adaptive review test 1

An elderly adult with Parkinson's disease falls while going to the bathroom and gets injured. The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system?

The nurse should document the incident in the occurrence report tool.

The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority?

assessing airway patency

What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing?

cheyne-stokes respirations

For which illness should airborne precautions be implemented?

chickenpox

What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath?

clubbing

A client is hospitalized with an overdose of benzodiazepines and presents with a respiratory rate less than 10 breaths per minute. Which nursing intervention should be provided as the first priority?

give oxygen

An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode?

gloves

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect?

kussmaul's respiration

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first?

respirations

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past 2 days. What is the first thing the nurse should do when caring for this client?

take the temperature

The oxygen saturation value of an African client measured through a pulse oximeter is 93%. What does the nurse infer from this reading?

the client has a normal SpO2 value

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client?

use standard precautions

The registered nurse is evaluating the statements of a new orienting nurse about wound dressing. Which statement made by the new orienting nurse indicates the need for further teaching?

"I should take the cotton swab placed on the table."

The registered nurse is teaching a student nurse about the interventions to be followed by a client to prevent the spread of infection. Which statement made by the student nurse indicates the need for further learning?

"I will advise the client to squeeze the pustules."

A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse?

95

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first?

Assess the patency of airway

What should be the priority action of the nurse who is caring for a client with a leg in traction?

Assessing the skin integrity

A hospitalized client is on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). Which statement by an unlicensed assistive personnel (UAP) (Canada: continuing care assistant, CCA) indicates a need for further teaching?

"I will remove the gown, then the gloves, before washing my hands."

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply.

- obtain blood cultures immediately - admin antibiotic STAT

What assessment findings indicate that a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply.

- pruritus - wheezing - bronchospasm

A client is admitted with a sudden onset of dyspnea and chest pain. What are the interventions in the order in which the nurse will perform them to provide comfort to the client?

1) notify the rapid response team 2) reassuring the client and the family members 3) elevating the head of the bed 4) preparing for O2 therapy and blood gas analysis 5) reassuring the client and family members

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply.

- check tubing for kinks - post "no smoking" signs in the clients rooms

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?

Elevate the head of the client's bed and obtain vital signs.

A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention should the nurse emphasize?

Giving small amounts of clear liquids frequently to prevent dehydration

Which diseases can be transmitted from client to client by droplet infection? Select all that apply.

- pertussis - diptheria

The nurse is assessing the core body temperature of four clients. Which client requires priority critical care?

Client with body temperature of 27°C

What is the priority nursing action for a client with delirium?

Creating a calm and safe environment

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension?

Sit on the edge of the bed for 5 minutes before standing.

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions?

Sputum is free of acid-fast bacteria

What assessment findings indicate that an older client is at risk for developing an infection? Select all that apply.

- thin skin - weak cough - sluggish bowel sounds - indwelling urinary catheter

What is the priority goal for a client with asthma who is being discharged from the hospital with prescriptions for inhaled bronchodilators?

Demonstrates use of a metered-dose inhaler

The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction?

Inhaling air fully before inserting the mouthpiece Incentive spirometry is used to improve inspiratory muscle action and to prevent or reverse atelectasis in a client with pneumonia. The client is instructed to exhale fully and then insert the mouthpiece. Inhaling the air before inserting the mouthpiece may cause harm to the client and therefore needs correction.

The nurse enters the client's room to do the beginning of shift assessment and notices the client has no pulse. What should be the nurse's first intervention?

Initiating cardiopulmonary resuscitation

The registered nurse finds that a client cared for by a student nurse has developed an infection. Which action of the student nurse does the registered nurse suspect to be the cause of infection?

Use of a wet dressing

The nurse is teaching a group of student nurses about caring for a hospitalized immunosuppressed client. Which statement(s) made by the student nurse indicates the need for further teaching? Select all that apply.

- "I should inspect the client's mouth at least every 4 hours." - "I should monitor the vital signs of the client every 8 hours. - "I should ensure that that the client's room and bathroom are cleaned at least once a week."

Which physical assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply

- a midline trachae - pink nasal mucosa - nonlabored respirations of 14 breaths/min

In what ways can a nurse prevent medication errors? Select all that apply.

- avoid using abbreviations and acronyms - minimize the use of verbal and telephone orders - check three times before giving a drug by comparing the drug order and medication profile

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply.

- bounding pulse - presence of dependent edema - neck vein distention in the upright position

The primary healthcare provider prescribes thioridazine and assigns the nurse to assess the client for orthostatic hypotension. Which interventions would the nurse perform? Select all that apply.

- Measuring the blood pressure before dosing - Measuring the blood pressure one hour after dosing -Measuring the blood pressure one or two minutes after the client sits or stands

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Select all that apply.

- aurborne - contact - standard

Which clients should be considered for assessing the carotid pulse? Select all that apply.

- client with cardiac arrest - client under physiologic shock

A client is admitted to the emergency department with dyspnea, a productive cough, and fever. The healthcare provider suspects pneumonia and writes prescriptions. Place the nursing actions in the order they should be performed.

1) obtain a sputum culture 2) elevate the head of the bed 3) admin the prescribed IV pggyback antibiotic 4) review the results of the sensitivity test 5) insert a catheter to establish access

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next?

Bending and then straightening their knees

A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply.

- bringing the equipment to the client's room - transporting the client to a diagnostic test

Which are extrinsic factors responsible for falls in older adults? Select all that apply.

- cognitive impairment - environmental hazards - inappropriate footwear - improper use of assistive devices

Which assessment finding is considered the earliest sign of decreased tissue oxygenation?

Unexplained restlessness

A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do?

Wear a particulate respirator mask

Which complications does the nurse anticipate in the client who has blue-colored nail beds?

cardiopulmonary disease

A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment?

A client with acute asthma and 85% oxygen saturation

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

A listing of facts related to the incident as witnessed by the nurse

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status?

A low hemoglobin level causes reduced oxygen-carrying capacity.

Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction?

Restraints can be used anytime without a written order from the healthcare provider.

After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion?

wheezing

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?

Assess the client's condition every hour.

Which physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth?

Auscultation The physical assessment maneuvers used for chest examination include inspection, palpation, percussion, and auscultation. During auscultation, the nurse instructs the client to breathe in slowly and a little more deeply than normal through the mouth. The nurse asks the client to breathe deeply while performing palpation. During inspection, the nurse asks the client to sit upright or to have the head of the bed upright. While performing percussion, the nurse helps the client to assume the semi-sitting or supine position.

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate?

Femoral

A client with multiple injuries from a motor vehicle accident now is permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse do what?

Fold the client's arms across the chest.

Which condition is an example of a bacterial infection?

Impetigo

The nurse is caring for clients in the pulmonary unit and suspects that one has tuberculosis. What is the priority nursing intervention in this situation?

Move the client to an airborne isolation unit

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider?

No prescription change The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure). There is no indication from the data that a prescription change is needed for this client.

Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury?

Performing a jaw thrust maneuver

A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription?

Recognizing that PRN prescriptions for restraints are unacceptable

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of?

Remittent

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?

Removing the catheter within 24 hours

The nurse is caring for a client with a platelet count of 50,000 cells per microliter. Which recommendation is inappropriate for the client?

Shaving with a straight blade razor

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation?

Stop administering the medication

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change?

The client may have a dysrhythmia

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding?

The pulse strength is barely palpable

While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse's conclusion?

Urine output is 25 mL per hr The urine output should be at least 30 ml per hour. Less than 30 ml per hour indicates the need for notifying the healthcare provider because low urine output indicates volume depletion that may result in renal damage

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take?

Wear a particulate respirator when caring for the client

What is considered to be the highest priority for an assault victim who presents to the emergency department?

What is considered to be the highest priority for an assault victim who presents to the emergency department?

A new nurse has been assigned to a school-aged child who is in contact isolation for methicillin-resistant Staphylococcus aureus (MRSA). The primary nurse observes the new nurse during morning care. Which behavior should the primary nurse address to improve isolation technique?

While changing the bed the nurse wears gloves but no gown

Which would the nurse consider to be a potential respiratory system-related complication of surgery?

atelectasis

The nurse decides to teach deep-breathing exercises to a client recovering from a surgery. Which professional responsibility does the nurse display?

autonomy

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client?

bradypnea

Which is an example of indirect contact transmission of microorganisms?

dirty hands

Which first line medication would the nurse state is used to treat anaphylactic reactions?

epinephrine

Which level of Maslow's hierarchy of needs is fulfilled by the nurse fitting a client who nearly died of asphyxiation with an oxygen mask?

first level

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate?

relapsing

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?

stop the blood transfusion immediately

The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse?

strong

A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply.

- checking the child's weight everyday - calculating the dose of drug as carefully as possible - assessing the child regularly to help prevent electrolyte loss

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply.

- minimizing medications - modifying the home environment - manage foot and footwear

The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Select all that apply.

- performing all hygiene tasks - helping the client in changing clothes

The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Select all that apply.

- sedation - respiratory rate

A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and diarrhea, with 10 stools in the past 24 hours. Which signs are evidence that the client most likely is dehydrated? Select all that apply.

- sunken eyes - dry mucous membranes

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The healthcare provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure?

surgical asepsis

Which intrinsic factors may contribute to falls in older adults? Select all that apply.

- deconditioning - impaired vision

The registered nurse (RN) is delegating tasks to several health care team members caring for a client with a bacterial infection and high fever. Which statements by the registered nurse would be most appropriate for the licensed practical nurse (LPN)? Select all that apply.

- "you should admin an antipyretic after the meal" - "you should admin prescribed antibiotics to the client twice a day" - you should collect data that can be used in the assessment of client's condition"

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply.

- lips - mouth - nail beds

An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation?

Teach coughing and deep-breathing exercises.

A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time?

client with epilepsy