Q Cards 1

The nurse is observing a new LPN insert an indwelling foley catheter for a client. The nurse knows it is necessary to intervene when the new LPN initiates what action? 1. Applies sterile gloves prior to opening catheter kit 2. Pours iodine solution over the sterile cotton balls 3. Lubricates catheter by dipping into water-soluble gel 4. Identifies client and elevates bed to waist height

1. Applies sterile gloves prior to opening catheter kit

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room? 1. gown 2. gloves 3. goggles 4. surgical mask 5. N95 respirator

1. gown 2. gloves

a nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse implement for the client's night sweats and fever. SATA

1. keep water by the bedside 2. place a plastic cover over the pillow 3. administer an antipyretic every 4 hours 4. keep a change of linen in the room 5. position the client in a semi-fowlers position

A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack occurs. What would be the nurse's best response to the client? 1. I understand that you feel anxious. But you must stop this behavior 2. The feelings that you described can occur in individuals with asthma. You may find that learning relaxation exercises may help 3. I am concerned that feeling anxious during an asthma attack means you need more education about asthma 4. Everyone with asthma experiences tough times with their symptoms. You are learning to manage your asthma

2. The feelings that you described can occur in individuals with asthma. You may find that learning relaxation exercises may help

The nurse is providing care for an elderly client who has a PEG feeding tube and is receiving continuous feeding. Which interventions should the nurse include when providing care? 1. Add meds to enteral feeding formula 2. Change dressing around insertion site weekly 3. flush feeding tube with 30 mL warm tap water every 4 hours 4. Maintain HOB at 30 degree elevation 5. Monitor for hypoglycemia

3. flush feeding tube with 30 mL warm tap water every 4 hours 4. Maintain HOB at 30 degree elevation

The nurse identifies that additional teaching about skin care is needed when an 80 year old makes what statement? 1. I shower 3-4 times per week 2. I apply moisturizers at least daily 3. I bathe in the tub at least 6 times per week 4. I drink 64 oz of liquid per day

I bathe in the tub at least 6 times per week

Which nursing statements about a client reflect correct documentation in the hospital medical record? 1. 20% of breakfast consumed 2. 4 inch by 2 inch wound noted on R arm 3. enema administered 4. Appears upset at spouse 5. Lying in bed

1. 20% of breakfast consumed 2. 4 inch by 2 inch wound noted on R arm

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? SATA 1. Ask a familiar person to stay with the client 2. apply position change sensor to the bed 3. move client closer to the nursing station 4. reinstruct the client to not get out of the bed 5. provide positive and negative reinforcement

1. Ask a familiar person to stay with the client 2. apply position change sensor to the bed 3. move client closer to the nursing station

Which discharge instruction should the nurse implement for a client diagnosed with insomnia? 1. Eliminate chocolate in the evening 2. Drink a glass of red wine 1 hour prior to bedtime 3. perform progressive relaxation techniques at bedtime 4. take acetaminophen/diphenhydramine 2 tablets at bedtime 5. leisurely walk 3 hours prior to bedtime

1. Eliminate chocolate in the evening 3. perform progressive relaxation techniques at bedtime 5. leisurely walk 3 hours prior to bedtime

A nurse enters the OR with artificial fingernails in place. Hat should the charge nurse explain to the nurse? SATA 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial nails 2. Artificial fingernails are allowed to be worn in the OR 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of SSI to the client 4. A more vigorous scrub is required if artificial fingernails are worn 5. Long fingernails and artificial fingernails increase microbial load on the hands

1. Pathogenic bacteria can be found on the fingertips of those who wear artificial nails 3. Fungal growth can occur under the artificial fingernail, thus increasing the risk of SSI to the client 5. Long fingernails and artificial fingernails increase microbial load on the hands

a client at 31 weeks gestation is being seen by the primary healthcare provider for reports of generalized illness. When assessing the client, the nurse would immediately report what symptom to the primary health care provider? 1. Right upper quadrant pain 2. nausea with vomiting 3. severe headache 4. blurred vision

1. Right upper quadrant pain

Which finding indicates to the nurse that a client is at risk for skin breakdown? 1. Weakness requiring assistance to move in bed 2. Daily intake of at least 85% of food offered 3. Occasional forgetfulness 4. Continent of bowel and bladder

1. Weakness requiring assistance to move in bed

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? 1. Weigh QD 2. IV of NS at 125 mL/hr 3. MRI of pituitary gland 4. Fludrocortisone acetate 0.1 mg by mouth TIW 5. Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day

1. Weigh QD 4. Fludrocortisone acetate 0.1 mg by mouth TIW

an Asian client, who cannot speak or comprehend English, is brought to the emergency department by family. One family member is able to understand simple sentences of English. How would the nurse best explain how to obtain a clean catch urine to the client? 1. have the family member repeat the nurse's explanation to the client 2. contact social services to find an authorized interpreter 3. use simple hand motions to explain the procedure to the client 4. Draw a diagram to demonstrate the use of the sterile cup when obtaining the specimen

2. Contact social services to find an authorized interpreter

The nurse is assisting the client on the correct procedure for applying anti-embolism stockings. Which statement by the client indicates that the client understands the procedure? 1. The stockings should be applied when my legs are swollen 2. I will apply the anti-embolism stockings before getting out of bed 3. I will apply cortisone-10 ointment to skin on both legs everyday 4. Prior to applying the stocking I will look for reddened areas on my skin 5. When pulling up the stockings, I will allow for an extra roll of the stocking at my calves

2. I will apply the anti-embolism stockings before getting out of bed 4. Prior to applying the stocking I will look for reddened areas on my skin

The nurse notices that the primary healthcare provider, who has been looking at a client's morning lab results, walked away from the computer work station without logging out the system, leaving the page of the client medical information visible on the computer screen. What is the most appropriate action by the nurse? 1. Log the primary healthcare provider off the facility's health information system 2. Minimize the screen so that the client information is no longer visible, and then ask the primary healthcare provider if the computer can be logged out 3. do not interfere since the primary healthcare provider is responsible for this information 4. Read the health information that the primary healthcare provider left visible on the computer screen to see if the document was completed

2. Minimize the screen so that the client information is no longer visible, and then ask the primary healthcare provider if the computer can be logged out

The nurse is planning care for the prevention of skin breakdown in a client diagnosed with a stroke. What intervention is important for the nurse to include? 1. Massage reddened skin areas located over bony prominences 2. Place pillows under lower extremities to raise heels off the bed 3. position client on paralyzed side for one hour 4. apply emollients to dry skin 5. place a gel seat cushion on the wheelchair seat 6. Shift client weight every two hours while sitting in a wheelchair

2. Place pillows under lower extremities to raise heels off the bed 4. apply emollients to dry skin 5. place a gel seat cushion on the wheelchair seat

The nurse is providing discharge dietary instructions to a client diagnosed with full thickness burns to the right hand. To promote tissue healing, which food examples should the nurse provide to the client? 1. pasta 2. oranges 3. brown rice 4. chicken breast 5. electrolyte drink

2. oranges 4. chicken breast

The nurse is reinforcing proper use of the walker with partial weight-bearing to a client with a total hip arthroplasty. Which action would indicate to the nurse that the client is using the walker correctly? 1. Leaning over the walker 2. Using a walker with 4 wheels 3. Elbows positioned at 30 degrees 4. Lifts the walker when climbing steps

3. Elbows positioned at 30 degrees

A client on the med-surg unit is being treated for dehydration and pneumonia. The UAP has entered the room to complete AM care, but the client refuses, reporting feeling too tired from a "poor nights sleep." The UAP reports the refusal to the nurse. What statement by the nurse provides the best explanation to the UAP? 1. Explain to the client that we are short staffed, so AM care needs done at this time. 2. Don't worry about it; just tell the next shift they will need to do this client care 3. Let's look over your shift assignments to see if we can rearrange some other tasks 4. It is crucial for this client to be able to rest, so clean sheets can with till tomorrow

3. Let's look over your shift assignments to see if we can rearrange some other tasks

the client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence

3. Slander

which action by the nurse is most likely to result in a possible breach of confidentiality of medical records? 1. entering the data on clients only at computers in nurse's station 2. recording the client history of abortion 3. sharing access controls like passwords with other healthcare professionals 4. leaving the computer terminal before logging off

4. leaving the computer terminal before logging off

The nurse assesses a diabetic client in the ED and notes a blood glucose of 400 mg/dL, muscle twitching, and an increased RR. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

Metabolic acidosis

A nurse is teaching a community education course regarding complementary and/or alternative therapies. Which therapies would the nurse include in the course as complement and/or alternative therapies? 1. Acupuncture 2. yoga 3. tai chi 4. reiki 5. zumba

acupuncture yoga tai chi reiki

A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour 2. Reduce the infusion rate to 25 mL/hour and reevaluate residual volume in 4 hours 3. Change the feeding schedule from continuous to intermittent delivery 4. discard the 200 mL and continue the feedings at the same rate

1. Stop the feeding and assess gastric residual volume in 1 hour

the charge nurse is assigning a UAP to take vital signs on a group of adult clients. The charge nurse would instruct the UAP that a rectal temperature is contraindicated for which client? 1. client with thrombocytopenia 2. client with a fractured femur 3. client with an inguinal hernia 4. client with irritable bowel syndrome

1. client with thrombocytopenia

The nurse is caring, for a client with a colostomy who is experiencing excess flatulence. Which instructions should the nurse provide the client? 1. limit the intake of carbonated beverages 2. encourage fluid intake of 1000 mL/24 hours 3. create a small hole in the colostomy stoma pouch 4. limit consumption of beans, onions, and broccoli 5. release the pouch clamp to release the gas in the colostomy pouch

1. limit the intake of carbonated beverages 4. limit consumption of beans, onions, and broccoli 5. release the pouch clamp to release the gas in the colostomy pouch

a charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? SATA 1. wearing clean gloves to convert an IV to a saline loc 2. donning sterile gloves for a cesarean dressing change 3. wearing a N95 respirator while caring for a child who has RSV 4. Putting on a gown to take care of a client who has toxoplasmosis 5. performing hand hygiene after removing gloves

1. wearing clean gloves to convert an IV to a saline loc 2. donning sterile gloves for a cesarean dressing change 5. Performing hand hygiene after removing gloves