Practice A

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

-Obtain the death pronouncement from the provider -remove tubes and indwelling lines -cleanse the client's body -ask family members if they wish to view the body -place a name tag on the body before transferring

A nurse is assessing an older adult client's risk for falls. What assessment should the nurse use to identify the client's safety needs?

-pupil clarity -visual fields -visual acuity

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance

A nurse is preparing an education program for staff about advocacy. What information should the nurse include?

Advocacy ensures clients' safety, health, and rights

A nurse is caring for a client who has a respiratory infection. What technique should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. What action should the nurse take?

Ask another nurse to observe the medication wastage

A nurse receives report about a client who has NaCl infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. What action should the nurse take first?

Check the IV tubing for obstruction

A nurse is responding to a call light and finds a client lying on the bathroom floor. What action should the nurse take first

Check the client for injuries

A nurse is admitting a new client. What action should the nurse take while performing medication reconciliation?

Compare the client's home medications with the providers prescriptions

A nurse is admitting a client who has an abdominal wound with a large amount of purulen drainage. What type of transmission precaution should the nurse initiate?

Contact precautions

A nurse is administering 1 L of NaCl to a client who is postop and has fluid volume deficit. What changes should the nurse identify as an indication that the treatment was successful

Decrease in heart rate

A nurse is caring for a client who is postop and refuses to use an incentive spirometer following major abdominal surgery. What action is the nurse's priority?

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

A nurse is caring for a client whohas pharyngeal diphtheria. What type of transmission precautions should the nurse initiate?

Droplet

A nurse is assessing four adult clients. what physical assessment technique should the nurse use?

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

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. What action should the nurse take?

Examine personal values about the issue

A nurse is caring for a client who requires an NG tube for stomach decompression. What action should the nurse take when inserting the NG tube?

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

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. What type of dressing should the nurse use?

Hydrocolloid

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. What statement should the nurse make?

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

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize what statement by the client's partner indicates effective coping?

I am relying on support from our family during this time?

A nurse is assessing a client's readiness to learn about insulin self-administration. What statements should the nurse identify as an indication that the client is ready to learn

I can concentrate best in the morning

A nurse is providing discharge instructions to a client who will be using a walker. What client statements indicates an understanding of the teaching?

I will hire someone to trim the tree that hangs low over the stairs of my front porch

A nurse is assessing a client who reports increased pain following physical therapy. What question should the nurse ask when assessing the quality of the client's pain?

Is your pain sharp or dull?

A client who is postop is verbalizing pain as a 2 on a pain scale of 0-10. What statement should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

It might help me to listen to music while I"m lying in bed

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." What response should the nurse make?

Let's talk about how the change in your job status will affect you

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. What precaution should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. What action should the nurse take?

Make sure two fingers can fit under the sleeves

A nurse is caring for a client who is postop and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and report back in 1 hr. What action should the nurse take next?

Notify the nursing manager

A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. What action should the nurse take?

Pad the client's wrist before applying the restraints

A nurse is caring for a group of clients. What action should the nurse take to prevent the spread of infection?

Place a client who has TB in a room w/ negative-pressure airflow

A nurse is planning to insert a peripheral IV catheter for an older adult client. What action should the nurse plan to take?

Place the client's arm in a dependent position

A nurse is reviewing a client's fluid and electrolyte status. What finding should the nurse report to the provider?

Potassium is 5.4

A nurse is administering an otic medication to an older adult client. What action should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. What action should the nurse take?

Reassure the client that this is an expected response to grief

A nurse is reviewing EBP principles about administration of oxygen therapy with a newly licensed nurse. What following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of now more than 6 L/min

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing what type of role-performance stress?

Role overload

A nurse is preparing a change-of-shift report. What tool or document should the nurse use to communicates continuity of care?

Situation, background, assessment, and recommendation (SBAR)

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, what action should the nurse take when lifting this object?

Stand close to the cabinet when lifting it

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. What action should the nurse take?

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

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

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

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. What observation should the nurse identify as proper safety protocol?

The client uses nonacetone nail polish removes

A home health nurse is performing a follow-up visit for a client who has a G tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. What finding should the nurse identify as a possible cause of the diarrhea?

The client's caregiver washed out the feeding bad with warm water once ever 24 hour

A nurse is caring for a client who asks about the purpose of advance directives. What statement should the nurse make?

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

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. What action should the nurse take?

Turn the client every 2 hrs

A nurse is caring for a client who has dementia. What intervention should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. What statement should the nurse manager plan to include in the teaching?

Use the complete name of the mediation magnesium sulfate

A nurse is planning strategies to manage time effectively for client care. What strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. What instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ED and I had difficulty breathing?" What response should the nurse make?

We would give you O2 through a tube in your nose.

A nurse is caring for a client who has diarrhea due to shigella. What precaution should the nurse implement for this client?

Wear a gown when caring for the client

A nurse is caring for a client who has a sodium level of 125. What finding should the nurse expect?

abdominal cramping

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for what therapy

accupuncture

A nurse is assessing a client who has required bed rest for the past month. What findings should the nurse identify as an indication that the client has developed thrombophebitis?

calf swelling

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission process

A nurse is providing discharge teaching to a client about self-administering heparin. What instruction should the nurse include in the teaching?

Administer the medication into the abdomen

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. What task should the nurse assign to an assistive personnel?

-assist the client with a partial bed bath -measure the client's BP after the nurse administers an antihypertensive med -Use a communication board to ask what the client wants for lunch

A nurse is caring for a client who is postop. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." What intervention is the nurse's priority action?

Administer pain medication 45 min before changing the clients dressing

A nurse is preparing to administer enoxaparin subq to a client. What action should the nurse take?

Administer the medication with the needle at a 45 angle