Nutrition, ATI- The Surgical Client Test, Sensory Perception, ATI Adult Repro/Sensory, Pain, Pain and Inflammation ATI, Hygiene ATI Test

A nurse is providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family?

"Your family member has the right to receive effective pain management."

A nurse is reviewing handwashing skills with a newly licensed nurse. In which order should the nurse plan to perform this task using soap and water? - use a disposable towel to dry - rub hands together vigorously for at least 15 seconds - apply the amount of soap recommended by the manufacturer - use a towel to turn off the faucet - wet hands with warm water - rinse hands with water

- wet hands with warm water - apply the amount of soap recommended by the manufacturer - rub hands together vigorously for at least 15 seconds - rinse hands with water - use a disposable towel to dry - use a towel to turn off the faucet

A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long?

20 min

A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take?

Administer 1 mg IM.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II?

Check the client's visual acuity using a Snellen chart.

A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management? (Select all that apply.)

Fear of addiction Belief that pain is an expected part of their illness Inadequate pain assessment

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments?

Glaucoma

A nurse is assessing a client who is experiencing digestive issues. Which of the following findings should the nurse expect. (select all that apply). A) Nausea B) Abdominal Pain C) Diarrhea D) Reports bloating E) reports of excessive salivation

Nausea Abdominal pain Diarrhea Reports of bloating

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain?

The client is diaphoretic.

A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client? - the nurse should perform personal hygiene tasks for the client - the client has a minor loss of strength on the right side of the body - The nurse should have the client remove clothing from the unaffected side first - oral care is much easier for the client to preform than bathing

The nurse should have the client remove clothing from the unaffected side first

a nurse is caring for a client who has a prescription for aspirin to treat an ankle pain. The nurse should instruct the client to report which of the following adverse drug reactions? polyuria bone pain weight gain infection

weight gain

A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client?

Keep the client's environment free from clutter.

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?

Risk factors for sensory deprivation include experiencing total vision or hearing loss.

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age? (Select all that apply.)

Sour Bitter Salty

a nurse is caring for a client who has a new prescription for prednisone for long-term treatment of rheumatoid arthritis. The nurse should monitor the client for which of the following adverse drug reactions? pulmonary embolism hepatitis bone loss breast cancer

bone loss

a nurse is caring for a client who has a new prescription for celecoxib. The nurse should tell the client to report which of the following adverse drug reactions? tinnitus chest pain constipation diaphoresis

chest pain

a nurse is teaching s client who has a new prescription for allopurinol. The nurse should instruct the client to report which of the following adverse drug reactions? (select all that apply) palpitations sore throat vertigo bruising vision changes

sore throat, vertigo, bruising, vision changes

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include? - the most common oral hygiene problem is gingivitis - the client's ability to obtain dental care is unaffected by their visual impairment - the visually impaired client has better oral hygiene than those clients without visual impairment - the nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health

the nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.)

"A client's religious beliefs might affect the way they respond to pain." "The client's past pain experiences are not related to their current pain and pain management." "Pain control might be harder to achieve if the nurse and client speak different primary languages."

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? (Select all that apply.)

Asks for questions to be repeated Withdraws from social activities Describes sounds as being muffled

A nurse is caring for a client who has bariatric care needs and has a rash between skin folds. Which of the following actions should a nurse take? - assist the client as needed to ensure proper hygiene is preformed - aggressively rub the skinfolds dry to manage moisture - use a lye soap bar to cleanse the skinfolds and the rash area - apply moisturizer to the skinfolds and rash area

Assist the client as needed to ensure proper hygiene is preformed

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)

Difficulty maintaining attention Agitation Hallucinations Rambling speech

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? (Select all that apply.)

Loop diuretics NSAIDS Aminoglycoside antibiotics

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? a. Place suction equipment at the client's bedside. b. Apply an eye patch to the client's right eye. c. Avoid the use of warm water to wash the client's face. d. Provide ROM exercises to the client's neck and shoulders.

a. Place suction equipment at the client's bedside.

A nurse is reviewing information about performing oral hygiene with assistive personnel (AP). Which of the following information should the nurse include? - a standard toothbrush is more effective than a battery-operated toothbrush in decreasing plaque - clean the tongue with the toothbrush or tongue scraper during oral hygiene - floss the teeth at least three times each day - have the client use mouthwash after brushing their teeth

clean the tongue with the toothbrush or tongue scraper during oral care

A nurse is planning care for an older adult client who has herpes zoster. Which of the following interventions should the nurse include in the plan? a. Restrict visitors who have not previously received a MMR vaccine. b. Place the client in protective isolation. c. Avoid the use of alcohol based hand rubs. d. Administer analgesics for pain.

d. Administer analgesics for pain.

a nurse is caring for a client who is taking acetaminophen at regular intervals for mild discomfort. The nurse should tell the client to report which of the following early indications of acetaminophen toxicity? (Select all that apply.) diaphoresis palpitations shortness of breath nausea diarrhea

diaphoresis, nausea, diarrhea

a nurse is teaching a client who is taking allopurinol about minimizing adverse effects. Which of the following instructions should the nurse include? eat a small meal before taking the drug suck on hard candy or chew gum take a stool softener daily avoid the use of NSAIDs

eat a small meal before taking the drug

a nurse is caring for a client who is taking allopurinol to treat gout. The nurse should monitor the client for which of the following manifestations of hypersensitivity syndrome? muscle pain fever anxiety tremors

fever

a nurse is caring for a client who has a new prescription for butorphanol. The nurse should monitor the client for which of the following adverse drug reactions? (select all that apply) infection nausea tachycardia dizziness headache

nausea, dizziness, headache

a nurse is caring for a client who is reeivng morphine to relieve severe pain. The nurse should monitor the client for which of the following adverse drug reactions? (select all the apply) diarrhea urinary retention respiratory depression sedation orthostatic hypotension

urinary retention, respiratory depression, sedation, orthostatic hypotension

A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"?

"Can you point to where you are having your pain?"

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions?

"I will keep the morphine bottle in a locked cabinet in my kitchen."

a nurse is caring for a client who takes low-dose aspirin to prevent cardiovascular events. The client asks the nurse about taking ibuprofen to treat rheumatoid arthritis. Which of the following responses should the nurse make? "ibuprofen will increase your risk for developing salicylism" "ibuprofen will reduce the cardioprotective effects of low-dose aspirin" "low-dose aspirin will reduce the anti-inflammatory effects of ibuprofen" "low-dose aspirin will reduce the analgesic efforts of ibuprofen"

"ibuprofen will reduce the cardio protective effects of low-dose aspirin"

A nurse is reviewing oral hygiene practices with assistive personnel (AP). Which of the following statements should the nurse include? - a fluoride mouthwash should be used to promote oral health - the teeth should be brushed twice daily for 2 min - poor oral hygiene can lead to gingivitis - teeth should be flossed every other day - use a soft-bristled toothbrush for brushing the teeth

- a fluoride mouthwash should be used to promote oral health - the teeth should be brushed twice daily for 2 min - poor oral hygiene can lead to gingivitis - use a soft-bristled toothbrush for brushing the teeth

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? - the nurse's hands become visibly soiled - the nurse removed the meal tray of a client who has infectious diarrhea - the nurse moves the cell phone of a client who has pneumonia from the bedside table - the nurse empties the urinal of a client who has Clostridium difficile - the nurse is preparing to insert an intravenous catheter

- the nurse's hands become visibly soiled - the nurse removes the meal tray of a client who has infectious diarrhea - the nurse empties the urinal of a client who has Clostridium difficile

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression?

A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN

A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain?

A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury

A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy?

A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.

A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include?

A tuning fork is placed against the client's mastoid bone during the Rinne test.

A nurse is caring for a client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake. (Select all that apply). A) increasing daily fiber intake can help alleviate the issue of constipation B) eating more whole grains can promote regular bowel movements C) consume 10 g of fiber per day D) Food such as white rice increase fiber intake E) decreasing daily fiber intake can help alleviate Digestive discomfort

A,B RATIONALE: an adequate amount of daily fiber intake helps relieve constipation by promoting bowel movements RATIONALE: whole grains contain fiber which helps to regulate bowel movements

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and reports discomfort and nausea. The nurse notes minimal bowel sounds on auscultation. The nurse should anticipate that the client may have which of the following conditions? A. An Ileus B. Dehiscence C. Irritable Bowel Syndrome D. Hemorrhoids

A. An ileus Rationale: Minimal Peristalsis, nausea, and mild discomfort are an indication that the client may have developed an ileus.

A nurse is assisting in planning postoperative care for a client who is scheduled for surgery. Which of the following interventions should the nurse include in the plan? A. Reposition the client every hour. B. Have the client cough and deep breathe every 4 hr. C. Instruct the client to perform ankle pump exercises once a day. D. Reinforce with the client that they should use an incentive spirometer every 2 hr.

A. Reposition the client every hour. Rationale: The nurse should reposition the client every hour to promote lung expansion and decrease the risk of muscle weakness, blood clots, and pneumonia. Incorrect B. Have the client cough and deep breathe every 4 hr. Rationale: The nurse should instruct the client to cough and deep breathe every 2 hr to promote lung expansion and clear secretions. C. Instruct the client to perform ankle pump exercises once a day. Rationale: The nurse should instruct the client to perform ankle pump exercises every hour while awake to promote venous return and decrease the risk for a thrombus formation. D. Reinforce with the client that they should use an incentive spirometer every 2 hr. Rationale: The nurse should instruct the client to perform 10 repetitions of an incentive spirometer every hour to promote lung expansion and clear secretions.

A nurse is assisting with teaching a newly licensed nurse about preoperative teaching. Which of the following statements should the nurse include? A. "Preoperative teaching can reduce the length of the client's hospital stay." B. "Preoperative teaching results in an increase in client anxiety." C. "Preoperative teaching results in a decrease in clients' participation in their health care plan." D. "Preoperative teaching can cause an increase in the cost of health care."

A: "Preoperative teaching can reduce the length of the client's hospital stay." Rationale: Effective preoperative teaching can reduce the length of the client's hospital stay by decreasing complications such as pneumonia, infection, and thrombophlebitis. Incorrect: B. "Preoperative teaching results in an increase in client anxiety." Rationale: Preoperative teaching can reduce client anxiety by informing the client what to expect before, during, and after the procedure. C. "Preoperative teaching results in a decrease in clients' participation in their health care plan." Rationale: Effective preoperative teaching promotes clients' participation in their health care plan. A client who is educated is empowered to ask questions and actively participate in their health care. D. Rationale: Effective preoperative teaching can reduce the cost of health care by decreasing complications such as pneumonia, infection, and thrombophlebitis.

A nurse is assessing a clients hair and knows that it is brittle. Which of the following should the nurse determine about the clients nutritional intake? A) The client is not getting enough vitamin A. B) The client has insufficient protein in their diet C) The client needs more vitamin D from sun exposure D) The client needs to eat five servings of fruits and vegetables daily

B Rationale: protein helps promote healthy hair and prevents brittle hair and hair loss. Therefore, the nurse should identify that this client might have inadequate protein intake

A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client's pain?

Chronic pain

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control? (Select all that apply.)

Consider each client's cultural preferences. Determine the effectiveness of nonpharmacological strategies. Use a pain scale specific to each client's cognitive abilities.

A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia?

Difficulty problem-solving

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? (Select all that apply.)

Ensure the client wears their hearing aids. Use a sign language interpreter. Communicate using paper and pen. Face the client when speaking.

A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.)

Face Legs Consolability

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply.)

Grimacing Restlessness Increased diaphoresis

A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?

Hearing loss

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? (Select all that apply.)

Inspect the feet every day. Wear closed-toe shoes. Manage glucose levels.

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with?

Negligence

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take?

Offer to assist the client with nonpharmacological relief strategies.

A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change?

Presbyopia

A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply.)

Respiratory rate Capnography Oxygen saturation

A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.)

Stress Culture Social support Disease severity

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.)

Transcutaneous electronic stimulating unit (TENS unit) Massage Acupuncture Cold therapy

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII?

Whisper something in one ear while occluding the other ear.

a nurse is caring for a group of postoperative clients. The nurse should identify that morphine is contraindicated for which of the following clients? a client who had a mastectomy a client who had a knee arthroplasty a client who had a colectomy a client who had a cholecystectomy

a client who had a cholecystectomy

A nurse is caring for a client who is 1 day postop following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast? a. Refusing to look at dressing or surgical incision. b. Asking for pain meds q3h. c. Asking questions about the information on her postop care pamphlet. d. Performing arm exercises once or twice a day.

a. Refusing to look at dressing or surgical incision.

a nurse is reviewing the medical record of a client who reports taking acetaminophen at home. The nurse should identify that which of the following client conditions is contraindicated for acetaminophen? asthma diabetes mellitus heart failure alcohol use disorder

alcohol use disorder

a nurse is caring for a child who has a viral infection. The nurse should identify that which of the following drugs can increase the risk of Reye syndrome in children who have viral infections? butorphanol acetaminophen tramadol aspirin

aspirin

a nurse is teaching a client who has a new prescription for allopurinol. Which of the following instructions should the nurse include? avoid driving or activities that require mental alertness avoid crushing the tablets limit fluid intake during therapy limit potassium while taking allipurinol

avoid driving or activities that require mental alertness

A nurse is caring for a client who asks to be screened for cervical cancer because a relative has been diagnosed with it. Which of the following tests should the nurse expect the provider to use? a. A serum prolactin level. b. A Papanicolaou test c. A vaginal ultrasound d. An endometrial biopsy.

b. A Papanicolaou test

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities? a. Immediate b. Cytotoxic c. Immune complex-mediated d. Delayed

b. Cytotoxic

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan? a. Enforce strict bedrest for 3 days. b. Apply fresh ice packs q4h. c. Elevate the affected leg on 2 pillows. d. Apply antibiotic ointment to the wound with dressing changes.

c. Elevate the affected leg on 2 pillows.

A nurse is assessing a client who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test corneal reflexes? a. Examine the eyes with a penlight. b. Instill drops of dye into the eyes. c. Visualize the red reflex of the eyes. d. Lightly touch the eyes with a wisp on cotton.

d. Lightly touch the eyes with a wisp on cotton.

A nurse is preparing an inservice for a group of nurses about saw palmetto. Which of the following information should the nurse include? a. Saw palmetto potentiates the sedation effect of antihistamine. b. Saw palmetto interacts with tamoxifen. c. Saw palmetto increases glucose uptake. d. Saw palmetto may cause PSA levels to result in falsely low readings.

d. Saw palmetto may cause PSA levels to result in falsely low readings.

a nurse is teaching a client who has a new prescription for prednisone. Which of the following instructions should the nurse include? (select all that apply) reduce the dose during periods of stress discontinue the drug gradually report illness or infection ] increase intake of calcium and vitamin D monitor for signs of gastric bleeding

discontinue the drug gradually, report illness or infection, increase intake of calcium and vitamin D, monitor for signs of gastric bleeding

A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse make? - ensure the nurse caring for the client is of the same sex - leave the water running while the client takes a bath - allow the client time for prayer immediately following bath time - discuss with the client their individual perspective on health and illness

discuss with the client their individual perspective on health and illness

A nurse is teaching the importance of hand-washing to a client. Which of the following statements should the nurse make about hand hygiene in a healthcare setting? - it is not important to wash your hands after removing gloves - effective hand-washing can decrease hospital infection rates - infections in health care staff are not considered healthcare-associated infections - healthcare-associated infections are a rare event in health care delivery

effective hand-washing can decrease hospital infection rates

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion? - enamel protects the teeth from pathogens - enamel is a substance that cannot be dissolved - enamel is a soft material that protects the teeth - enamel covers the pulp

enamel protects the teeth from pathogens

a nurse is caring for a client who is about to begin taking aspirin. The nurse should instruct the client to report which of the following manifestations of salicylism? (select all that apply) fever tinnitus diaphoresis thrombophlebitis dizziness

fever, tinnitus, diaphoresis, dizziness

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bating at home. Which of the following statements should the nurse make? - that is unusual. as clients age, they are typically more receptive to bathing - it is fine if the client does not bathe regularly at home - give the client choices regarding their bathing preferences to encourage them to bathe - provide the client with the reasons why they need to bathe

give the client choices regarding their bathing preferences to encourage them to bathe

A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include? - health promotion programs emphasize behavior changes in relation to the prevention of illness - health promotion programs encourage decreased use of health services - health promotion programs restrict the client's control over their general health - health promotion programs discourage community involvement

health promotion programs emphasize behavior changes in relation to prevention of illness

a nurse is caring for a client who currently takes furosemide and has a new prescription for prednisone. The nurse should monitor the client for which of the following manifestations during concurrent use of the drugs? hypercalcemia hypoglycemia hypothermia hypokalemia

hypokalemia

a nurse is teaching a client who has a new prescription for tramadol. Which of the following instructions should the nurse include? (select all that apply) increase fiber and fluid intake take the drug with food avoid driving after taking the drug change positions gradually reduce exercise level temporarily

increase fiber and fluid intake, take the drug with food, avoid driving after taking the drug, change positions gradually

a nurse is caring for a client who is taking naloxone to treat acute morphine toxicity. The nurse should monitor the client for which of the following drug reactions? (select all the apply) increased respiratory rate increased pain thromboplebitis ventricular arrhythmias hypertension

increased respiratory rate, increased pain, ventricular arrhythmias , hypertension

a nurse is planing care for a client who has started taking prednisone. Which of the following interventions should the nurse include? monitor the clients blood glucose administer an antacid 30 min prior to prednisone administer aspirin rather than NSAIDs if the client has pain monitor the client for hyperkalemia

monitor the clients blood glucose

a nurse is reviewing the medical record of a client who has a new prescription for tramadol. The nurse should identify that which of the following conditions is a contraindication for tramadol? hyperthyroidism seizure disorder rheumatoid arthritis urinary incontinence

seizure disorder

a nurse is reviewing the medical record of a client who has a new prescription for celecoxib. The nurse should identify that which of the following conditions is a contraindication to celecoxib? rheumatoid arthritis ankylosing spondylitis sulfonamide allergy adrenocortical insufficiency

sulfonamide allergy

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include? - nails, made of pterygium, protect the fingers and toes - the cuticle is a form of keratin that connects the skin and the nail plate together - the cuticle of the nail forms a barrier to prevent infections - the nail consists of layers of pterygium that protect against pathogens

the cuticle of the nail forms a barrier to prevent infections

A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis? - the epidermis acts as a cushion against physical trauma - the epidermis separates the dermis from the underlying organs - the epidermis consists of squamous epithelial cells - the epidermis contains blood vessels and blood

the epidermis consists of squamous epithelial cells

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include? - the mucous membranes secrete a thing, salty liquid that traps pathogens and particles - the mucous membranes provide a chemical barrier against pathogens - the mucous membranes of the auditory tube contain cilia that move particles toward the front of the nose - the mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body

the mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which id the following statements should the nurse include? - the skin contains Langerhans cells that kill pathogens - the skin is the smallest organ of the body - the skin is the second line of defense against mircoorganisms - the dermis is the outermost layer of the skin

the skin contains Langerhans cells that kill pathogens

a nurse is caring for a client who asks about taking acetaminophen. The nurse should identify that acetaminophen is indicated for which of the following conditions? (select all that apply) to reduce fever to decrease inflammation to relieve pain to promote sedation to alleviate anxiety

to reduce fever, to relieve mild pain

A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take? - trim the nails to a length that reaches beyond the edge of the finger - perform hand hygiene once nail hygiene is complete - avoid the use of wooden orange sticks - trim the nails straight across

trim the nails straight across

A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skincare for the client? - changes in skin integrity decrease the risk of infection - urinary incontinence can cause a yeast infection - mild soap is contraindicated for cleaning the skin - a pH-balanced cleanser increases skin irritation

urinary incontinence can cause a yeast infection

A nurse is performing foot care for a client. Which of the following actions should the nurse make? - soak the feet prior to washing the feet - use hot water when performing foot care - use a towel to completely dry between the toes - file the nail edges straight across with a file

use a towel to completely dry between the toes

a nurse is caring for a client who is opioid dependent and has a new prescription for butorphanol. The nurse should monitor the client for which of the following manifestations of abstinence syndrome? (select all that apply) bronchospasm vomiting peripheral edema abdominal cramps hypertension

vomiting, abdominal cramps, hypertension

a nurse is reviewing the drug list for a client who has a new prescription for allopurinol. The nurse should identify that which of the following drug reacts with allopurinol? Warfarin Ibuprofen Insulin Furosemide

warfarin

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client? - bathing the client completely in bed preserved the client's dignity - washing the client in bed is less effective than taking a shower - a complete bed bath should be performed using a basin, soap, and water - perform this type of bath early in the morning

washing the client in bed is less effective than taking a shower

A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make?

"It is a test that determines if there is nerve damage affecting a muscle."

A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make?

"Justice allows the client the opportunity to be treated fairly."

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?

"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."

A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make?

"This test is performed using lenses of various prescription strengths."

A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.)

"You can be taught how to use TENS therapy at home." "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."

A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include?

"You should write down the pain interventions you use and your pain rating before and after."

A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make?

"You will have a small probe placed in your ear canal during the test."

And Marissa is reviewing a client medical record and notes that their BMI is 25.5. How should the nurse interpret this finding A) The client is overweight B) The client is underweight C) The client BMI is within normal range D) The client is obese

A Rationale: according to the body mass index chart, a client who has BMI between 25 and 29.9 is considered overweight therefore the nurse should identify that a client who has a BMI of 25. Five is in the overweight category

A nurse is caring for a client whose provider prescribed a heart healthy diet. Which of the following information should the nurse include for the client regarding heart healthy diets? ( select all that apply). A) you should limit saturated fats in your diet B) you should increase sodium intake to your taste C) Foods with whole grains in your new diet D) it is important to eat larger portions of fruits and vegetables E) limiting high calorie food intake will promote adherence to your new diet F) continue to avoid skim milk and lean meats

A C D E

A nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO diet prescription for the client. Which of the following should the nurse identify as the rationale for the providers prescription? A) The client is at risk for aspiration due to the upcoming surgery B) The client is at risk for dysphasia due to the upcoming surgery C) The nutrients consumed as a part of the regular diet will interact with the sedation use in the procedure D) The client reports having to drink a few sips of water before the procedure

A Rationale: The client is at risk for aspiration to their upcoming surgery with sedation. To decrease the risk of aspiration, the client should remain NPO prior to surgery

A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide? A) you should eat white bread B) you can drink 2 cups of milk per day C) you should limit broccoli to 3 cups per week D) you can have four servings of oatmeal per week

A Rationale: The nurse should instruct the clients eat white bride instead of whole grain bread. Whole grains are high in phosphorus

A nurse is caring for a client who is receiving tube feedings via peg. Which of the following action should the nurse implement in order to help prevent the client from aspirating? A) keep the clients head elevated to at least 30° for a minimum of one hour after a feeding B) verify the initial two placement with an x-ray after the first feeding C) check the clients tube feeding tolerance every 12 hours D) check the pH of the gastric contents each day

A Rationale: The nurse should keep the clients head elevated to at least 30° for a minimum of one hour after the feeding because this gives clients time to adjust the feeding and helps prevent aspiration

A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply.)

A 3-year-old toddler who has a fractured femur A 14-year-old client who has severe cognitive and developmental delays A 5-year-old preschooler who is experiencing pain during a sickle cell crisis

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include?

A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? (Select all that apply.)

A walking cane A walker

The nurse is caring for a client who is prescribed a low glycemic index diet. The client states, " I don't understand what this means." Which of the following responses should the nurse make? (Select all that apply). A) The glycemic index of food relates to its ability to increase the blood glucose level B) you should eat food such as whole grains, fruits and vegetables C) consuming white bread will increase your blood glucose level slowly D) try to limit or avoid potatoes due to their high glycemic index E) Foods with a high glycemic index will cause your blood glucose to increase rapidly

A,B,D,E

A nurse is planning postoperative care for a client. Which of the following actions should be the nurse's priority? A. Monitor the client's oxygen saturation. B. Check the client's bowel sounds. C. Administer analgesics to the client. D. Measure the client's intake and output.

A. Monitor the client's oxygen saturation. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority action is to monitor the client's oxygen saturation because the client is at risk for hypoxia. Incorrect B. Check the client's bowel sounds. Rationale: The nurse should check the client's bowel sounds to determine bowel function; however, there is another action the nurse should take first. C. Administer analgesics to the client. Rationale: The nurse should administer analgesics to the client to promote comfort and relieve pain; however, there is another action the nurse should take first. D. Measure the client's intake and output. Rationale: The nurse should measure the client's intake and output to monitor the client's hydration status; however, there is another action the nurse should take first.

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?

Availability of aids to enhance vision

A nurse discussing macronutrients with the client. Which of the following statements should the nurse make? A) macro nutrients include vitamins and minerals, which your body needs a large amount of B) macro nutrients include carbohydrates, proteins, and fats, which make up the majority of a persons diet C) macro nutrients include carbohydrates and fats, which your body needs very little of D) while essential, macarnutrients should be limited to weekly consumptions

B Rationale: macro nutrients are essential parts of the diet and include proteins fats and carbohydrates. These provide the body with energy to function and are the building blocks of the diet

A nurse is helping a client calculate how many net carbohydrates they consume in their last meal. The clients food had a total of 72 g of carbohydrates and 9 g of fiber. How many net calories did the client consume? A) 81 B) 63 C) 8 D) 72

B Rationale: to calculate net carbohydrates use the following equation: total carbohydrates- (fiber + sugar alcohols if applicable)= Net Carbohydrates. In this case! 72g carbs- 9fibers= 63

A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium. (Select all that apply). A) apples B) bananas C) dried beans D) spinach E) tomatoes

B,c,d,e Rationale: should avoid to eat these types of foods because the food is high in potassium. Consuming foods that are high in potassium can lead to heart arrhythmias and increase the risk of myocardial infarction for clients who have renal disease

A nurse is monitoring a postsurgical client for dysphagia. Which of the following factors puts the client at risk? A. History of foot surgery B. Parkinson's disease C. Leukemia D. History of a total abdominal hysterectomy

B. Parkinson's disease Rationale: Parkinson's disease is a risk factor for a client to develop dysphagia.

A nurse is collecting data on a client who is postoperative following abdominal surgery. Which of the following findings is a manifestation of an infection? A. A report of pain as a 2 on a 0 to 10 pain scale B. Redness around the incision site C. Constipation D. Serosanguinous drainage on the dressing

B. Redness around the incision site Rationale: Redness around the incision site is a manifestation of an infection. Other manifestations of an infection can include, fever, pain, and purulent drainage. Incorrect A. A report of pain as a 2 on a 0 to 10 pain scale. Rationale: A report of pain as a 2 on a 0 to 10 pain scale is an expected finding following abdominal surgery. Persistent pain could be a manifestation of an infection. C. Constipation Rationale: Constipation is an expected finding following abdominal surgery due to limited mobility, anesthesia, and opioid analgesics. It is not a manifestation of an infection. D. Serosanguinous drainage on the dressing Rationale: Serosanguinous drainage is an expected finding following abdominal surgery. Purulent drainage is a manifestation of an infection.

A nurse is discussing the time-out procedure with a newly licensed nurse. The nurse should include that a time-out is performed at which of the following times? A. Once at the beginning of the procedure B. Several times throughout the procedure C. Once at the end of the procedure D. After anesthesia has been administered

B. Several times throughout the procedure Rationale: A time-out is performed at the beginning of the procedure, prior to any additional procedures performed, and at the completion of the procedure.

A nurse is reinforcing teaching provided to a client about postoperative complications. Which of the following should the nurse identify as creating a risk for the client to develop pneumonia? A. Diarrhea B. Aspiration C. Pain D. Pruritis

B: Aspiration Rationale: Aspiration is a postoperative complication that can increase the risk for pneumonia. Incorrect: A. Diarrhea Rationale: Diarrhea could be a concern, but it is not a postoperative complication that can increase the risk of pneumonia. C. Pain Rationale: Pain could be a concern, but it is not a postoperative complication that can increase the risk for pneumonia. D. Pruritis Rationale: Pruritis is not a postoperative complication that can increase the risk for pneumonia.

A nurse is assisting a postsurgical client who has had previous trouble swallowing prepare for a meal. Which of the following actions should the nurse take? A. Instruct the client to quickly eat their food. B. Assist the client to sit upright to eat. C. Cut the food into medium-sized pieces. D. Encourage the client to talk during the meal.

B: Assist the client to sit upright to eat. Rationale: The nurse should assist the client to sit upright to eat. Remaining in an upright position for at least 1 hr is also recommended. This can help to prevent aspiration. Incorrect: A. Instruct the client to quickly eat their food. Rationale: Clients should be instructed to eat and drink slowly to prevent aspiration. C. Cut the food into medium-sized pieces. Rationale: The food should be cut into small pieces, and the client should be encouraged to chew completely before swallowing. D. Encourage the client to talk during the meal. Rationale: Clients should be encouraged to avoid watching TV or talking while eating.

A nurse is caring for a client who has a new prescription for a clear liquid diet. The client asks the nurse, "how long will I have to be on this type of diet?" Which of the following responses should the nurse make? A) you will be on this diet as long as the provider feels you need to be B) you might be on this diet for a week or two C) you should not be on this diet for more than a few days D) you should speak with the provider about your concern

C Rationale : The nurse should identify that a clear liquid diet should be limited to a few days because this type of diet has inadequate nutritional value

A nurse is caring for a client who states, " I feel like I don't have to eat a varied diet when I take my multivitamin." Which of the following responses should the nurse make? A) if taken four or more days a week, a multivitamin provides all the nutrients you need. B) as long as you take a multivitamin daily, you do not need to eat a very diet each day C) A multivitamin should not be used in place of a nutritious diet D) as long as the multivitamin isn't generic, it can replace unhealthy dietary choices

C Rationale: The nurse to tell the client that supplemental vitamin should not be used as a substitute for nutritious diet. The client should eat a varied, nutritious diet daily even while taking a multivitamin

A nurse is caring for a nondiabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the clients blood glucose level and it is 67mg/dL. Which of the following action should the nurse take next? A) document the client's blood glucose level B) Report the clients blood glucose level to the provider C) provide the client with a 15 g carbohydrate snack D) recheck the blood sugar in 15 minutes

C Rationale: according to the evidence base practice, the nurse should provide the client with the 15 g carbohydrate snack to help bring up their blood glucose level to the expected reference range. The client's glucose level is low, less than 70mg/dL, which means the client is hypoglycemic

A nurse is caring for a client was a new prescription for parenteral nutrition. The client states, " i'm scared that I will be on this therapy for the rest of my life." Which of the following responses should the nurse make? A) there's a good chance you'll be on this therapy for the rest of your life B) Parenteral nutrition is very common and should not interfere with your daily activities C) this type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change D) i'm sure you will need parenteral nutrition Temporarily

C Rationale: this response gives the client objective information without false reassurance

Which of the following members of the surgical team is responsible for ensuring that the necessary tools are sterile and ready to use? A. Circulating nurse B. Anesthesiologist C. Certified surgical technologist D. Surgeon

C. Certified surgical technologist Rationale: The certified surgical technologist (CST) is responsible for ensuring that the necessary tools are sterile and ready to use. Incorrect: A. Circulating nurse Rationale: The circulating nurse is not responsible for ensuring that the necessary tools are sterile and ready to use. B. Anesthesiologist Rationale: The anesthesiologist is not responsible for ensuring that the necessary tools are sterile and ready to use. D. Surgeon Rationale: The surgeon is not responsible for ensuring that the necessary tools are sterile and ready to use.

A nurse is planning care for a client who has a distended bladder and has not voided 8 hr after surgery. Which of the following interventions should the nurse plan to take? A. Instruct the client to perform pelvic muscle exercises. B. Restrict the client's fluid intake. C. Insert a straight urinary catheter into the client. D. Administer an anticholinergic medication to the client.

C. Insert a straight urinary catheter into the client. Rationale: The nurse should plan to insert a straight urinary catheter into the client to relieve the client's distended bladder and assist with voiding. Incorrect A. Instruct the client to perform pelvic muscle exercises. Rationale: Pelvic muscle exercises are used to treat urinary stress incontinence and will not treat urinary retention. B. Restrict the client's fluid intake. Rationale: The nurse should monitor the client's hydration status and maintain the client's fluid intake to reduce the risk for dehydration. D. Administer an anticholinergic medication to the client. Rationale: The nurse should not plan to administer an anticholinergic medication to the client as this can cause an increase in urinary retention.

A nurse is caring for a client who has dementia and is scheduled for surgery. Which of the following creates a risk for the client to develop a postoperative complication? A. Use of probiotics B. Prescribed antibiotics C. Prescribed anticholinergics D. Use of antiseptic skin cleanser

C. Prescribed anticholinergics Rationale: Anticholinergics are given to decrease secretions in the upper airway, but they can cause delirium, which poses a risk for a client who has dementia. Incorrect A. Use of probiotics Rationale: Probiotics help keep the body healthy. They do not pose a risk to a client who has dementia. B. Prescribed antibiotics Rationale: Antibiotics are used to prevent bacterial infections and are not expected to create a risk for a postoperative complication. D. Use of antiseptic skin cleanser Rationale: Antiseptics slow the growth of micro-organisms on external surfaces and do not pose a risk for a client who has dementia.

A client is having surgery on their hand and tells the nurse that they understand that anesthesia will be administered so that they will have a temporary loss of feeling in their arm. Which of the following types of anesthesia is the client describing? A. General B. Local C. Regional D. Epidural

C. Regional Rationale: With regional anesthesia, the client will experience a temporary loss of feeling to an area of the body. Incorrect A. General Rationale: General anesthesia is medications or inhalants used to depress the central nervous system. B. Local Rationale: Local anesthesia affects the moto and sensory nerves at the surgical site. D. Epidural Rationale: Epidural anesthesia is combined with general anesthesia and is generally used for abdominal and thoracic surgeries.

A nurse is collecting data on a client who is preparing for discharge following surgery. Which of the following findings should be the nurse's priority concern? A. The client lives alone B. The client cares for a pet C. The client takes medication that causes dizziness D. The client takes medications that cause heartburn

C. The client takes medications that cause dizziness. Rationale: The greatest risk to this client is injury from a fall because the client is taking a medication that can cause dizziness; therefore, this finding is the nurse's priority. Incorrect: A. The client lives alone Rationale: The nurse should collect data regarding whether the client can take care of themselves; however, another finding is the priority. B. The client cares for a pet Rationale: The nurse should collect data about whether the client needs assistance caring for a pet; however, another finding is the priority. D. The client takes medications that cause heartburn Rationale: The nurse should provide instructions to the client about how to reduce heartburn; however, another finding is the priority.

A nurse is reviewing the medical record of a postoperative client. Which of the following findings in the client's history are risk factors for poor wound healing? (Select all that apply.) A. Type 2 diabetes mellitus B. BMI 28 C. Married D. Current smoker E. Corticosteroid use F. 68 years old

Correct A. Type 2 diabetes mellitus Rationale: Clients who have type 1 or type 2 diabetes are at an increased risk for poor wound healing. D. Current smoker Rationale: Clients who smoke are at risk for poor wound healing. E. Corticosteroid use Rationale: Clients who use corticosteroids on a regular basis are at an increased risk for poor wound healing. F. 68 years old Rationale: Clients who are older than 65 years of age are at an increased risk for poor wound healing. Incorrect: B. BMI 28 Rationale: Clients who are obese with a BMI greater than 30 are at an increased risk for poor wound healing. C. Married Rationale: Marital status is not a risk factor for poor wound healing.

A nurse is preparing a client for surgery and needs to scrub the surgical site. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) -Start at the center and move to the area away from the site is the second step. -Drape the client. -Scrub the surgical site in a circular fashion with an antiseptic -Repeat with a new sponge -Scrub the outer edge and discard the sponge

Correct Order: 1 - Scrub the surgical site in a circular fashion with an antiseptic Rationale: The nurse should first scrub the surgical site in a circular fashion with an antiseptic. 2 - Start at the center and move to the area away from the site Rationale: When scrubbing, the nurse should start at the center and move to the area away from the site. 3 - Scrub the outer edge and discard the sponge Rationale: Once the nurse reaches the outer edge, the sponge is considered to be contaminated and the nurse must discard it. 4 - Repeat with a new sponge Rationale: Next, the nurse repeats the scrubbing process with a new sponge. 5 - Drape the client Rationale: After scrubbing the site, the nurse should drape the client.

A nurse is collecting data from a client who is preoperative for a surgical procedure. Which of the following information should the nurse document in the client's medical record? (Select all that apply.) A. Allergies B. Discontinued medications C. Alcohol use D. Spiritual beliefs E. Financial status

Correct: A. Allergies Rationale: The nurse should identify any allergies to medications, foods, and other substances the client might have, and then place an allergy band on the client. C. Alcohol use Rationale: The nurse should identify and document the client's history of alcohol and tobacco use. D. Spiritual beliefs Rationale: The nurse should document the client's spiritual beliefs to provide empathy and emotional support to the client. Incorrect B. Discontinued medications Rationale: The nurse should identify and document any current medications or supplements the client is taking. E. Financial status Rationale: The nurse should not document the client's financial status in the client's medical record.

A nurse is assisting in developing a plan to manage a client's perioperative pain. Which of the following interventions should the nurse include in the plan? (Select all that apply.) A. Ask the client what interventions they prefer B. Limit medications to one type of analgesic C. Determine how the client has responded to analgesics in the past D. Include the use of a placebo for pain management E. Include nonpharmacological methods to reduce pain

Correct: A. Ask the client what interventions they prefer. Rationale: the nurse should ask the client about what interventions they prefer when planning perioperative pain management. C. Determine how the client has responded to analgesics in the past. Rationale: The nurse should ask the client how they have responded to analgesics in the past to provide safe and effective pain management. E. Include nonpharmacological methods to reduce pain. Rationale: The nurse should include nonpharmacological methods, such as massage, in the plan to promote pain control. Incorrect B. Limit medications to one type of analgesic Rationale: The nurse should include a variety of analgesics to reduce the client's pain in order to limit adverse effects of high-dose pain medications. D. Include the use of a placebo for pain management Rationale: The nurse should not plan to use a placebo for pain management as this can result in client distrust and might not effectively decrease the client's pain.

A nurse is collecting data on the surgical wound of a postoperative client. Which of the following information should the nurse include in the documentation of the wound? (Select all that apply.) A. The client states the wound is painful. B. The client's blood pressure is 115/72 mm Hg. C. The edges of the wound are red. D. The client is ambulating frequently. E. The client has a fever.

Correct: A. The client states the wound is painful Rationale: The nurse should record the client's level of pain in the documentation, as well as actions taken to alleviate the pain. C. The edges of the wound are red Rationale: The nurse should include in the documentation that the edges of the wound are red. E. The client has a fever Rationale: The nurse should include in the documentation that the client is experiencing a fever, along with actions taken to treat the fever. Incorrect B. The client's blood pressure is 115/72 mm Hg. Rationale: The client's blood pressure is within the expected reference range and is not pertinent to the appearance of the surgical wound. D. The client is ambulating frequently. Rationale: The nurse should record the client's mobility in the activity section of the documentation, but this is not pertinent to the description of the wound.

A nurse is reinforcing teaching with a newly licensed nurse about informed consent. The nurse should include that which of the following is the nurse's responsibility when obtaining informed consent from a client? (Select all that apply.) A. Verify the client has signed the consent. B. Describe the procedure to the client. C. Check that the client is of legal age to provide consent. D. Explain alternatives to the procedure to the client. E. Confirm the client is competent.

Correct: A. Verify the client has signed the consent. Rationale: The nurse is responsible for verifying the client has signed the consent. C. Check that the client is of legal age to provide consent. Rationale: The nurse is responsible for verifying the client is of legal age to provide consent. E. Confirm the client is competent. Rationale: The nurse is responsible for verifying the client is competent. Incorrect: B. Describe the procedure to the client. Rationale: The provider is responsible for explaining the procedure to the client. It is not the responsibility of the nurse. D. Explain alternatives to the procedure to the client. Rationale: The provider is responsible for explaining any alternatives to the procedure to the client.

Surgical attire for the surgical suite consists of which of the following items? (Select all that apply.) A. Belt B. Cap C. Shoe covers D. Gown E. Mask F. Gloves

Correct: B. Cap Rationale: A surgical cap is part of the surgical attire for the surgical suite C. Shoe covers Rationale: Surgical shoe covers are part of the surgical attire for the surgical suite D. Gown Rationale: A surgical gown is part of the surgical attire for the surgical suite. E. Mask Rationale: A surgical mask is part of the surgical attire for the surgical suite F. Gloves Rationale: Surgical gloves are part of the surgical attire for the surgical suite. Incorrect A. Belt Rationale: A surgical belt is not part of the surgical attire for the surgical suite.

And nurses is preparing to measure a nasogastric tube for insertion. The nurse recalls that the clients xyphoid process should be used as the last place of measurement. Which of the following landmarks should the nurse measure before the xyphoid process A) Measure from the bottom of the ear B) Measure from the tip of the chin C) Measure from the bottom of the jawline D) Measure from the tip of the nose to the earlobe

D Rationale: The NG tube is measured from the tip of the nose to the earlobe, then from the ear lobe to the xiphoid process. This would give an accurate measurement for the tube insertion allowing appropriate tube placement

A nurse is caring for a client who states, " I only a diet high in protein and carbohydrates." Which of the following responses should the nurse make? A) Make sure to get enough servings of red meat in your diet daily B) your diet is varied but should also be high in calorie intake C) A varied diet should be high in protein and carbohydrate consumption D) nutritious diet should include carbohydrates, proteins, fiber, and healthy fats

D Rationale: The nurse should instruct the client to consume a balanced diet from a variety of different food groups, such as dairy, grains, fruits, vegetables, and proteins

A nurse is preparing to assist with feeding a client who is at risk for aspiration. Which of the following action should the nurse take? A) position the client upright at a 45° angle B) turn on the television per the clients request C) avoid allowing the client to drink until meal is finished D) Cut the clients food in small bites

D Rationale: To prevent aspiration, the nurse should cut food into small bites

A nurse is caring for a client who states, " I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make? A) A lack of protein can cause a problem with cavities B) cavities can be caused by a diet low in vitamin C C) increasing your consumption of leafy green vegetables and tomatoes can help with this D) drinking sugary beverages can make you prone to cavities

D Rationale: The nurse should instruct the client that consuming sugary beverages can lead to cavities, also known as dental caries

A nurse is caring for a client who is postoperative following a femur fracture repair. The client suddenly reports chest pain and is experiencing shortness of breath. Which of the following conditions should the nurse suspect? A. Deep vein thrombosis B. Thrombotic stroke C. Hypovolemic shock D. A pulmonary embolism

D. A pulmonary embolism Rationale: Chest pain, shortness of breath, tachycardia, and hypoxia is indicative of a pulmonary embolism and is a medical emergency. The nurse should immediately activate the emergency response team and notify the client's provider. Incorrect: A. Deep vein thrombosis Rationale: A client who is experiencing a deep vein thrombosis will experience pain, redness, and swelling within the lower extremity. B. Thrombotic stroke Rationale: A client who is experiencing a thrombotic stroke will have neurological deficits such as confusion, impaired speech or understanding, dizziness, or numbness or weakness on one side of the body. C. Hypovolemic shock Rationale: A client who is experiencing hypovolemic shock following surgery will have a major loss of intravascular fluid and will have manifestations of hypotension, confusion, tachycardia, and oliguria.

A nurse is caring for a client who is preoperative and reports a history of regular tobacco use. The nurse should identify that the client is at the greatest risk for which of the following postoperative complications? A. Urinary Retention B. Constipation C. Nausea D. Blood Clots

D. Blood clots Rationale: According to evidence-based practice, the nurse should identify that a history of regular tobacco use places the client at an increased risk for blood clots. The nurse should monitor the client for areas of swelling and redness, and implement measures to promote venous return, such as graded compression stockings and early ambulation. Incorrect A. Urinary Retention Rationale: The nurse should monitor the client for urinary retention, which can occur as a result of taking opioid analgesics. However, evidence-based practice indicates the client is at an increased risk for another complication. B. Constipation Rationale: The nurse should monitor the client for constipation, which can occur as a result of taking opioid analgesics. However, evidence-based practice indicates the client is at an increased risk for another complication. C. Nausea Rationale: The nurse should monitor the client for nausea, which can occur as a result of taking opioid analgesics. However, evidence-based practice indicates the client is at an increased risk for another complication.

A nurse is caring for a client who is scheduled for surgery and is at risk for postoperative venous thromboembolism (VTE). Which of the following prescriptions should the nurse anticipate to reduce the risk of VTE? A. Incentive spirometer B. Antibiotic therapy C. Antihypertensive medication D. Sequential compression devices

D. Sequential compression devices Rationale: Sequential compression devices are prescribed for clients postoperatively to decrease the risk of VTE. Clients should wear the devices while in bed and sitting in a chair. Incorrect: A. Incentive spirometer Rationale: An incentive spirometer is prescribed for a postoperative client to assist with deep breathing to reduce the risk of atelectasis and pneumonia. It is not therapy for VTE. B. Antibiotic therapy Rationale: Antibiotic therapy is prescribed postoperatively as treatment for an infection or as prophylaxis against infection occurring. It is not therapy for VTE. C. Antihypertensive medication Rationale: Antihypertensive medication prescribed postoperatively is for treatment of hypertension that can occur following surgery. It is not therapy for VTE.

A nurse is collecting data on a client who is postoperative following a hip arthroplasty. Which of the following findings is a possible manifestation of bleeding? A. Oxygen saturation 97% on room air B. Respiratory rate 14/min C. Heart rate 72/min D. Blood pressure 88/60 mm Hg

D: Blood pressure 88/60 mm Hg Rationale: A blood pressure of less than 90 mm Hg systolic is considered hypotension and is a manifestation of bleeding. The nurse should notify the provider and monitor the client for other manifestations of bleeding, such as tachycardia and tachypnea. Incorrect: A. Oxygen saturation 97% on room air Rationale: Oxygen saturation of 97% on room air is within the expected reference range of greater that 95%. A decrease in oxygen saturation is a possible manifestation of bleeding. C. Heart rate 72/min Rationale: A respiratory rate of 14/min is within the expected reference range of 12 to 20/min. Tachypnea is a possible manifestation of bleeding. D. Blood pressure 88/60 mm Hg Rationale: A heart rate of 72/min is within the expected reference range of 60 to 100/min. Tachycardia is a manifestation of bleeding.

A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take?

Evaluate the client for pain by observing their behavior.

A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.)

Muscular pain Backache Menstrual discomfort

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression?

Naloxone

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? (Select all that apply.)

Trauma to the outer ear Inflammation Cerumen buildup Otitis media

A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, "I feel so isolated and alone in this room". After acknowledging the client's feelings of loneliness, which of the following responses should the nurse provide? a. I will come and sit with you for 10 minutes each hour. b. Do you have a cell phone you can talk to friends and family on? c. I'll ask the charge nurse to admit someone to your room for company. d. You're scheduled for discharge in 2 days so this isolation will be over soon.

b. Do you have a cell phone you can talk to friends and family on?

A nurse is planning care for a client who is 2 hours postop following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include? a. Restrict the client's oral fluid intake. b. Remind the client that he might feel a constant urge to void. c. Monitor the client's urine output q6h. d. Weigh the client every evening.

b. Remind the client that he might feel a constant urge to void.

A nurse is caring for a client who has Meniere's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? a. Yes, you are free to move around as you wish b. No, you are on strict bedrest and must not be up. c. Please ring for assistance when you wish to get out of bed. d. We will have to get a prescription from your provider.

c. Please ring for assistance when you wish to get out of bed.

A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? a. A history of pelvic inflammatory disease. b. Abdominal bloating starting several days before menses. c. An atypical Papanicolaou smear at her last clinic visit. d. Dysmenorrhea that is unresponsive to NSAIDS.

d. Dysmenorrhea that is unresponsive to NSAIDS.

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? a. Use a natural membrane condom rather than a polyurethane condom. b. You may use a condom more than once. c. Use an oil-based lubricant when you use a condom. d. Female condoms can help prevent transmission of sexually transmitted viruses.

d. Female condoms can help prevent transmission of sexually transmitted viruses.

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? a. Take ibuprofen for eye discomfort. b. Creamy white drainage is an indication of infection. c. Notify the provider immediately if the operative eye itches. d. The client should wear dark glasses while outdoors.

d. The client should wear dark glasses while outdoors.