should be included as a source of vitamin C d) strawberries strawberries should be included as a source of vitamin C

A nurse is teaching a client who has constipation about a high fiber diet. Which of the following foods should be included as sources of fiber. (SELECT ALL THAT APPLY) a) kidney beans b) blackberries c) refined cereals d) whole wheat bread e) lean turkey

a) kidney beans kidney beans should be included in the teaching as a source of fiber b) blackberries blackberries should be included in the teaching as a source of fiber d) whole wheat bread Whole wheat bread should be included in the teaching as a source of fiber

A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? (SELECT ALL THAT APPLY) a) kidney beans b) blackberries c) refined cereals d) whole wheat bread e) lean turkey

a) kidney beans b) black berries d) whole wheat bread

A nurse is teaching a class of older adults about the expected physiological changes of aging. Which of the following changes should the nurse include in the discussion? (SELECT ALL THAT APPLY) a) more difficulty seeing due to a greater sensitivity to glare b) decreased cough reflex c) decreased bladder capacity d) decreased systolic blood pressure e) dehydration of intervertebral discs

a) more difficulty seeing due to a greater sensitivity to glare b) decreased cough reflex c) decreased bladder capacity e) dehydration of intervertebral discs

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing action should the nurse take to promote the clients comfort? a) obtain a pair of slipper-socks for the client b) run the clients feet briskly for several minutes. c) increase the clients oral fluid intake d) place a moist heating pad under the clients feet

a) obtain a pair of slipper-socks for the client in cold weather, or when the clients feet are cold, he should wear extra socks, or slipper socks, to help provide warmth, and increase his level of comfort

A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding? a) obtain a venous duplex ultrasound b) obtain impendance plethysmography c) Monitor Homan's sign d) Apply cold therapy to the affected leg

a) obtain a venous duplex ultrasound venous duplex ultrasonography is a non-invasive diagnostic test that assesses the flow of blood and is used to detect distal deep vein thrombosis ( DVT )

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (SELECT ALL THAT APPLY) a) Offer the client a back rub. b) Remind the client to use incisional splinting c) Identify the client's pain level. d) Assist the client to ambulate e) Change the client's position

a) offer the client a back rub is correct Nonpharmacological comfort measures can improve pain management b) remind the client to use incisional splinting is correct Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. c) Identify the client's pain level is correct The nurse should use a standard scale to determine and document the severity of the client's pain. d) Change the client's position is correct. Nonpharmacological measures for managing pain include repositioning imagery, and distraction.

A nurse is caring for a client who has stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? a) transparent dressing b) wet-to-dry gauze dressing c) hydrogel dressing d) alginate dressing

a) transparent dressing A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? a) urinary tract infection b) urinary incontinence c) urinary frequency d) urinary retention

a) urinary tract infection A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCs, RBCs and bacteria. The urine often has an unpleasant odor.

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamin that promote would healing should the nurse include in the teaching? (SELECT ALL THAT APPLY) a) vitamin A b) vitamin B12 c) vitamin C d) vitamin D e) vitamin K

a) vitamin A Vitamin A is important for tissue synthesis, wound healing, and immune functioning. b) vitamin B12 Vitamin B12 assists in the development of red blood cells, maintenance of nerve function, and is needed for cell maintenance and tissue synthesis. c) vitamin C Vitamin C is important for capillary formation, tissue synthesis, and wound healing. e) vitamin K Vitamin K functions as an enzyme in the synthesis of prothrombin and other proteins requires for normal blood clotting.

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a) "I wish I didn't have to attach the electrodes to my skin." b) "It's unfortunate that I have to be in the hospital for this treatment." c) I'll need to shave the hair off the skin where I place the electrodes." d) "I hope I don't have to take as many pain pills."

b) "It's unfortunate that I have to be in the hospital for this treatment." TENS units are portable. The client can use his TENS unit at home or wherever he chooses.

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage? a) .2 mg b) 0.2 mg c) 0.20 mg d) 2.0 mg

b) 0.2 mg The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point, but should not follow a decimal point unless a whole number follows the zero, as in 1.05 mg.

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium? a) 1 cup carrot strips b) 3 oz canned salmon c) 1 cup chopped chicken breasts d) 1 plain baked potato

b) 3 oz canned salmon The nurse should recommend canned salmon as a food to increase calcium intake. A 3 oz serving of canned salmon contains 197 mg of calcium

A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the following foods should the nurse recommend? a) Carrots b) Raisins c) Maple syrup d) Orange juice

b) Raisins Foods high in iron are recommended to improve a low hemoglobin level. Raisins are a high source of iron.

A nurse is teaching a client who is postpartum and has ben diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan? a) Yogurt and mozzarella b) Spinach and beef c) Milk and turkey slices d) Fish and cottage cheese

b) Spinach and beef Spinach and beef are high in iron and would be recommended for this client.

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching? a) the client should drink two to three 8 oz glasses of water each day b) The client should follow a high-fiber diet to establish bowel regularity. c) The client should try to take in all of the required dietary fiber with the morning meal. d) The client should be taught that the goal of therapy is to have a bowel movement daily.

b) The client should follow a high-fiber diet to establish bowel regularity. The client who has chronic constipation should consume a diet with high-fiber food sources, including bran and complex carbohydrates.

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? a) call the client's provider b) assess the client c) notify the nurse manager d) complete an incident report

b) assess the client The first action the nurse should take using the nursing process is to assess the client. The nurse must first determine whether or not the error has caused the client any harm and also provide any relevant interventions.

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? a) sleep on the abdomen to facilitate would healing b) avoid lifting anything heavier than 4.5 kg (10lb) for 1 week c) bend at the waist to pick objects up from the floor d) notify the surgeon if white drainage develops on the eyelids

b) avoid lifting anything heavier than 4.5 kg (10lb) for 1 week The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? a) steatorrhea b) blood c) bacteria d) parasites

b) blood A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.

A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet? a) carrots b) broccoli c) cabbage d) potatoes

b) broccoli broccoli is high in calcium. Most vegetables contain considerably less calcium, except for kale, collard greens with stems, and turnip greens, which are also good sources of calcium.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? a) ask the x-ray technician to come to the client's room to obtain a portable x-ray. b) have the client wear a mask c) notify the x-ray department that the client requires airborne precautions d) wear a filtration mask and gloves during transport

b) have the client wear a mask When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse on a medical surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? a) respiratory alkalosis b) increased anteroposterior diameter of the chest c) oxygen saturation level 96% d) petechiae on chest

b) increased anteroposterior diameter of the chest The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? a) elevating her feet b) massaging her legs c) flexing her ankles d) ambulating soon after surgery

b) massaging her legs massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is caring for an older client who was alert and orientated at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? a) call the family and ask them to stay with the client b) move the client to a room closer to the nurses' station c) apply wrist a leg restraints to the client d) administer medication to sedate the client

b) move the client to a room closer to the nurses' station This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.

A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. Diff) infection. Which of the following actions should the nurse plan to take? a) place a surgical mask on the client during transport b) Place the client on contact precautions c) use an alcohol-based agent to perform hand hygiene when caring for the client. d) obtain a blood specimen to test for C. Diff

b) place the client on contact precautions Clients who have manifestations of C. difficile should be placed on contact isolation until proven otherwise to prevent cross-transmission to uninfected and potentially susceptible clients.

A nurse is teaching a class about safe medication administration. The nurse include in the teaching that which of the following references are acceptable for safe medication administration? (SELECT ALL THAT APPLY) a) a website that ends in .com b) published journals c) pharmacists d) physicians' desk reference e) pharmaceutical sales representative

b) published journals c) pharmacists d) physicians desk reference

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? a) apply a heat lamp twice a day b) reposition the client at least every 2 hours c) clean the wound with hydrogen peroxide solution d) massage reddened areas with dressing changes

b) reposition the client at least every 2 hours The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

A nurse is establishing health promotion goals for a female client, who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals for the nurse include? a) the client will list foods that are high in calcium, which should be avoided. b) the client will walk for 30 min 5 days a week. c) the client will increase calorie intake by 200 calorie per day d) the client will replace cigarettes with smokeless tobacco products

b) the client will walk for 30 min 5 days a week. CDC recommendations include engaging in moderate exercise, such as walking, for a total of 150 minutes each week

A nurse is providing teaching about nutrition to a group of clients. The nurse should include that which of the following foods contains the highest level of thiamine per serving? a) 1 hard boiled egg b) 1 cup dried pears c) 1 cup whole grain wheat flour d) 1 cup brussel sprouts

c) 1 cup whole grain wheat flour Whole or enriched grains contain 0.981 mg thiamine, which is the highest level of thiamine.

A nurse is teaching a group of adults about nutrition. The nurse should include which of the following amounts as an appropriate daily intake of fiber for adult women? a) 5 to 10 g b) 10 to 15 g c) 20 to 35 g d) 40 to 50 g

c) 20 to 35 g The adequate intake (AI) for total fiber for women is 20 g per day; therefore 10 g would not be adequate.

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? a) Liver b) Milk c) Beans d) Eggs

c) Beans any food that does not contain animal products does not contain cholesterol. Beans are good source of protein for a client who follows a low-cholesterol diet.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should perform first? a) Reposition the client. b) Administer the medication. c) Determine the location of the pain. d) review the effects of the pain medication.

c) Determine the location of the pain. The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administrating pain medication, repositioning the client, and teaching the client about the effects of the medication.

A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain? a) FACES scale b) OUCHER scale c) FLACC scale d) PANAD scale

c) FLACC scale The FLACC scale is used for children 2 months to 7 years. It uses facial expression, leg movement, activity, cry, and consolability to assess the client's level of pain.

A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of food contains the highest level of carbohydrates? a) Milk, eggs, and cheese b) Butter oils, and avocados c) Rice, potatoes, and oranges d) Chicken, green beans, and apple

c) Rice, potatoes, and oranges This group of foods contains the highest level of carbohydrates

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? a) Remind the client to tell the nurse when he has to urinate. b) Use adult diapers to prevent frequent clothing changes. c) Take the client to the bathroom every 2 hr. d) Request a prescription for an indwelling urinary catheter.

c) Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? a) Pertussis b) Mycoplasma pneumonia c) Tuberculosis d) Respiratory syncytial virus

c) Tuberculosis Tuberculosis is transmitted by small droplets. Therefore, nurses providing care to clients who have tuberculosis should wear individually fitted N95 respirator masks.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? a) nausea b) dysphagia c) agitation d) hypotension

c) agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange

A nurse is caring for an older adult client who is disorientated and has a history of falls. Which of the following actions should the nurse take? (SELECT ALL THAT APPLY) a) raise all side rails on the client's bed b) obtain a prescription to restrain the client PRN c) check on the client hourly d) instruct the client in the use of the call light e) apply ambulation alarm to the client's leg.

c) check on the client hourly Implementation of hourly rounds facilitates safety by reducing client falls. Hourly nursing actions should include toileting, turning, and ensuring that possessions and call lights are within reach. d) instruct the client about use of the call light Call lights are used for communication with nursing staff. When clients call for and wait for assistance before getting out of bed, the occurrence of accidents and falls is minimized. Nursing staff should make sure the call light is within the client's reach and should instruct the client frequently about its use. e) apply an ambulation alarm to the client's leg The ambulation alarm signals when the client's leg is in a dependent position, such as over the side rail or on the floor. The signal alerts the staff to check on the client immediately.

A nurse is caring for a client who is unconscious and has breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? a) kussmaul respirations b) apneustic respiration c) cheyne-stokes respirations d) stridor

c) cheyne-stokes respirations Cheyne stokes respirations (CSR) are characterized by a rhythmic increase and decrease in the rate and depth of respiration. CSR are common respiratory alteration seen in clients, who are unconscious, comatose, or moribund.

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? a) he is hard of hearing b) pain c) confusion d) language barrier

c) confusion Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion.

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take? a) contact the pharmacy and confirm that the dosage is safe to administer. b) ask another nurse to verify that the dosage is appropriate for the client. c) contact the provider to question the dosage. d) inform the charge nurse and administer the dose of the medication the provider prescribed.

c) contact the provider to question the dosage. When a nurse believes there is an error in a prescription, the nurse must question the provider.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the clients lunch tray? a) lemon sherbet b) plain yogurt c) cranberry juice d) carrot juice

c) cranberry juice cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

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

c) droplet The nurse should initiate droplet precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? a) bear down hard when defecating. b) drink four to five glasses of water daily c) increase dietary intake of raw vegetables d) limit activity

c) increase dietary intake of raw vegetables The client should increase dietary intake of raw vegetables to help provide fiber in the diet, which will increase stool bulk and move the stool through the colon to prevent constipation.

A nurse is preparing medication for a client when another client has an emergency. Which of the following action should the nurse take? a) have another nurse guard the medication preparations until the nurse returns b) have another nurse finish preparing medications c) lock the medication in a room and finish preparing it after returning from the emergency d) discard the prepared medications and begin again after returning

c) lock the medication in a room and finish preparing it after returning from the emergency no one else should have access to or administer medications a nurse has prepared. Securing them and returning later to finish, preparing and administering them, decreases the risk of medication errors.

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection? a) changing the client's bed linens each day b) encouraging the client to consume a high-protein diet c) performing hand hygiene before, during, and after direct contact with the client d) placing the client in a room with positive-pressure airflow

c) performing hand hygiene before, during, and after direct contact with the client The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after client care procedures.

A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan? a) oranges b) cashews c) red meat d) yogurt

c) red meat red meat is a good source of iron. If the client is vegetarian, kidney beans with high iron content are a good substitute.

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray? a) cranberry juice b) flavored gelatin c) skim milk d) chicken broth

c) skim milk Full liquids include milk and milk products, so the client may now ask for skim milk.

A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron? a) fiber b) vitamin A c) Vitamin C d) oxalates

c) vitamin C vitamin C enhances the bodies absorption of iron

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

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

A nurse is teaching a client about which foods she should include in her low-fiber diet. Which of the following statements indicates the client understands the teaching. a) "A fresh pear would be a good snack option" b) "I can prepare refried beans for supper." c) "Bran cereal would be a good breakfast choice." d) "I should choose white rice as a side dish."

d) "I should choose white rice as a side dish." White rich is a refined grain and has less fiber than whole or unrefined grains. The client can include white rice as part of a low-fiber diet.

A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make? a) "Why would you want to put your partner's health at further risk?" b) "Everyone likes food from home, but it can delay your partner's recovery." c) "You will need to discuss your concerns about your partner's diet with the provider." d) "Let's try to find ways to incorporate your partner's favorite food into her diet plan."

d) "Let's try to find ways to incorporate your partner's favorite food into her diet plan." this response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the partner to modify the proposal so that is meets the client's dietary needs at this time.

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statement should the nurse identify as an indication of the client needs further teaching? a) "I will be able to tell how much oxygen i'm getting by looking at the flowmeter." b) "i should call my doctor if i find it harder to concentrate." c) "i will make sure my visitors smoke outside." d) "i will wear synthetic clothing and woolen socks when using my oxygen."

d) "i will wear synthetic clothing and woolen socks when using my oxygen." woolen and synthetic materials can generate static electricity. Because oxygen is a flammable gas, the client should wear cotton clothing and use cotton bedding and blankets.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? a) Creatine kinase b) Troponin c) Total bilirubin d) Albumin

d) Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.

A nurse is caring for a client who has chronic obstructive, pulmonary disease (COPD). This client tells a nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious, bronchial secretions? a) maintaining a semi Fowlers position as often as possible b) Administering oxygen via nasal cannula at 2 L per minute c) Helping the client select a low salt diet d) Encouraging the client to drink 2 to 3 L of water daily

d) Encouraging the client to drink 2 to 3 L of water daily COPD is a term for two diseases of the respiratory system ; chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitator expectoration

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? a) Mix the three medications together prior to administering. b) Dilute each medication with 10 mL of tap water. c) Maintain the head of the bed in a flat position for 30 min following medication administration. d) Flush the NG feeding tube with 30 mL of water immediately following medication administration

d) Flush the NG feeding tube with 30 mL of water immediately following medication administration The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.

A nurse is caring for a 6-month-old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure? a) Decreased heart rate b) Decreased respiratory rate c) Increased formula consumption d) Increased crying episodes

d) Increased crying episodes Infants and children younger than 7 years of age may exhibit certain behavior that suggests pain. Some of the behavioral indicators include facial expressions, legs drawn, increased activity, and excessive crying with inability to be consoled. The FLACC (faces, legs, activity, cry, and consolability) pain scale is frequently used to monitor postoperative pain.

A nurse is teaching a newly hired group of assistive personnel (AP) abut infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? a) Properly disposing of contaminated equipment b) Discarding used syringes in appropriate containers c) Changing soiled linens daily for clients who have draining wounds d) Performing hand hygiene frequently and consistently

d) Performing hand hygiene frequently and consistently The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care.

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

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

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? a) BUN b) Potassium c) RBC count d) WBC count

d) WBC count An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

A nurse is reviewing the medication administration records for the previous shift. Which of the following findings should indicate to the nurse a need for an incident report? a) a client received gentamicin intermittent IV bolts over 1 hr b) a nurse used a 25-gauge 3/8 inch needle to administer a heparin injection c) a nurse injected Demerol IM into the vastus lateralis sit of of adult d) a client received a crushed bupropion XL tablet mixed with applesauce

d) a client received a crushed bupropion XL tablet mixed with applesauce extended or sustained release medications are intended to release medication levels over a long period of time to sustain therapeutic relief. Crushing, breaking, or chewing and extended release. Medication releases the medication at once into the bloodstream, and could be like-threatening. Mixing this medication in applesauce deviates from standard of care and requires the nurse to complete an incident report.

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? a) a client who has scabies b) a client who has pertussis c) a client who has streptococcal pharyngitis d) a client who has measles

d) a client who has measles A client who has measles requires airborne precautions as well as a negative pressure room.

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should nurse take? a) request a prescription for an oral formulation of the medication b) administer the crushed medication through the NG tube c) dissolve the medication in water and give it through the NG tube d) administer the medication under the client's tongue

d) administer the medication under the client's tongue The nurse should administer the sublingual medication under the client's tongue. Sublingual preparations work via direct absorption into the bloodstream. Swallowing it exposes it to gastric juices, which can inactivate the medication.

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? a) pernicious anemia b) dehydration c) prostate enlargement d) bladder infection

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

A nurse is transcribing a clients medication prescriptions and is having difficulty reading a written prescription by the provider. Which of the following nursing action should the nurse take? a) clarify the prescription with the clients family b) interpret the prescription based on the clients health history c) ask the pharmacist for clarification of the prescription d) contact the provider to clarify the prescription

d) contact the provider to clarify the prescription The nurse should contact the provider for clarification of the prescription to confirm the correct interpretation of the prescription

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? a) speak using his usual tone of voice b) stand directly in front of the client c) rephrase statements the client does not hear d) determine if the client uses hearing aids

d) determine if the client uses hearing aids The first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning.

A nurse in a public clinic is planning a health fair for older adult client in the community. And teaching medication, safety, which of the following foods should the nurse advisor clients to avoid when taking their prescriptions? a) carbonated beverage b) milk c) orange juice d) grapefruit juice

d) grapefruit juice there is a high rate of blood drug interactions between grapefruit juice and many medication, frequently taken by older adults, especially lipid lowering agents. It is thought that one or more of the chemicals in grapefruit juice alter the activity of specific enzymes in the intestinal tract. These enzymes decrease the rate at which medication enter the systemic circulation. This could allow a larger amount of these drugs to reach the bloodstream, resulting in increase drug levels, and possibly toxicity.

A nurse is assessing a client who has urine output of 250 mL in a 24-hour period. Which of the following descriptive terms should the nurse place in the client's electronic record? a) enuresis b) anuria c) nocturia d) oliguria

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

A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse tell the family members to omit? a) boiled rice b) flat bread c) broiled fish fillet d) pickled vegetables

d) pickled vegetables due to a pickling brine, pickled vegetables are high in sodium. The family should not bring this food item to the client.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The clients oxygen saturation is 85%. Which of the following action should the nurse take first? a) administer oxygen at 2L/min b) administer prescribed analgesic medication. c) encourage coughing and deep breathing d) raise the HOB

d) raise the HOB elevating the head of the bed, uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patient airway. This is the first action the nurse should take and is the least invasive

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? a) use a sterile swab to obtain the specimen b) place the specimen in a sterile container c) label the paper bag in which specimen container is placed d) send specimen container immediately to the lab

d) send specimen container immediately to the lab The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? a) serous b) purulent c) sanguineous d) serosanguineous

d) serosanguineous Watery red drainage should be documented as serosanguineous.

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status? a) Enroll the client in a nutritional class on the unit b) weigh the client at the same time every morning c) ask provider to arrange a consultation with the facility chaplain d) sit with the client during snacks and meals

d) sit with the client during snacks and meals A change in appetite is a major symptom of depression. Being present during meals and snacks to support and encourage the client is an appropriate nursing intervention that might help the client at this time.