ATI Exam

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? -"I will return shortly after I document this in your record." -"Most men live a long time with prostate cancer." -"I am available to talk, if you should change your mind." -"I will make a referral to cancer support group for you."

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

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? (make sure there is not false hope)

"I am relying on support from out family during this time"

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? -"I can take echinacea to improve my immune system" -I can take feverfew to reduce my level of anxiety" -"I can take ginger to improve my memory" -"I can take ginkgo biloba to relieve nausea"

"I can take echinacea to improve my immune system"

A nurse is caring for a client who require 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? -"I had a bowel movement, but I was able to save the urine" -"I have a specimen in the bathroom from about 30 minutes ago" -"I flushed what I urinated at 7:00 am and have saved all urine since" -"I drink a lot, so I will fill up the bottle and complete the test quickly"

"I flushed what I urinated at 7:00 am and have saved all urine since"

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? -"I can place an extension cord across my living room to plug in my television." -"I will hire someone to trim the trees that hangs low over the stairs of my front porch." - "I will place my alarm clock on my bedroom dresser across the room." -"I will replace the old throw rug in my kitchen with a new one."

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

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of pain? -"Is your pain constant or intermittent" -"What would you rate your pain on a scale of 0-10" -"Does the pain radiate?" -"Is your pain sharp or dull?"

"Is your pain sharp or dull?" (1. Asking whether the pain is constant or intermittent determines the onset, duration and pattern of the pain.) (2. Asking the client to rate the pain using the pain scale determines the intensity) (3. Asking the client whether the pain radiates determines the pains location.)

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make" -"You would have so much more time to spend with your family." -"You should consider getting a part-time job or doing volunteer work." -"Let's talk about how the change in your job status will affect you." -"Why wouldn't you want to retire and relax."

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

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? -"Drink a cup of hot coco before bedtime" -"Maintain a consistent time to wake up each day" -"Exercise 1 hour before going to bed" -"Watch a television program in bed before going to sleep"

"Maintain a consistent time to wake up each day"

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

"People in middle adulthood often find satisfaction in nurturing and guiding your people"

a nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? -"They allow the court to overrule an adult client's refusal of medical treatment." -"They indicate the form of treatment a client is willing to accept in the event of a serious illness." -"They permit a client to withhold medical information from health care personnel." -"They allow health care personnel in the emergency department to stabilize a client's condition.

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

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching. -"Use the complete name of the medication magnesium sulfate." -"Delete the space between the numerical dose and the unit of measure." -"Write the letter U when noting the dosage of Insulin." -"Use the abbreviation SC when indicating an injection."

"Use the complete name of the medication magnesium sulfate."

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

"We can talk about advance directives, and I can also give you some brochures about them"

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficult breathing?" Which of the following responses should the nurse make? -"We would consult the person appointed by your health care proxy to make decisions." -"We would give you oxygen through a tube in your nose" -You would be unable to change your previous wishes about your care." -"We would insert a breathing tube while we evaluate your condition"

"We would give you oxygen through a tube in your nose"

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 indication that the client understands the teaching? -"When descending stairs, I will first shift my weight to my right leg" -"I should place my crutches 12 inches in front and to the side of each foot" -"As I sit down, I will hold one crutch in each hand" -"I will make sure the shoulders rest are snug against my armpits"

"When descending stairs, I will first shift my weight to my right leg"

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? -"I'll get a blood sample from you and send it for screening test." -"Beginning at age 60, you should have a colonoscopy" -"You should have fecal occult blood test every year" -"The recommendation is to have a sigmoidoscopy every 10 years"

"You should have fecal occult blood test every year" (Blood tests do not detect colorectal cancer) (Colonoscopys at age 50) (Sigmoidoscopy every 5 years)

A nurse is paling an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? -"You should have an eye examination every 2 years" -"You should receive a tetanus booster every 5 years" -"You should receive a shingles vaccine when you are 70 years old" -"You should receive a pnemococcal vaccine when you are 65 years old"

"You should receive a pnemococcal vaccine when you are 65 years old"

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. DAY 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. DAY 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. -Stop the IV infusion -Elevate the client's left arm -Apply heat to the client's left hand -Place a pressure dressing over the IV site -Start a new IV in the client's left hand

- Stop the IV infusion -Elevate the client's left arm -Apply heat to the client's left hand

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

-Assess the client for orthostatic hypotension

A nurse is providing discharge teaching for 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 all that apply) -Check the cord routinely for frays or tearing -Keep the unit at least 1.2 m (4ft) away from a gas stove -Consider purchasing a generator for power backup -Observe for signs of hypoxia -Select synthetic clothing and bedding

-Check the cord routinely for frays or tearing -Consider purchasing a generator for power back up -Observe for signs of hypoxia

1000: Client states "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a '7' on a 0-10 pain scale. Brusising notes on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with a low-intermittent decompression. IV fluids started and infusing in left peripheral IV site. Select the 3 tasks the nurse should delegate to an assistive personnel (AP) - Document the client's vital sings -Measure the client's intake and output -Transfer the client from wheelchair to bed -Insert an NG tube for the client -Collect data about the client's pain level.

-Document the client's vital signs -Transfer the client from wheelchair to bed. -Insert an NG tube for the client.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? -During the admission process. -As soon as the client's condition is stable. -During the initial team conference. -After consulting with the client's family.

-During the admission process

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? -Activate the emergency fire alarm -Extinguish the fire -Evacuate the client -Confine the fire

-Evacuate the client

A nurse is reviewing a client's medication prescription that reads, "digoxin .25 PO every day." Which of the following components of the prescription should the nurse verify with the provider? -Medication name -Route of administration -Medication dose -Frequency of administration

-Medication dose

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? -Place the client in a room with negative pressure airflow -Wear gloves when assisting the client with oral care -Limit each visitor to 2 hr increments -Wear a surgical mask when providing client care -Use antimicrobial sanitizer for hand hygiene

-Place the client in a room with negative pressure airflow -Wear gloves when assisting the client with oral care -Use antimicrobial sanitizer for hand hygiene

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? - Lacrimal apparatus - Pupil Clarity - Appearance of bulbar conjunctivae - Visual Fields - Visual Acuity

-Pupil Clarity -Visual Fields -Visual Acuity

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? -.3 mg - 0.3 mg - 0.30 meg - 3/10 mg

0.3 mg

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure? -Withdraw the correct dose or regular insulin from the bottle -Inject 10 units of air into the bottle of NPH insulin -Withdraw the correct dose of NPH insulin from the bottle -Inject 5 unites of air into the bottle of regular insulin

1. Inject 10 units of air into the bottle of NPH insulin 2. Inject 5 units of air into the bottle of regular insulin 3. Withdraw the correct dose of regular insulin from the bottle 4. Withdraw the correct dose of NPH insulin from the bottle

A nurse in long-term care facility is caring for a client who dies during the nurses shift. Identify in which the nurse should perform the following steps? -Place a name tag on the body -Obtain the pronouncement of death from the provider -Remove tubes and indwelling lines -Wash the clients body -Ask the clients family members if they would like to view the body.

1. Obtain the pronouncement of death from the provider 2. Remove tubes and indwelling lines 3. Wash the clients body 4. Ask the clients family members if they would like to view the body. 5. Place a name tag on the body

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr?

107 mL/hr

BMI Levels

18-24.9

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

Make sure two fingers can fit under the sleeves

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? -Gown -N95 Respirator -Shoe covers -Surgical cap

N95 Respirator

A nurse is preparing a heparin infusion for a client who was admitted to the facility with DVT. The prescription reads: 25,000 units of heparin with 0.9% sodium chloride 250mL to infuse at 800 units/hr. What rate should the nurse set the infusion pump

8 mL/hr

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

8 oz of ice chips

A nurse is teaching a group of staff nurses about the se of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? -A client who has a history of physical abuse -A client who has a permanent peacemaker -A client who has ulcerative colitis -A client who has asthma

A client who has asthma

A nurse is caring for a client who is postoperative is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vitals signs every 15 minutes and to report back in 1 hour. Which of the following actions should the nurse take next step? -Document the provider's statement in the medical record. -Complete an incident report. -Consult the facility's risk manager -Notify the nursing manager

Notify the nursing manager

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 principle of veracity? -A client who is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively. -A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes -A client who has a do-not-resuscitate (DNR)order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. -A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.

A client who is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively.

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension. -A client who is 52 years old -A client who smokes one pack of cigarettes each day -A client who walks for 30 min every day -A client who drinks one glass of wine three times per week

A client who smokes one pack of cigs each day

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? -A lesion with uniform pigmentation -New appearance of petechiae -A mole with an asymmetrical appearance -The presence of a papule

A mole with an asymmetrical appearance

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? -Biofeedback -Aloe -Feverfew -Acupuncture

Acupuncture (Biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders.) (Aloe is a complementary and alternative therapy that can help improve disorders and can have the wound healing effects.) (Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew)

A nurse is providing a discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? -Insert the needle at a 15 degree angle. -Aspirate for blood return prior to administration. -Administer the medications in the abdomen. -Massage the site following the injection.

Administer the medication into the abdomen.

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

Administer the medication with the needle at 45 degree angle.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? - Advocacy ensures client's safety, health, and rights. -Advocacy ensures that nurses are able to explain their own actions. - Advocacy ensures that nurses follow through on their promises to clients. - Advocacy ensures fairness in client care delivery and use of resources.

Advocacy ensures client's safety, health, and rights.

A nurse is preparing to delegate a client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? -Ambulating a client who is postoperative -Inserting an indwelling urinary catheter for a client -Demonstrating the use of incentive spirometer to a client -Confirming that a client's pain has decreased after receiving an alagesic

Ambulating a client who is post operative

A nurse is assessing four adult clients. Which of the following physical assessments techniques should the nurse use? -Use the Face, Legs, Activity, Cry, and Consolabilty (FLACC) pain rating scale for a client who is experiencing pain. -Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. -Obtain an apical heart rate by osculating at the third intercostal space left of the sternum. -Palpate the client's abdomen before ausculating bowel sounds.

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

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

Examine personal values about the issue

A nurse is caring fora client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? -Place a pillow under the client's knees -Positiona trochanter roll under each of the client's hips. -Advise the client to wear rubber-soled slippers -Apply an ankle-foot orthotic device to the client's feet

Apply an ankle-foot orthotic device to the client's feet

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? -Assign a staff member to feed the client -Provide small-handled utensils for the client -Thicken liquids on the client's tray -Arrange food in a consistent pattern on the client's plate

Arrange food in a consistent pattern on the client's plate

A nurse is preparing to administer an injection of an opiod medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? -Ask another nurse to observe the medication wastage -Notify the pharmacy when wasting medication -Lock the remaining medication in the controlled substance cabinet -Dispose of the vial with the remaining medication in a sharps containerA

Ask another nurse to observe the medication wastage

A nurse is administering IV fluids to a client. When monitoring the adverse effects, which of the following assessments should the nurse identify as the priority? -Asculate lung sounds -Measure the urine output -Monitor blood pressure readings -Monitor electrolyte levels

Ausculate lung sounds

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

Breath sounds

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? -Check the client for injuries. -Move hazardous objects away from the client. -Notify the provider. -Ask the client to describe how she felt prior to the fall.

Check the client for injuries

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? -Seal unused medications from the facility in a plastic bag -Evaluate the client's ability to self-administer medication -Report an identified discrepancy to the Joint Commission -Compare prescriptions with medications the clients received while at the facility

Compare prescriptions with medications the clients received while at the facility

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconcilliation? -Verify the client's name on their identification bracelet with the medication administration record. -Call the pharmacy to determine whether the client's medication are available. -Compare the client's home medications with the provider's prescriptions. -Place the client's home medication bottles in a secure location.

Compare the client's home medications with the provider's prescriptions.

A nurse is admitting a client who has a abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? -Protective environment -Airborne precautions -Droplet precautions -Contact precautions

Contact precautions. (Protective environment for clients who have compromised immune system) (Airborne precautions for clients who have infections spreading via droplets nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles.) (Droplet precautions for clients who have infections spreading via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis) (Contact precautions are direct contact)

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

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

Breath Sounds LISTEN TO DIF TYPES OF BREATH SOUNDS

Crackles are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus. Rhonchi are dry-low-pitched, snore like noises produced in the throat due to a partial obstruction, such as secretions. Friction rub is scratching or squeaking sound that persists throughout the respiratory cycle. Normal breath sounds are normal

A nurse is in acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? -Client flow sheet -Acuity ratings -Current medications -Incident reports

Current medications

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? -Increase in hematocrit -Increase in respiratory rate -Decrease in heart rate -Decrease in capillary refill time

Decrease in heart rate

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority. -Request that a respiratory therapist discuss the techniques for incentive spirometry with the client. -Determine the reasons why the client is refusing to use the incentive spirometer. -Document the client's refusal to participate in health restorative activities. -Administer a pain medication to the client.

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

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? -Hypotension -Weak, thready pulse -Slow capillary refits -Distended veins

Distended veins (Other ones are signs of fluid volume deficit)

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? -Contact -Droplet -Airborne -Protective

Droplet

A nurse is caring for a client who has pharygeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? -Contact -Droplet -Airborne -Protective

Droplet (Contact are vancomycin-resistant entercocci and herpes simplex infections) (Airbrone (Varicella, tuberculosis, and measles) Protective (Allogeneic stem cell transplant)

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility -Describe the procedure to the client -Witness the client's signature on the consent form -Inform the client of alternatives to the procedure -Tell the client which team members will assist the procedure

Witness the client's signature on the consent form

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? -Dissolve each medication in 5 mL of sterile water -Draw up medications together in the syringe -Push the syringe plunger gently when feeling resistance -Flush the tube with 15 mL of sterile water

Flush the tube with 15 mL of sterile water

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? -Gently shake the container of medication prior to administration -Transfer the medication to a medicine cup -Place the client in a semi fowler position prior to medication administration. -Verify the dosage by measuring the liquid before administering it.

Gently shake the container of medication prior to administration

A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. Which of the following information should the nurse including in the teaching? -Assign the client to a room with a negative airflow system. -Use alcohol-based hand sanitizer when leaving the client's room. -Clean contaminated surfaces in the client's room with a phenol solution. -Have family members wear a gown and gloves when visiting

Have family members wear a gown and gloves when visiting

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? -Touch the face with a cotton ball -Apply a vibrating tuning fork to the client's forehead -Have the client stand with their arms at their sides and their feet together -Performs direct percussion over the area of the kidneys

Have the client stand with their arms at their sides and their feet together

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube. -Position the client with HOB elevated to 30 degrees prior to the insertion of the NG tube. -Remove the NG tube if the client begins to gag or choke. -Apply function to the NG tube prior to insertion. -Have the client take sips of water to promote insertion of the NG tube into the esophagus.

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

0800: Packed RBC's initiated by the charge nurse through an 18-gauge peripheral IV to infuse over 2 hours. 0815: Client reports itching and anxiety. Client's face is flushed and has hives.

Having an allergic reaction due to the itching.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? (Know all stages and all dressings pertaining to each stage)

Hydrocolloid -Transparent: stage 1 -Hydrocolloid: stage 2 -Alginate: Stage 3 and 4 -Moistened gauze: stage 4

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? -Insert an implanted port -Close a laceration with sutures -Place an endotracheal tube -Initiate an enteral feeding through a gastrostomy tube

Initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? -Instruct the family to refrain from using the button for the client while she is asleep -Inform the client that because she is on a PCA, vital signs will be taken every 8 hr. -Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10. -Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high

Instruct the family to refrain from using the button for the client while she is asleep

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

It might help me to listen to music while Im lying in bed

A nurse is reviewing a client's fluid and electrolytes status. Which of the following findings should the nurse report to the provider?

Know electrolyte values

A nurse on medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? -Pad the client's wrist before applying the restraints. -Evaluate the client's circulation every 8 hours after application. -Remove the restraints every 4 hours to evaluate the client's status. -Secure the restraint ties to the bed's side rails.

Pad the client's wrist before applying the restraints.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? -Insert the catheter at a 45 degree angle. -Place the client's arm in a dependent position. -Shave excess hair from the insertion site. -Initiate IV therapy in the veins of hand.

Place the client's arm in a dependent position.

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

Practice sessions

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? -Neck vein distention -Urine specific Gravity is 1.010 -Rapid Heart Rate -Blood Pressure

Rapid Heart Rate

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? -Discuss the risk factors for colon cancer. -Focus teaching on what the client will need to do in the future to manage his illness. -Provide the client with written information about the phases of loss and grief. -Reassure the client that his is an expected response to grief.

Reassure the client that his is an expected response to grief.

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

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performing stress? -Role ambiguity -Sick role -Role overload -Role Conflict

Role Overload. (Role ambiguity occurs when people are unclear about the expectations of their role in a given situation.) (Sick Role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver.) (Role conflict develops when a person must assume multiple roles that have opposing expectations.)

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse to use to communicate continuity of care? -Critical pathway -Situation, background, assessment, and recommendation (SBAR) -Transfer Report -Medication Administration Record (MAR)

SBAR

A nurse is reviewing protocol in preparation for for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? -Use a resuscitation bag with 80% oxygen prior to the procedure -Select a suction catheter that is half the size of the lumen -Place the end of the suction catheter in water-soluble lubricant -Adjust the wall suction apparatus to the pressure of 170 mm Hg.

Select a suction catheter that is half the size of the lumen

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse indetify as indicating infiltration? -Purulent exudate -Warmth -Skin blanching -Bleeding

Skin Blanching

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a char. To prevent self-injury which of the following actions should the nurse take when lifting this object? -Bend at the waist. -Keep his feet close together. -Use his back muscles for lifting. -Stand close to the cabinet when lifting it.

Stand close to the cabinet when lifting it.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? -Place the client in a side-lying position. -Instill 15 mL of irrigation fluid into the catheter with each flush. -Subtract the amount of irritant used from the client's urine output. -Perform the irrigation using a 20 mL syringe.

Subtract the amount of irritant used from the client's urine output.

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 actions should the nurse take? -Rinse the feeding bag with water between feedings -Tell the client to keep the head of the bed elevated at least 30 degrees -Make sure the enteral formula is at room temperature -Wipe the top of the formula with alcohol

Tell the client to keep the head of the bed elevated at least 30 degrees

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? -The caregivers is the client's financial power of attorney. -The client is in a wheelchair with the wheels locked -The client reports receiving a full bath twice each week -The caregiver insists on remaining in the room

The caregiver insists on remaining in the room

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? - The top of the cane is parallel to the client's waist. - When walking, the client moves the cane 46 cm forward. -The client hold the cane on the stronger side of her body. - The client moves her stronger limb forward with the cane.

The client hold the cane on the stronger side of her body. (The top of the cane should be parallel to the client's greater trochanter). (The client should advance 15-30 cm) (The client should move the cane with her weaker foot.)

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? -The client uses a wool blanket on their bed. -The client identifies the location of a fire extinguisher. -The client stores an extra oxygen tank on its side under their bed. -The client has a weekly inspection checklist for oxygen equipment.

The client identifies the location of a fire extinguisher.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? -The newly licensed nurse places the cap of a bottle of sterile saline solutions on the sterile field. -The newly licensed nurse places sterile objects 2.5 cm (1in) within the border of the field. -The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. -The sterile field is positioned at the level of the newly licensed nurse's waist.

The newly licensed nurse places the cap of a bottle sterile saline solution on the sterile field.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements. -I'm having a mild pain (severity; not quality) -The pain is like a dull ache in my stomach -I notice that the pain gets worse after I eat (describes a factor that aggravates the pain; not the quality) -The pain makes me feel nauseous (describing a manifestation that accompanies the pain)

The pain is like a dull ache in my stomach

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? -Turn the client every 2 hours -Administer an altimetric every 6 hours -Hold oral care. -Increase the room's temperature

Turn the client every 2 hours.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? -Use a bed exit alarm system. -Raise four side rails while the client is in bed. -Apply one soft wrist restraint. -Dim the lights in the client's room.

Use a bed exit alarm system.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? -Combine client care tasks when caring for multiple clients. -Wait until the end of the shift to document client care. -Use the planning step of the nursing process to prioritize client care delivery. -Allow for interruptions in tasks to discuss client care issues with colleagues.

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

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

Use tracheostomy covers when outdoors.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? -Walking briskly -Riding a bicycle -Performing isometric exercises -Engaging a high-impact aerobics

Walking briskly

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have blood transfusion. Which of the following actions should the nurse take? -Ask the client to consider a direct donation -Withhold the blood transfusion -Request a consultation with the ethics committee -Ask the client's family to intervene

Withhold the blood transfusion

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 of the following precautions should the nurse take? -Ensure sterilization of non disposable items with ethylene oxide -Wrap monitoring cords with stockinette and tape them in place -Cleanse latex ports on IV tubing with chlorhexidine before injecting medication -Wear hypoallergenic latex gloves that contain powder

Wrap monitoring cords with stockinette and tape them in place