Ati

A nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the client's safety needs? (Select all that apply). A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctivae D. visual fields E. visual acuity

B,D,E

A nurse is performing a skin assessment of a client who has a lesion on hisanterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? A) Uniform pigmentation B) A regular border C) An uneven shape D) A diameter smaller than 6 mm

C

A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggestthat the client add to his diet? A) Beef liver B) Shellfish C) Egg yolks D) Avocados

D

A nurse in a long-term care facility is caring for a client who dies during thenurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body

2,3,4,5,1

A charge nurse is observing a newly licensed nurse prepare a sterile field.Which of the following actions should the charge nurse identify as contaminating the sterile field? A) The nurse opens the sterile field on a wet surface. B) The nurse opens the first fold away from his body. C) The nurse holds sterile objects above the waist. D) The outer edge of the sterile field is touching a bottle.

A

A nurse has an order to remove sutures from a client. After retrieving thesuture remover kit and applying sterile gloves, which of the following actions should the nurse take next? A) Clean sutures along the incision site. B) Grasp at the knot of the sutures with forceps. C) Cut the sutures close to the skin on one side. D) Pull out the sutures with forceps in one piece.

A

A nurse is administering IV fluid to an older adult client. the nurse shouldperform which priority assessment to monitor for adverse effects? A. auscultate lung sounds B. masure urine output C. monitor blood pressure readings D. monitor serum electrolyte levels

A

A nurse is administering an otic medication to an older adult client. which ofthe following actions should the nurse take to ensure that the medication reaches the inner ear? A. press gently on the tarsus of the client's ear B. pack a small piece of cotton deep into the cent's ear canal C. move the client's auricle down and back toward her head D. tilt the client's head backward for 5 min

A

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client'splan of care? A) Wrap blankets around all four sides of the bed. B) Apply restraints during seizure activity. C) Place the client in a supine position during seizure activity. D) Have a tongue depressor at the client's bedside.

A

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? A) During the admission process B) As soon as the client's condition is stable C) During the initial team conference D) After consulting with the client's family

A

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of thefollowing actions should the nurse take? A) Examine personal values about the issue. B) Tell the parents that this is a necessary procedure. C) Inform the parents that the staff does not require their consent. D) Contact a spiritual support person to explain the importance of the procedure.

A

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of thefollowing actions should the nurse take? A) Talk directly to the client, instead of the interpreter, when speaking. B) Use a family member as the client's interpreter. C) Make sure that the interpreter has a college degree. D) Avoid asking the client personal questions through the interpreter.

A

A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the followinglocations should the nurse place the bell of the stethoscope? A) Second intercostal space at the left sternal border B) Fourth intercostal space at the right sternal border C) Fourth intercostal space at the left sternal border D) Second intercostal space at the right sternal border

A

A nurse is caring for a client who has a terminal diagnosis and whose healthis declining. The client requests information about advance directives. Which of the following responses should the nurse make? A) "We can talk about advance directives, and I can also give you some brochures about them." B) "You should set up a time to talk with your provider about that." C) "Let's discuss how you are feeling today, and we'll save the planning forwhen you are feeling a little better." D) "Why do you want to discuss this without your partner here to plan thiswith you?"

A

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principleof veracity? A) A client unaware of her recent cancer diagnosis asks the nurse if she hascancer, and the nurse responds affirmatively. B) A client who has a prescription for a nasogastric tube refuses it, and thenurse complies with the client's wishes. C) A client with a do-not-resuscitate (DNR) status has a cardiac arrest, andthe nurse does not perform CPR despite requests from the client's family. D) A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she wouldgive her.

A

A nurse is performing a peripheral vascular assessment for a client. whenplacing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent bloodflow. this sound indicates which of the following? A. narrowed arterial lumen B. distended jugular veins C. impaired ventricular contraction D. asynchronous closure of the aortic and pulmonic valve

A

A nurse is preparing to administer enoxaparin subcutaneously to a client.Which of the following actions should the nurse take? A) Administer the medication with the needle at a 45° angle. B) Administer the medication into the client's nondominant arm. C) Pull the client's skin laterally or downward prior to administration. D) Massage the injection site after administration.

A

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should thenurse implement to prevent infection? A) Thread the IV catheter so that the hub rests at the insertion site. B) Shave excess hair from around the insertion site. C) Cleanse the site with hydrogen peroxide before IV catheter insertion. D) Palpate the site carefully just before inserting the IV catheter.

A

A nurse is responding to a call light and finds a client lying on the bathroomfloor. which of the following actions should the nurse take first? A. check the client for injuries B. move hazardous objects away from the client C. notify the provider D. ask the client to describe how she felt prior to the fall

A

A nurse is reviewing the medical records of a client who has a pressure ulcer.Which of the following findings should the nurse expect? A) Albumin level of 3 g/dL B) HDL level of 90 mg/dL C) Norton scale score of 18 D) Braden scale score of 20

A

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indicationthat the client understands the teaching? A) "When descending stairs, I will first shift my weight to my right leg." B) "I should place my crutches 12 inches in front and to the side of eachfoot." C) "As I sit down, I will hold one crutch in each hand." D) "I will make sure the shoulder rests are snug against my armpits.

A

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should thenurse manger plan to include in the teaching? A. "use the complete name of the medication magnesium sulfate." B. "delete the space between the numerical dose and the unit of measure." C. "write the letter U when noting the dosage of insulin." D. "use the abbreviation SC when indicating an injection."

A

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should thenurse take? A) Pad the client's wrist before applying the restraints. B) Evaluate the client's circulation once per shift after application. C) Remove the restraints every 4 hr to evaluate the client's status. D) Secure the restraint ties to the client's bed side rails.

A

a nurse is caring for a client who has terminal live cancer. which of thefollowing statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "what could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "where is my daughter at a time like this?" D. "will I ever begin to feel in charge of my life again?"

A

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assignto an assistive personnel (AP)? (Select all that apply.) A) Assist the client with a partial bed bath. B) Measure the client's BP after the nurse administers an antihypertensive medication. C) Test the client's swallowing ability by providing thickened liquids. D) Use a communication board to ask what the client wants for lunch. E) Irrigate the client's indwelling urinary catheter.

A,B,D

A nurse is caring for a client who has tuberculosis. which of the followingactions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene

A,B,E

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select allthat apply.) A) Check the cord routinely for frays or tearing. B) Keep the unit at least 4 feet away from a gas stove. C) Consider purchasing a generator for power backup. D) Observe for signs of hypoxia. E) Select synthetic clothing and bedding.

A,C,D

A nurse has just inserted an NG tube for a client. Which of the followingassessment findings should the nurse expect to confirm correct tube placement? A) The tube aspirate has a pH of 7. B) An x-ray shows the end of the tube above the pylorus. C) Bowel sounds are present on auscultation. D) The client reports relief of nausea.

B

A nurse in a provider's office is assessing the deep tendon reflexes of a client.Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? A) Back of foot (heel) B) Knee cap C) Elbow D) Back of elbow

B

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which ofthe following precautions should the nurse take? A. ensure sterilization of non disposable items with ethylene oxide B. wrap monitoring cords with stockinette and tape them in place C. cleanse latex pots on IV tubing with chlorohexidine before injection medication D. wear hypoallergenic latex gloves that contain powder

B

A nurse is caring for a client who has a respiratory infection. Which of thefollowing techniques should the nurse use when performing nasotracheal suctioning for the client? A) Insert the suction catheter while the client is swallowing. B) Apply intermittent suction when withdrawing the catheter. C) Place the catheter in a location that is clean and dry for later use. D) Hold the suction catheter with her clean, nondominant hand.

B

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? A) Turn the client every 4 hr. B) Elevate the head of the client's bed. C) Hold oral care. D) Increase the room's temperature.

B

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actionsshould the nurse take first? A. rinse the feeding bag with water between feedings B. tell the client to keep the head of the bed elevated at least 30o C. make sure the enteral formula is at room temperature D. wipe the top of the formula can with alcohol

B

A nurse is caring for a client who has diarrhea due to shigella. Which of thefollowing precautions should the nurse take? A) Have the client wear a mask when receiving visitors. B) Wash her hands before and after contact with the client. C) Assign the client to a room with negative-pressure airflow exchange. D) Instruct all visitors to limit their time with the client.

B

A nurse is caring for a client who has pharyngeal diphtheria. Which of thefollowing types of transmission precautions should the nurse initiate? A) Contact B) Droplet C) Airborne D) Protective

B

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in1 hr. From a legal perspective, which of the following actions should the nurse take next? A) Document the provider's statement in the medical record. B) Notify the nursing manager. C) Consult the facility's risk manager. D) Complete an incident report.

B

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A) Carry a client's soiled linens out of the room in a mesh linen bag. B) Place a client who has tuberculosis in a room with negative-pressureairflow. C) Provide disposable plates and utensils for a client who is HIV-positive. D) Dispose of a client's blood-saturated dressing in a trash bag inside asecond trash bag.

B

A nurse is educating a client who has a terminal illness about her request todecline resuscitation in her living will. The client asks what would happen ifshe arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? A) "We will determine who the durable power of attorney for health careform has designated." B) "We will apply oxygen through a tube in your nose." C) "We will ask if you have changed your mind." D) "We will insert a breathing tube while we evaluate your condition."

B

A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information isthe priority for the nurse to provide? A) Admitting diagnosis B) Breath sounds C) Body temperature D) Diagnostic test results

B

A nurse is initiating a protective environment for a client who has had anallogeneic stem cell transplant. Which of the following precautions shouldthe nurse plan for this client? A) Make sure the client's room has at least 6 air exchanges per hour. B) Make sure the client wears a mask when outside her room if there is construction in the area. C) Place the client in a private room with negative-pressure airflow. D) Wear an N95 respirator when giving the client direct care.

B

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of thefollowing actions should the nurse include? A) Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B) Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. C) Make sure the reservoir bag of a partial rebreathing mask remainsdeflated. D) Use petroleum jelly to lubricate the client's nares, face, and lips.

B

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurseinclude in the teaching? A) Remove the outer cannula cautiously for routine cleaning. B) Use tracheostomy covers when outdoors. C) Use sterile technique when performing tracheostomy care at home. D) Cleanse irritated skin with full-strength hydrogen peroxide.

B

a nurse is admitting a client who has influenza. which of the following typesof transmission precautions hold the nurse initiate? A. airborne B. droplet C. contact D. protective environment

B

a nurse is caring for a client who is refusing a blood transfusion for religiousreasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? A. ask the client to consider a direct donation B. withhold the blood transfusion C. request a consolation with the ethics committee D. ask the client's family to intervene

B

a nurse is caring for a client who is terminally ill. which of the following statements should the nurse identify as an indication that the client's familymember is coping effectively with the situation? A. "we are not worried. we still have hope that everything will be ok." B. "this is a difficult time, but we are helping each other though this." C. "after he comes home, we can plan out family reunion." D. "we don't need to talk about funeral arraignments at this time."

B

a nurse is planning to insert a peripheral IV catheter for an older adultclient. which of the following actions should the nurse plan to take? A. insert the other at a 45o angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiative IV therapy in the veins of the hand

B

a nurse is preparing a change-of-shift report. which of the of the following tools or documents should the nurse use to communicate continuity of care? A. critical pathway B. SBAR C. transfer report D. medication administration record (MAR)

B

a nurse is reviewing protocol in preparation for suctioning secretions from client who has a new tracheostomy. which of the following actions should thenurse plan to take? A. use a resuscitation bag with 80% oxygen prior to the procedure B. select a suction catheter that is half of the size of the lumen C. place the end of the function catheter in water-soluble lubricant D. adjust the wall suction apparatus to a pressure of 170 mm Hg

B

a nurse manager is overseeing the care on a unit. which of the followingshould the nurse manager identify as a violation of HIPAA guidelines? A. a nurse who is caring for a client reviews the client's medical chart withthe nursing student who is working with the nurse B. a nurse asks a nurse from another unit to assist with her documentation C. a nurse who is caring for a client returns a call to the client's durablepower of attorney for health care designee to discuss the client's care D. a nurse discusses a client's status with the physical therapies that iscaring for the client's bedside

B

A nurse working in the emergency department is witnessing the signing ofinformed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legallywitness? (Select all that apply.) A) A teacher who brings in a 7-year-old student B) A 16-year-old client who is married C) A 27-year-old client who has schizophrenia D) An adoptive parent who brings in his 8-year-old son E) A 17-year-old mother who brings in her toddler

B,C,D,E

A client who is nonambulatory notifies the nurse that his trash can is on fire.After the nurse confirms the fire, which of the following actions should the nurse take next? A) Activate the emergency fire alarm. B) Extinguish the fire. C) Evacuate the client. D) Confine the fire.

C

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she receivedabout pain management? A) "I think I should take my pain medication more often, since it is not controlling my pain." B) "Breathing faster will help me keep my mind off of the pain." C) "It might help me to listen to music while I'm lying in bed." D) "I don't want to walk today because I have some pain."

C

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell overthe bedrail onto the floor. Which of the following statements should the nurse document about this incident? A) "Incident report completed." B) "Client climbed over the bedrails." C) "Client found lying on floor." D) "Client was trying to get out of bed."

C

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A) Increase in hematocrit B) Increase in respiratory rate C) Decrease in heart rate D) Decrease in capillary refill time

C

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake andoutput record as 120 mL of fluid? A) 2 cups of soup B) 1 quart of water C) 8 oz of ice chips D) 6 oz of tea

C

A nurse is caring for a client who has a prescription for wound irrigation.which of the following actions should the nurse take? A. wear sterile gloves when removing the old dressing B. warm the irrigation solution of 40.5oc (105oF) C. cleanse the wound from the center outward D. use a 20 mL syringe to irrigate the wound

C

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. Which of the following statements should the nurse make? A) "I will return shortly after I document this in your record." B) "Most men live a long time with prostate cancer." C) "I am available to talk if you should change your mind." D) "I will make a referral to a cancer support group for you."

C

A nurse is caring for a client who has an indwelling urinary catheter. Whichof the following assessment findings indicates that the catheter requires irrigation? A) Urine has an unusual odor. B) Urine specific gravity is 1.035. C) Bladder scan shows 525 mL of urine. D) Urine is positive for ketones.

C

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compressiondevice. Which of the following actions should the nurse take? A) Assist the client into a prone position. B) Place a sleeve over the top of each leg with the opening at the knee. C) Make sure two fingers can fit under the sleeves. D) Set the ankle pressure at 65 mm Hg.

C

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? A) Small air bubbles are in the IV tubing. B) IV flow stops when the client bends her arm. C) Swelling and coolness are observed at the IV site. D) Blood is visible in the IV catheter and tubing.

C

A nurse is caring for a client who requires bed rest and has a prescription foranti embolic stocking. which of the following actions should the nurse take? A. apply the stockings so the creases are on the front of the leg B. apply the stockings while the client's legs are in a dependent position C. remove the stockings at least once per shift D. remove the stockings while the client is sitting in a reclining chair

C

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following assessment findings should the nurse expect? A. neck vein distention B. urine specific gravity 1.010 C. rapid heart rate D. blood pressure 144/82 mm Hg

C

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? A) Reduce dietary sodium B) Administer a loop diuretic C) Evaluate electrolytes D) Restrict intake of oral fluids

C

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? A) Insert the IV catheter into the back of the client's hand. B) Massage the area of the venipuncture site vigorously. C) Insert the IV catheter without using a tourniquet. D) Apply traction to the skin proximal to the insertion site to stabilize the vein.

C

A nurse is preparing to transfer a client who can bear weight on one legfrom the bed to a chair. After securing a safe environment, which of thefollowing actions should the nurse take next? A) Rock the client up to a standing position. B) Pivot on the foot that is the farthest from the chair. C) Assess the client for orthostatic hypotension. D) Apply a gait belt to the client.

C

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which ofthe following practices should the nurse intervene? A) The client is receiving formula at room temperature. B) The feedings infuse at a slow, continuous drip over 8 hr each night. C) The family member washes out the feeding bag with warm water onceevery 24 hr. D) The family member flushes the tubing with water before and after giving medications.

C

A nurse is talking with the partner of an older adult male client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. the nurse should identify that he is going through which of the following types of role-performing stress? A. role ambiguity B. sick role C. role overload D. role conflict

C

A nurse is using an open irrigation technique to irrigate a client's indwellingurinary catheter. which of the following actions should the nurse take? A. place the client in a side-lying position B. instill 15 mL of irrigation fluid into the catheter with each flush C. subtract the amount of irritant used from the client's urine output D. perform the irrigation using a 20 mL syringe

C

a nurse is performing a Romberg's test during the physical assessment of aclient. which of the following techniques should the nurse use? A. touch the face with a cotton ball B. apply a vibrating tuning fork to the clients forehead C. have the client stand with her arms at her side and her feet together D. perform direct percussion over the area of the kidneys

C

A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following informationshould the nurse include in the teaching? A. assign the client to a room with a negative air-flow system B. use alcohol-based hand sanitizer when leaving he client's room C. clean contaminated surfaces in the client's room with a phone solution D. have family members wear gown and gloves when visiting

D

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurseconsult the provider before using this complementary therapy? A) A client who has a history of physical abuse B) A client who has a permanent pacemaker C) A client who has ulcerative colitis D) A client who has asthma

D

A middle adult client tells the nurse, "I feel so useless now that my childrendo not need me anymore." Which of the following responses should the nurse make? A) "Most people are happy when their children grow up and leave home." B) "You should be proud that your children are becoming independent." C) "Maybe you should consider why you are feeling useless." D) "People in middle adulthood often find satisfaction in nurturing andguiding young people."

D

A nurse in a long-term care facility is planning to perform hygiene care for anew resident. which of the following assessment questions is the nurse's priority before beginning this procedure? A. "when do you usually bathe, in the morning or evening?" B. "do you prefer a bath or a shower?" C. "at what temperature do you prefer your bath water?" D. "are you able to help with you hygiene care?"

D

A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time shewas taking an antibiotic. Which of the following information should the nurse give the client? A) "Rashes are very common, especially if you have dry skin. Did it go awayon its own?" B) "Virtually all medications have adverse effects. It sounds like this couldhave been an adverse effect of the antibiotic." C) "It's unlikely that your doctor will prescribe an antibiotic for what seemsto be a minor viral infection, so we shouldn't be concerned about that rash." D) "We need to document the exact medication you were taking because youmight be allergic to it."

D

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which of the following types of transitionprecautions hold the nurse initiate? A. protective environment B. airborne precautions C. droplet precautions D. contact precautions

D

A nurse is assessing a client who reports increased pain following physicaltherapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A) "Is your pain constant or intermittent?" B) "What would you rate your pain on a scale of 0 to 10?" C) "Does the pain radiate?" D) "Is your pain sharp or dull?"

D

A nurse is auscultating the anterior chest of a client newly admitted to a medical- surgical unit. Listen to the audio clip of what the nurse auscultatesthrough his stethoscope and identify the type of breath sounds he hears. A) Crackles B) Rhonchi C) Friction rub D) Normal breath sounds

D

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which ofthe following findings should the nurse expect? A) Numbness of the extremities B) Bradycardia C) Positive Chvostek's sign D) Abdominal cramping

D

A nurse is caring for a client who has recently started using a behind-the-earhearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? A) "This type of hearing aid does not allow for fine tuning of volume." B) "I shouldn't have trouble keeping the hearing aid in place during exercise." C) "I expect to hear a whistling sound when I first insert the hearing aid." D) "I will be sure to remove my hearing aid before taking a shower."

D

A nurse is caring for a client who is expressing anger over his diagnosis ofcolorectal cancer. which of the following actions should the nurse take? A. discuss the risk factors for colon cancer B. focus teaching on what the client will need to do in the future to managehis illness C. provide the client with written information about the phases of loss andgrief D. reassure the client that this is an expected response to grief

D

A nurse is caring for a client who is postoperative. When the nurse preparesto change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priorityaction? A) Encourage the client to relax and take deep breaths during the dressing change. B) Educate the client about the importance of the dressing change to prevent infection. C) Assist the client to a comfortable position for the dressing change. D) Administer pain medication 45 min before changing the client's dressing.

D

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? A) Oat cereal B) Refried beans C) Peanut butter D) Cheddar cheese

D

A nurse is completing an admission assessment of an older adult client.Which of the following findings should the nurse identify as a potentialindication of abuse? A) Loss of skin turgor on the back of the hands B) Varicosities on the lower extremities C) Thick, discolored nails with ridges D) Bruises on the arms in various stages of healing

D

A nurse is planning teaching for a group of adolescents who each recentlyhad surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? A) Role play B) Group discussions C) Question-answer meetings D) Practice sessions

D

A nurse on a medical unit is preparing to discharge a client to home. Whichof the following actions should the nurse take as part of the medication reconciliation process? A) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization.

D

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which ofthe following actions should the nurse take first? A) Reposition the client. B) Document the client's IV intake in the medical record. C) Request a new IV fluid prescription. D) Check the IV tubing for obstruction.

D

a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take wheninserting the NG tube? A. position the client with the head of the bed elevated to 30o prior toinsertion of the NG tube B. remove the NG tube if the client begins to gag of choke C. apply suction to the NG tube prior to insertion D. have the client take sips of water to promote insertion of the NG tube intothe esophagus

D

a nurse is lifting a bedside cabinet to move it closer to a client who is sittingin a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? A. bend at the waist B. keep his feet close together C. use his back muscles for lifting D. stand close to the banner when lifting it

D

a nurse is providing care to four clients. which of the following situationsrequires the nurse to complete an incident report? A. a nurse tied a client's restraints straps to the moveable part of the bedframe B. an assuétude personnel placed a surgical mask on a client who has TBbefore transporting her to radiology C. a nurse administer a medication to a client 30 min before the dose is due D. a client who has an IV infusion pump receives an additional 250 mL of IV fluid

D

a nurse is reviewing a client's fluid and electrolyte status. which of thefollowing findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mg/dL D. Potassium 5.4 mg/dL

D

a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that iswithin the RN scope of practice? A. insert an implanted port B. close a laceration with sutures C. place an endotracheal tube D. initiate an enteral feeding though a gastrostomy tube

D