ATI

A nurse educator is teaching newly licensed nurse about safe medication administration. which of the following statements indicates understanding? (select all that apply) A. "I will observe for adverse effects." B. " I will monitor for therapeutic effects." C. " I will prescribe the appropriate dose." D. " I will change the dose if adverse effects occur." E. " I will refuse to give a medication if I believe it is unsafe."

A. "I will observe for adverse effects." B. " I will monitor for therapeutic effects." E. " I will refuse to give a medication if I believe it is unsafe."

A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come and speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your loved one at this time." E. "Tell me more about how you are feeling."

A. "Would you like me to contact the chaplain to come and speak with you?" D. "You know, it is quite normal to feel anger toward your loved one at this time." E. "Tell me more about how you are feeling."

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took a toxic dose of sodium bicarbonate antacid

A. A client who has nasogastric suctioning

A nurse is reviewing a clients prescribed medication at the beginning of the day shift. Which of the following 0900 medication can be given anytime between 0700 and 1100? (select all that apply) A. A once-daily multivitamin B. Eye drops prescribed every 3hr C. An antibiotic prescribed every 8 hr D. A blood pressure pill prescribed twice daily E. A subcutaneous injection prescribed once weekly

A. A once-daily multivitamin E. A subcutaneous injection prescribed once weekly Rational: Multivitamen: administer a once-daily non-time-critical medication within 1 to 2hr of the prescribed time Subcutaneous injection- administer medication prescribed once weekly within 1 to 2hr of the prescribed time

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP commiting? A. Assault B. Battery C. False Imprisonment D. Invasion of privacy

A. Assault

A nurse is caring for a client who weighs 80 kg (176lb) and is 1.6m (5ft 3in) tall. Calculate the body mass index (BMI) and determine whether this clients BMI indicates a healthy weight, underweight, overweight, or obese. A. BMI= weight (kg) / height (m2)

A. BMI= weight (kg) / height (m2) Rational: A BMI greater than 30 identifies obesity.

A nurse is caring for a client who has a prescription for a 24hr urine collection. Which of the following actions should the nurse take? A. Discard the first voiding B. Keep the urine in a single container at room temperature C. Dispose of the lasting voiding D. Ask the client to urinate into the toilet., stop midstream, and finish urinating into the specimen container

A. Discard the first voiding

A nurse is beginning a complete bed bath for a client. After removing the clients gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the clients head to the side B. Place two fingers in the clients mouth to open it C. Bush the clients teeth once per day D. Inject a mouth rinse into the center of the clients mouth

A. Turn the clients head to the side

A nurse is reviewing factors that increase the risk of urinary tractinfection (UTIs) with a client who has reccurent UTIs. Which of the following factors should the nurse include? (select all that apply) A. Frequent sexual intercourse B. Lowing a testosterone level C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catherization

A. Frequent sexual intercourse D. Location of the urethra closer to the anus E. Frequent catherization

A nurse is caring for client who has several risk factors for hearing loss. Which of the following medication the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Aminodarone

A. Furosemide B. Ibuprofen

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply) A. Hct 55% B. Blood osmolarity 260 mOsm/kg C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035

A. Hct 55% C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035 Rational: Hct- the Hct is greater than the expected reference range of 42-52% for males and 37-47 for females and is an indication of dehydration due to hemoconcentration Blood sodium- levels is greater than expected 136-145 mEq/L indication of dehydration Urine specific gravity- greater than expected 1.005-1.030 indicationof dehydration

A nurse in the clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (select all that apply) A. Help the client see the benefits of their actions B. Identify the clients support system C. Suggest and recommend community resources D. Devise and set goals for the client E. Teach stress management strategies

A. Help the client see the benefits of their actions B. Identify the client's support systems C. Suggest and recommend community resource E. Teach stress management strategies

A nurse is caring for client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (select all that apply) A. Make sure the surgeon obtained the clients consent B. Witness the clients signature on the consent form C. Explain the risk and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery

A. Make sure the surgeon obtained the clients consent B. Witness the clients signature on the consent form

A nurse is discussing occurrence that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? ( Select all that apply) A. Medication Error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test

A. Medication Error B. Needlesticks D. Omission of prescription

A nurse prepares an injection of morphine to administer to client who report pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following action should the second nurse take? A. Offer to assist the client who needs the bedpan B. Administer the injection the other nurse prepared C. Prepare another syringe and administer the injection D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication

A. Offer to assist the client who needs the bedpan

A nurse in a senior center is counseling a group of older adult about their nutritional needs and considerations. Which of the following information should the nurse include? (select all that apply) A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins and minerals as younger adults do C. Many older men and women need calcium supplementation D. Older adult need mor calories than they did when they were younger E. Older adults should consume a diet low in carbohydrates

A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins and minerals as younger adults do C. Many older men and women need calcium supplementation

A nurse in a providers office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (select all that apply) A. Posture B. Skin Lesions C. Speech D. Allergies E. Immunization Status

A. Posture B. Skin lesions C. Speech

A Nurse at a clinic is collecting data about pain from of a client who reports severs abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A. Presence of associated manifestations Rational: Attempt to identify manifestations that occur along with the clients pain, such as nausea, fatigue, or anxiety.

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (select all that apply) A. Repeat that details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the providers signature on the prescription 24hr D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone

A. Repeat that details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the providers signature on the prescription within 24hr

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the clients plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible' D. Ask a family member to come in to bathe the client

A. Schedule rest periods during morning care

A nurse in the health clinic is caring for a 21-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screening should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

A. Testicular examination

Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (select all that apply) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Sit facing the client

A. Use an open posture C. Establish and maintain eye contact E. Sit Facing the client

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (select all that apply) A. Warm the enema solution prior to instillation B. Position the client on the left side with the right leg flexed forward C. lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 5cm (2in) E. Hang the enema container 61cm (24 in) above the clients anus

A. Warm the enema solution prior to instillation B. Position the client on the left side with the right leg flexed forward C. lubricate the rectal tube or nozzle

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicates a sensorineural hearing loss in the left ear? A. Weber test showing laterlaization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear

A. Weber test showing laterlaization to the right ear D. Rinne test showing less time for air and bone conduction

A client who has an indwelling catheter reports a need to urinate. which of the following actions should the nurse take? A. check to see whether the catheter is patent B. Reassure the client that it is not possible for them to urinate C. Recatherize the bladder with a larger-gauge catheter D. Collect a urine specimen for analysis

A. check to see whether the catheter is patent

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply) A. inspect the feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let them air dry D. use over-the-counter products to treat abrasions E. Wear cotton socks

A. inspect the feet daily B. Use moisturizing lotion on the feet E. Wear cotton socks

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findingshould the nurse expect? (select all that apply) A .Bradycardia B .Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral edema

B .Hypotension D. Poor skin turgor Rational: Hypotension: Prolonged diarrhea leads to dehydration. expect the client to have a decrease in blood pressure Skin Turgor: Prolonged diarrhea leads to dehydration. Expect the client to have poor skin turgor

A nurse is preparing information for a change-of- shift report. Which of the following information should the nurse include in the report? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record

C. Bone scan scheduled for today

A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A. " A second nurse enters the prescription into the clients medical record." B. " Another nurse should listen to the phone call" C. " The provider can clarify the prescription when they sign the health records." D. "I should omit the read back if this is a one-time prescription."

B. " Another nurse should listen to the phone call"

A nurse at a providers' office is talking about routine screening with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. " So I don't need the colon cancer procedure for another 2 or 3 years" B. " For now, I should continue to have a mammogram each year." C. " Because the doctor just did a Pap smear, I'll come back next year for another one" D. " I had my blood glucose test last year, so I won't need it again for 4 years."

B. " For now, I should continue to have a mammogram each year."

A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect to prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites

B. A client who has heart failure Rational: Anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart

A nurse is collecting data for clients comprehensive physical examination. after inspecting the clients abdomen, which of the following skills of the physical process should the nurse perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion

B. Auscultation

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the dentures with a toothbrush and denture cleaner C.Rincse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them

B. Brush the dentures with a toothbrush and denture cleaner

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client weight each morning C. Notify the provider of a urine output greater than 30ml/hr D. Encourage independent ambulation four times a day

B. Check the client weight each morning Rational: include obtaining the clients weight each day in the plan of care. To ensure accuracy the clients weight should be obtained at the same time each day using the same scale. By determining the clients weight gain or loss each day the nurse can evaluate that client's response to treatment.

While a nurse is administering a cleanse enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold their breath briefly and bear down B. Clamp the enema tubing C. Remind client that cramping is common at this time D. raise the level of the enema fluid container

B. Clamp the enema tubing Rational: Clamp the enema tubing for 30 seconds to reduce intestinal spasms.

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (select all that apply) A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Take calcium supplements D. Avoid drinking alcohol E. Use the Cred. manuever

B. Decrease or avoid caffeine D. Avoid drinking alcohol

Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts and feelings C. Give the nurse-client communication no time limits D. Allow communication to occur spontaneously throughout the nurse-client relationship

B. Encourage the client to communicate their thoughts and feelings

A nurse is caring for a competent adult client who tells the nurse, " I am leaving the hospital this morning whether the doctor discharge me or not." The nurse believes that this is not in the clients best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

B. False imprisonment

A nurse manager is discussing the HIPPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select al that apply) A. A single electronic records password is providing for nurses on the same unit. B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses' station D. A client can request a copy of their medical record E. A nurse can photocopy a clients medical record for transfer to another facility

B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client can request a copy of their medical record E. A nurse can photocopy a clients medical record for transfer to another facility.

A nurse is preparing to initiate a bladder- retraining program for a client who has incontinence. Which of the following actions should the nurse take? (select all that apply) A. Restrict the clients intake of fluids during the daytime B. Have the client record urination times C. Gradually increase the urination intervals D. Remind the client to hold urine until the next schedule urination time E. Provide a sterile container for urine

B. Have the client record urination times C. Gradually increase the urination intervals D. Remind the client to hold urine until the next schedule urination time

A nurse is caring for a client who is high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck their chin when swallowing C.Have the client use a straw D. Encourage the client to lie down and rest after meals

B. Instruct the client to tuck their chin when swallowing

A nurse is caring for client who had stroke and has aphasia. Which of the following interventions should the nurse use to promote communications with this client? (select all that apply) A. Speak at higher volume to client B. Make sure only one person speaks at a time C. Avoid discouraging the client by indicating that they cannot be understood D. Allow plenty of time for the client to respond E. Use brief sentences with simple words

B. Make sure only one person speaks at a time D. Allow plenty of time for the client to respond E. Use brief sentences with simple words

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Macaroni and cheese B. One medium apple with skin C. One cup of plain yogurt D. Roast chicken and white rice

B. One medium apple with skin Rational: One medium apple with the skin is the best food source to recommend because it contains 4.4g of fiber

A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (select all that apply) A. Expect the session to be shorter than for a younger client B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions E. Invite the client to use the bathroom before beginning the examination

B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. Tell the client to take their time answering questions E. Invite the client to use the bathroom before beginning the examination

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients record? (Select all that apply) A. Cover errors with correction fluid and write in the correct information B. Put the date and time on all entries C. Document objective data, leaving out opinions D. Use as many abbreviation as possible E. Wait until the end of the shift to document

B. Put the date and time on all entries C. Document objective data, leaving out opinions

A nurse is caring for a client who states, " I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating

B. Reflecting

A nurse is caring for school-age child who is sitting in a chair. To facilitate effective communication which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture

B. Sit at eye level with the child

A nurse at the health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? A. Provide cholesterol screening B. Teaching about a healthy diet C. Providing information about antihypertensive medication D. Developing a list of cardiac rehabilitation programs

B. Teaching about a healthy diet

A nurse provider an introduction to a client as the first step of a comprehensive physical examination. which of the following strategies should the nurse use with this client? ( select all that apply) A. Address the client with the appropriate title and their last name B. Use a mix of open- and closed- ended questions C. Reduce environmental noise D. Have the client complete a printed history form E. Perform the general survey before the examination

B. use a mix of open-and-closed-ended questions C. Reduce environmental noise E. Perform the general survey before the examination

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client know how to use the device? A. "I'll wait to use the device until its absolutely necessary." B. "I'll be carefull about pushing the button to much so i dont get an overdose." C. " I should tell the nurse if the pain doesnt stop while I am using this device." D. " I will ask my adult child to push the dose button when I am sleeping."

C. " I should tell the nurse if the pain doesn't stop while I am using this device." Rational: PCA allows the client to self- administer pain medication on an as-needed basis. The provider can modify the PCA setting if needed to ensure the client achieves adequate pain relief.

A nurse in a surgeons office is providing preoperative teaching for a client who is scheduled for surgery the following week. the client tells the nurse that "I plan to prepare my advance directive before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. " I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. " I will get my regular doctor to approve my plan before I hand it in at the hospital."

C. "I plan to write that I don't want them to keep me on a breathing machine."

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being a avid swimmer. Which of the following statements should the nurse make? (Select all that apply) A. "You will do great! You just have to get used it." B. "Why are you worried about going home?" C. "Your daily routine will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "it sounds like you are not sure how a colostomy will affect swimming."

C. "Your daily routine will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "it sounds like you are not sure how a colostomy will affect swimming."

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (select all that apply) A. Remove the dentures from the body B. Make sure the body is lying completely flat C. Apply fresh linens and place a clean gown on the body D. Remove all equipment from the bedside E. Dim the lights in the room

C. Apply fresh linens and place a clean gown on the body D. Remove all equipment from the bedside E. Dim the lights in the room

A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, " I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my childs wdding. " Based on the Kubler-Ross model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance

C. Bargaining

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C. Bradypnea D. Orthostatic hypotension E. Nausea Rational: Badypnea- Opioid analgesia can cause respiratory depression, which causes respiratory rates to drop to dangerously low levels. Monitor the clients respiratory rate, and administer naloxone if indicated. Orthostatic hypotension- Opioid analgesia can cause orthostatic hypotension. monitor for dizziness or lightheadedness when changing positions. Nausea- Opioids analgesia can cause nausea and vomiting. Monitor for and treat these complications as needed.

A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? A. Give the client information about immunization against meningitis B. Tell the client to have a TB skin test every 2 years C. Determine the clients health risk D. Teach the client about exercise recommendations

C. Determine the clients health risk

A nurse in a providers office is performing a physical examination of an adult client. Which part of the hands should the nurse use during the palpation for optimal assessment of skin temperature? A. Palmar Surface B. Fingertips C. Dorsal surface D. Base of the fingers

C. Dorsal Surface

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the clients pain? A. Ask the client what precipitation the pain B. Question the client about the location of the pain C. Offer the client a pain scale to measure their pain D. Uses open- ended questions to identify the clients pain sensation

C. Offer the client a pain scale to measure their pain Rational: Use a pain rating scale to help the client report the intensity of the pain. The nurse should use a numeric, verbal, or visual analog scale appropriate to the clients individual needs.

A nurse is caring for a client who had a amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement. A. Immediately complete a thorough assessment B. Encourage visitors to distract the client C. Provide a private room, and limit stimulation D. Speak at a higher volume to the client

C. Provide a private room, and limit stimulation

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? A. Alert the American Nurse Association B. Fill out an incident report C. Report the observation to the nurse manager on the unit D. Leave the nurse alone to sleep

C. Report the observation to the nurse manager on the unit

A nurse reviewing a clients health record notes a new prescription for lisinopril 10mg PO once every day. The nurse should identify this as which of the following types of prescription? A. Single B. Stat C. Routine D. Now

C. Routine

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (select all that apply) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor

C. Tachycardia D. Syncope E. Decreased skin turgor

A nurse is caring for a client who has terminal lung cancer. The nurse observes the clients family assisting with all ADLs. Which of the following rationals for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen muscle and promote healing B. The client needs privacy at times for self-reflecting and organizing life. C. The clients sense of loss can be lessened through retaining control of some areas of life D. Performing ADLs is a requirement prior to discharge from an acute care facility

C. The clients sense of loss can be lessened through retaining control of some areas of life

A nurse is caring for a client who requires a low -residue diet. The nurse should expect to see which of the following foods on the clients meal tray? A. cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C. Vanilla custard

A nurse sis reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. which of the following statements should the nurse identify as an indication that the client understands the intructions? A. " I use a damp cloth to clean the outside part of my hearing aids". B. "I clean the ear mold of my hearing aids with rubbing alcohol." C. "I keep the volume of hearing aids turned up so i can hear better." D. "I take the batteries out of the hearing aids when i take them off at night."

D. "I take the batteries out of the hearing aids when i take them off at night."

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain B. A client who has incisional pain 72 hr following pacemaker insertion C. A client who has food poisoning and reports abdominal cramping D. A client who has episodic back pain following 2 years ago

D. A client who has episodic back pain following 2 years ago Rational: A client who reports pain that lasts more than 6 months and continues beyond the time of tissue healing is experiencing chronic pain. Assist with planning interventions to relieve manifestations associated with the pain.

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

D. Carbohydrates

A nurse is caring for a client who has a terminal illness. Death is expected within 24hr. The clients family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone

D. Decreased muscle tone

A nurse is caring for a client who will perform fecal occult blood test at home. Which of the following information should be included when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. One stool specimen is sufficient for testing C. A red color change indicates a positive test D. The specimen cannot be contaminated with urine

D. The specimen cannot be contaminated with urine Rational: For fecal occult blood testing, instruct the client not to contaminate the stool specimens the stool specimen with water or urine