ATI Fundamental Practice Test

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

"Documentation is a communication tool for the interprofessional health care team." Documentation provides information to facilitate communication among members of the interprofessional health care team in making client-centered decisions, planning appropriate therapies and evaluating a client's progress.

A nurse is preparing to administer methylnaltrexone 12 mg subcutaneously to a client who has opioid-induced constipation. Available is methylnaltrexone 8 mg/0.4 mL. How many mL should the nurse administer?

0.6

A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is another 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?

1800. The IV will infuse at 125 mL/hr. The next bag of IV solution will need to be administered at 1800.

A nurse is preparing to administer naproxen 500 mg PO BID for a client who has osteoarthritis. The amount available is naproxen 125 mg/5 mL oral suspension. How many mL should the nurse administer per dose?

20

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea. Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)

Offer the client a back rub. Remind the client to use incisional splinting. Identify the client's pain level. Change the client's position. Non-pharmacological comfort measures can improve pain management. Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. The nurse should use a standard scale to determine and document the severity of the client's pain. Non-pharmacological measures for managing pain include repositioning, imagery, and distraction.

A nurse preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Opening a sterile package over the middle of the sterile field. Opening a sterile package over the middle of the sterile filed requires reaching into the field, which can result in contamination. The nurse should place the object on the field by approaching the field from an angle.

A nurse is preparing to administer moxifloxacin 400 mg by intermittent IV bolus over 60 min. Available is moxifloxacin 400 mg in 250 mL dextrose 5% (DSW). The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

63

A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000 mL IV to infuse over 12 hr. The nurse should set the IV pump to deliver how many mL/hr?

83

A nurse is preparing to administer an IV fluid bolus of 500 mL 0.9% sodium chloride over 60 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

84

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms. Asking the client to push with her feet against the nurse's hands is an appropriate method of determining the client's level of physical strength, which is needed for ambulation.

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should use nurse use?

Ask the client's full name and date of birth. The nurse must use two identifiers before administering medications. Acceptable identifiers include the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge.

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1 C (98.8 F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

BP. A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

A nurse is helping an older adult ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her. The client should lift the walker and advance it about 15 cm (6 in), then set it down. This allows her a wide base of support while she moves forward.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working. The first action the nurse should take using the nursing process is to assess the situation. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect & organize client data. The steps in the nursing process include assessment, analysis/diagnosis, planning, implementation and evaluation. The nurse should first collect client data, and then critically analyze the data to determine the clients' priorities. This is followed by the nurse planning client-centered, measurable and realistic goals. The nurse implements care, which involves putting the plan into action, followed by evaluation to determine the effectiveness of the interventions.

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, " I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving?

Denial. During the denial stage of Kübler-Ross's stages of grieving, the client acts as though nothing has happened and might refuse to believe or understand that a loss has occurred.

A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Determine the level of fluency in their primary language. It is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all)

Excessive laxative use. Ignoring the urge to defecate. Inadequate fluid intake. Chronic use of laxatives causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives. Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause alterations in bowel habits, such as constipation. Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Identify delayed gastric emptying. The nurse should measure the amount of unabsorbed formula from the previous enteral feeding to identify delayed gastric emptying. If it is delayed, the nurse should avoid overfeeding the client and causing gastric distention.

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightly sue the nurse for which of the following?

Malpractice. The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client.

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver. The client cannot talk, coughs only once, and is demonstrating the universal choking sign: grasping at the throat with the hands. Choking requires immediate intervention. The Heimlich maneuver is the most effective method for clearing the obstruction in the airway of a choking person.

A nurse in a long-term care facility is observing an assistive personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag. Linen that touches the floor or the AP drops requires laundering.

A nurse finds an open vial of morphine lying on top of the cabinet in the client's room. Which of the following actions should the nurse take?

Report the discrepancy immediately. Because this medication is a controlled substance, the nurse should remove the medication from the client's bedside and report the incident according to the facility's policy. After that, she may dispose of it with another nurse witnessing the discard.

A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning nurse-client relationship?

They are more direct when discussing issues. Men focus on issues and discuss them more directly and readily than women do.

A nurse arrives for her shift and is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take?

Verify that the amounts of each medication they count matches the amount on the inventory record. If the amounts available do not match the amounts on the inventory record after subtracting what the nurses administered during the previous shift and adding any medications the nurses added to the cabinet, the nurse must address and reconcile the count.

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

WBC count. An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene?

Washes and rinses hands for 10 seconds. The nurse should intervene because the AP should wash her hands for at least 20 seconds.

A nurse is providing nail care for a client. Which of the following actions should the nurse take?

Clean under the nail with an orange stick. The nurse should use an orange stick to push back the cuticle and clean under the nail.

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I watch television until I fall asleep at night." The client should minimize environmental stimuli just before bedtime, because it can interfere with falling asleep.

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?

"Consensus evolves in this stage." Consensus occurs and cooperation develops during the norming stage of the group development process.

A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

"He has an electrical burn. He is stable, and we will update you with any changes." This response provides concrete information without medical jargon, and offers ongoing support.

A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I can detect the presence of carbon monoxide by a metallic odor." Carbon monoxide gas is odorless, tasteless, and colorless.

A nurse is rehearsing assertive communication to use when declining leadership of a nursing department committee. Which of the following should the nurse make?

"I decline the opportunity at this time." This is an assertive form of communication because it contains an "I" statement and it is clear and firm.

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I have a set of my brother's crutches in my basement that I can also use." The client should not use crutches that belong to someone else. The client's crutches must fit his body dimensions, not someone else's.

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

"I will begin upon the client's admission to the facility." Effective discharge planning must begin upon admission of the client to the facility.

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

"I will cover the catheter so he cannot see it." Using stockinet or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter.

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will wear synthetic clothing and woolen socks when using my oxygen." Woolen and synthetic materials can generate static electricity. Because oxygen is a flammable gas, the client should wear cotton clothing and use cotton bedding and blankets.

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

"I'll apply ice to my ankle today and tomorrow." The RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation. The client should apply ice for the first 24 to 48 hr after the injury.

A nurse is reviewing information about Health Insurance Portability and Accountability Act (HIPPA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time." This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide?

"It's my responsibility to remind you that we have to respect our clients' privacy." This therapeutic response provides clarification to the messenger that the hospital staff cannot disclose information about clients.

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"It's unfortunate that I have to be in the hospital for this treatment." TENS units are portable. The client can use his TENS unit at home or wherever he chooses.

A nurse is teaching a client about crutch walking using the three-point gait. Which of the following by the nurse should be included in the teaching?

"Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches." The nurse should instruct the client to use this method of crutch walking for a three-point gait.

A newly licensed nurse is seeking advice from their preceptor about the need to purchase personal professional liability insurance. Which of the following statements should the preceptor make?

"Personal liability coverage is not mandatory, but you should consider purchasing your own coverage." Clients can sue nurses, and health care facilities do have insurance that covers all its employees. However, the facility could countersue the nurse if the nurse was negligent and the facility lost and had to pay damages. Therefore, it is a recommendation that nurses obtain their own professional liability insurance.

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

"Tell me more about your concerns." This response is an example of the therapeutic communication technique of providing general leads. It encourages the client to express his feelings and gives the nurse additional data about the client.

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

"The client was lying on the floor next to his bed." In an incident report, the nurse should only document what she actually witnessed, along with the date, time, place, and any other actual facts about the incident.

A nurse is caring for a client whose partner asks to speak with the nurse. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Which of the following responses should the nurse make?

"What have you done in the past to cope with this issue?" This asks a relevant question and is therapeutic; it moves the discussion from a general direction to a specific focus on the partner's concerns and is open-ended.

A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. Prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate. The client has an IV of D5 ½ NS running at 75 mL/hr from 0700 until 1200. The IV runs at 30 mL/hr from 1200 to 1500, the client has 6 oz juice. How many mL Should the nurse document as the client's intake for the shift?

1,005 mL

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

0.45% sodium chloride. A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.

A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?

125 mL/hr

A nurse is preparing to administer 1,000 mL of lactated Ringer's IV over 6 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/mL?

28

A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute?

31 gtt/min

A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr?

35 mL/hr

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

4.0. This is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed.

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

90° With this angle, the nurse will deposit the medication deeply into the muscle to ensure rapid absorption of the medication due to the vascularity of muscle tissue.

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions?

Advocate. A client advocate acts to protect clients' rights and helps clients to speak for themselves.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An older adult who has a hip fracture and is in Buck's traction. According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands. The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take?

Ask the client to rate her pain on a scale from 0 to 10. Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions.

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Bladder infection. The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of this test is to check the stool for which of the following substances?

Blood. A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all.)

Broth. Grape juice. Lemon gelatin. Fat-free broth is an acceptable component of a clear liquid diet. Coffee and tea are also acceptable. Grape juice is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice. Lemon gelatin is an acceptable component of a clear liquid diet, along with sugar, honey, hard candy, and ice pops.

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse explains that the client should see a dentist for this problem, which they should document as which of the following disorders?

Bruxism. Bruxism, a clenching or grinding of the teeth during sleep, can damage the teeth. A dentist can provide a custom-fitted, comfortable dental appliance to protect the teeth during sleep.

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assess bilaterally at the same time?

Carotid. The nurse should avoid assessing the carotid pulse sites bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light. Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

Client concerns. Information the nurse obtains directly from the client is generally the most accurate and provides the best information available. The client is a primary source of information.

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions by only nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

Confusion. Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae. To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Contact the provider to question the dosage. When a nurse believes there is an error in a prescription, the nurse must question the provider.

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? (Select all.)

Coordinator. Evaluator. Energizer. Coordinator is a task performance role that focuses on clarification and coordination of ideas. Evaluator is a task performance role that focuses on comparing group accomplishments with expected standards. Energizer is a task performance role that focuses on stimulating the group to higher levels of action.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the tray?

Cranberry juice. Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice.

A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids. The first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain. The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.

A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

Determine what the client knows about the surgery. The first step in planning preoperative care is to identify the client's learning needs. The nurse does this by determining the client's past experiences with surgery, his current knowledge about the scheduled procedure, and identifying his expectations and fears.

A nurse is inserting an IV catheter for a client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

Dorsal metacarpal vein. The nurse can access the metacarpal vein in the dorsum of the client's hand. Initially, the nurse should choose the most distal vein available in the upper extremity and then move up the arm for subsequent IV insertion sites if necessary.

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet. The nurse should initiate droplet precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis.

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

Elicit information from the client. Obtaining information from the client is a component of the orientation phase.

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use?

Explore the client's feelings about dietary modifications. This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning.

A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take?

Explore the client's feelings. Asking the client to share his feelings encourages him to express the nature of his feelings of anxiety. The nurse can begin by offering general leads.

A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?

False imprisonment. False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital.

A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching, the nurse asks the client to describe one physical effect. The nurse is focusing on which of the following elements of the communication process?

Feedback. Feedback indicates whether the client understands the message, which was in the nurse's teaching.

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

Gait belt. The nurse should use a gait belt to help support the client during ambulation. A gait belt helps keep the client's center of gravity stable and helps maintain balance and prevent falls.

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (In order.)

Gloves. Eyewear. Gown. Mask. Hand hygiene. The nurse should remove the most contaminated item of PPE first and the least contaminated item last. The gloves are the most contaminated, so the nurse should remove them first, and then the eyewear, the gown, and finally, the mask. Finally, the nurse should perform hand hygiene and then leave the room.

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?

Grape juice. A clear liquid diet includes foods that are fluids and clear at body and room temperatures. This includes apple and grape juices, broth, black coffee, and plain gelatin.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

Have the client wear a mask. When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse should explain that nurses may share a client's protected health information with which of the following groups?

Health care team members caring for the client. To coordinate safe and effective care delivery, the nurse may share details of a client's health status and treatment plan with others who are responsible for delivering client care. The Health Insurance Portability and Accountability Act (HIPAA) allows sharing of information necessary for treating clients.

A nurse is preparing to administer an ophthalmic solution to a client. Which of the following actions should the nurse take?

Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac. The nurse should hold the bottle of ophthalmic solution 1 to 2 cm (1/2 to 3/4 in) above the lower conjunctival sac.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions?

Include any relevant statements the client made about the ulcer. The nurse should document any relevant statements the client makes about the ulcer and use quotation marks to indicate that they are the client's words and not the nurse's.

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion. Prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium excretion.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax. Isometric exercises involves static (no movement) contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.

A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?

Intimacy vs. isolation. During this stage, young adults (18 to 25 years) develop commitments to others and to their careers.

A nurse is caring for an older adult who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room. This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take?

Lock the medication in a room and finish preparing it after returning from the emergency. No one else should have access to or administer medications the nurse has prepared. Securing them and returning later to finishing preparing and administering them decreases the risk of medication errors.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair. The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving when transferring a client.

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective should the nurse wear when setting up the client's meal tray?

Mask. The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client.

A nurse is measuring a client for knee-high anti-embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space. If the stocking is too short, if could impair circulation at its upper end. If it is too long, it can bunch together, which would cause pressure and irritate the skin. Measuring the length from the feet to the popliteal space helps the nurse identify the right size stockings for the client's legs.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity. The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

A nurse asks a client to share personal stories. Which of the following types of interventions is the nurse using to promote the development of the nurse-client relationship?

Narrative interaction. Narrative interaction involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship.

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?

Negligence. Negligence is the failure to provide the expected standard of care. The expected standard of care was strict bedrest.

A nurse has completed an informed consent form with a client. The client states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take?

Notify the surgeon that the client wishes to withdraw informed consent for the procedure. The client has the right to withdraw informed consent; therefore, the surgeon who is the one to obtain the informed consent should be notified of the request.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper-socks for the client. In cold weather or when the client's feet are cold, he should wear extra socks or slipper socks to help provide warmth and increase his level of comfort.

A nurse is caring for a client who states, "I have to get out of this hospital! They have found my address and are coming for my family!" The nurse responds. "Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent?

Offering false reassurance. Offering false reassurance discourages further communication because there are no facts to support it. A better response would be to clarify the client's misperceptions.

A nurse is teaching a newly hired group of AP about infection-control on the unit/ IT is crucial for the nurse to reminding the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequently and consistently. The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care.

A nurse is preparing to administer three liquid medications to a client who has a NG tube with intermittent suction. Which of the following actions should the nurse take?

Pinch the tube prior to attaching the medication syringe. After detaching the NG tube from the suction tubing, the nurse should pinch or kink the tube to prevent distention from air entering the tube.

A nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The nurse chooses to confront this client. Which of the following approaches should the nurse use when using confrontation?

Point out inconsistencies in the client's behavior. A nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. It also helps the client deal with issues that are important to him.

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen. According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to maintain the integrity of the client's skin?

Provide the client with a diet high in protein. Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all.)

Relief of urinary retention. Measurement of residual urine after urination. An open perineal wound. Valid indications for urinary catheterization include urinary retention, bladder distention, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery.

A nurse is performing care activities for a client in the zone of touch that requires his consent. Which of the following activities should the nurse perform in this zone? (Select all.)

Removing the client's dentures. Palpating for pedal edema. Counting radial pulse. The nurse removes the client's dentures within the consent zone, which includes the mouth, wrists, and feet. The nurse palpates for pedal edema within the consent zone, which includes the mouth, wrists, and feet. The nurse counts a radial pulse within the consent zone, which includes the mouth, wrists, and feet.

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all.)

Repeat the order back. Question any part that's unclear or inappropriate. Transcribe the order into the client's health record. The nurse should read the order back and have the provider verbally confirm that it is correct. The nurse should question any part of the prescription or an order that is unclear or inappropriate. This is essential for any verbal or written prescription or order. The prescription should be entered in the health record as it is obtained and verified.

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. (In order.)

Rescue and remove the clients from the room. Activate the fire alarm. Confine the fire/close the door. Extinguish the fire. Remember: RACE! The nurse's priority action is to remove the clients from the room. The nurse should then sound the fire alarm and close the door to confine the fire. Finally and if possible, the nurse should extinguish the fire.

A nurse is caring for a client who needs a stool specimen. Which of the following actions should the nurse take when obtaining the specimen?

Send specimen container immediately to the lab. The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings.

A nurse is caring for a client who is receiving heat applications using an aquathermia pad? Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red. Reactions such as unusual pain or redness are indications for removing the pad and notifying the provider.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes. Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

Surgeon. The health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client. The surgeon who is performing the surgical repair of the fracture would be responsible for obtaining informed consent.

A nurse in a long-term care facility is caring for an older adult who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention. Until the bladder regains its full tone, it is common for clients to develop urinary retention. If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Test the pH of gastric aspirate. Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations.

A nurse is reviewing the goals of the nurse-client therapeutic relationship with a client who is seeking counseling. Which of the following information should the nurse include in this discussion?

The client achieves optimal personal growth. The goal of a therapeutic nurse-client relationship is to help the client with achieving optimal personal growth, forming relationships, and reaching personal goals.

A nurse is caring for 4 patients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

The client who has a nasogastric (NG) tube to suction. Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.

A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?

The client's sociocultural background influences nonverbal communication. Sociocultural background has a major influence on what a client's nonverbal behavior means.

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

The left second intercostal space. The left second intercostal space is the location where the nurse can palpate pulsations at the pulmonic valve area. This is the site for palpating lifts and heaves in this area.

A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include?

The nurse may serve as a witness to informed consent for organ donation. Nurses may witness the consent for organ donation after a specially trained professional requests consent.

A nurse is caring for an older adult who has a fractured hip and will require rehabilitative care. The client family ask the nurse for information about this type of care. Which of the following explanations should the nurse provide?

This service began with the client's admission to the hospital. Rehabilitation is a process that assists an ill person or a person with a disability or impairment to achieve the highest possible level of functioning. The process of rehabilitation begins with the client's admission to a health care facility for treatment.

A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include?

Tie linen bags securely at the top. This action secures the linen inside the bag, keeping any soiled linen from contaminating surfaces or the hands of whoever has to pick it up and bag it again.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before starting oral care. Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Two nurses using a friction-reducing device. This method reduces the risk of injury to the nurses and to the client. The nurses can use a draw sheet as a friction-reducing device.

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Use attentive listening with the client. When establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding.

A nurse is caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact. The nurse should establish intermittent eye contact and maintain it during active listening. It demonstrates interest is what the client is saying.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Use soap and water to wash the catheter after each use. The client should wash the catheter using soap and water and store it in a clean container after each use.

A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

Veracity. Veracity is the duty to tell the truth. The nurse violated the ethical principle of veracity when choosing not to report the error instead of being truthful.

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all.)

Water heater temperature 54.4°C (130° F). Throw rugs. The nurse should recommend setting the water heater's temperature no higher than 49°C (120° F). The nurse should recommend removing or securing any rugs or mats that could move and cause the client to slip, slide, or trip.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

Weak pulse. A decreased volume of circulating blood and less pressure within the vessels results in weak peripheral pulses (rated as +1), which can be described as thready.

A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Wear an N95 respirator mask. The nurse should wear an N95 respirator mask or a high-efficiency particulate air (HEPA) filter mask when caring for a client who has an infection that requires airborne precautions, such as disseminated varicella zoster, rubeola, or tuberculosis.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client pulse. Which of the following actions should the nurse?

Wear clean gloves. The nurse should wear clean gloves to prevent the transmission of MRSA.

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

When the client has the urge to defecate. When on a bowel training program, the nurse should take the client to the toilet when the client recognizes the urge to defecate. A bowel training program focuses on identifying times in the client's bowel pattern to promote self-control of defecation.

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

Witness the client's signature. It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that the client is consenting voluntarily and appears to be competent to do so.

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Tell the client to blow her nose gently before the instillation. Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

The client's self-report of pain severity. Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly.

A Nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

"I will come back later and we can talk." With this response, the nurse offers herself to the client, which encourages open communication.

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will place a bath seat in my shower to use when I bathe." A bath seat can help reducing slipping and falling in the bathtub or shower.

A nurse in a clinic is teaching a group of clients about low back pain & injury. Which of the following should the nurse identify as an indication that the client requires further clarification?

"I will sit with my knees lower than my hips." To prevent back injuries, the clients should sit with their knees slightly higher than their hips.

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my meds at the first sign of an attack." Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?

"I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." This statement by the AP indicates an understanding of the teaching. Restraints should be tied to the portion of the bed that moves when the head of the bed is raised or lowered.

A nurse is teaching assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

"I will wear gloves and a gown when bathing a client who has open skin lesions." The AP should wear personal protective equipment when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.

A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse make?

"Please explain what you mean by the word 'nervous.'" The nurse is using a clarifying statement to understand the meaning of the client's statement.

A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?

"Respite care allows for the primary caregiver time away from day-to-day care responsibilities." A client who has quadriplegia requires support for many activities of daily living. Primary caregivers need time to meet their own personal needs as well. Respite care allows primary caregivers time away from their day-to-day care responsibilities for the client.

A nurse is readmitting a client to the medical unit after a transfer to ICU following self-administration of an overdose of medication. The client looks down at the floor and mumbles, "Hello." Which of the following responses should the nurse make?

"Tell me a little more about what happened." This response is an example of the therapeutic communication technique of providing general leads. It encourages the client to express his feelings and gives the nurse additional data about what is troubling him.

A nurse at an extended-care facility is instructing a class of assisted personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the Aps about the client's use of a cane?

"When the client moves, cane moves first." When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.

A nurse enters an older adult's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

A nurse is calculating a client's intake and output for a 8-hr shift. The client's intake includes 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?

1720 mL

A charge nurse is planning a room assignment for a client who has a productive couch, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, position-pressure airflow room. To which of the following rooms should the nurse assign the client?

208. A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.

A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two bolus INFUSIONS OF 250 Ml OF 0.9% SODIUM CHLORIDE, RANITIdine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water. How much mL of intake should the nurse record?

2525 mL

A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose?

3 capsules

A nurse is preparing to administer digoxin 12 mcg/kg/day PO to divide equally every 12 hr to a school-age child who weighs 66 lb. Available is digoxin elixir 0.05 mg/mL. How many mL should the nurse administer per dose?

3.6

A nurse is preparing to administer amoxicillin 320 mg PO every 12 hr to an infant. The amount available is amoxicillin suspension 400mg/5mL. How many mL should the nurse administer per dose?

4

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (Select all that apply.)

A protective mask. A closed door. A puncture-proof sharps container. Hand hygiene. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering the room requires respiratory protection, in the form of an appropriate filtration mask. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering or leaving the room should close the door behind them. Nurses must always dispose of needles and sharp instruments in puncture-proof sharps containers. Hand hygiene is essential before and after all contact with clients.

When auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

A systolic murmur. Cardiac murmurs are relatively loud, turbulent sounds the nurse can hear between the usual, expected heart sounds. They create a whooshing or a swishing sound. Those between S1 and S2 are systolic murmurs. Those between S2 and the next S1 are diastolic murmurs.

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions the nurse initiate for the client?

Airborne. The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative-pressure airflow room, and staff should wear an N95 respirator when in contact with the client.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Albumin. A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurses should evaluate the client for which of the following alterations that the client has an infection? (Select all.)

An increase in neutrophils. Localized edema. During the inflammatory stage of wound healing, neutrophils move into the interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroy micro-organisms. Edema develops in the first stage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein to pour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulated fluid appears as localized swelling or edema.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply bag for 30 min at a time. The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects.

A nurse is caring for a client who has a mental disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following nontherapeutic communications is the nurse using?

Asking for an explanation. The use of a "why" question requires that the client provide an explanation that he may not have, causing him to become defensive. A better response would be to give a reasonable answer to the question and clarify any additional concerns the client has.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute. For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity or irregularity of the heart.

A client receives wrong medication. The nurse who made the medication error should take which of the following actions first?

Assessing the client. The first action the nurse should take using the nursing process is to assess the client. The nurse must first determine whether or not the error has caused the client any harm and also provide any relevant interventions.

A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity?

Assigning tasks to an UAP. Delegation of nursing care to an AP is considered indirect care. To meet the clients' needs, activities of daily living such as ambulation, bathing and vital signs may be assigned to an AP, but the nurse is responsible for verifying that the tasks have been completed according to standards of care.

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted?

Bear down. Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

Bend at the knees when picking up an object. Bending at the knees can help the client maintain her center of gravity. Then when she lifts the object, she should use her leg muscles, not her back muscles, to lift it.

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Call the dietary department and ask for a kosher tray. This action shows cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who practice the Orthodox Jewish faith do not eat meat and dairy together.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all.)

Contractures of the extremities. Crackles in the lungs. Pressure ulcers. Contractures of the extremities are a complication of immobility because of disuse of muscles and joints. Crackles in the lungs are a complication of immobility, due to mucus that collects in the dependent airways. The client often cannot cough effectively and oxygenation status declines. Pressure ulcers are a complication of immobility, due to increased pressure on skin and bony prominences, which affects tissue metabolism.

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus immunization. The greatest risk to this client is injury from infection with Clostridium tetani; therefore, the priority assessment the nurse should perform is to determine whether the client will require a tetanus immunization by identifying the date the client last received one. An adult should have a tetanus booster immunization every 10 years and after any severe or dirty wound.

A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?

Dehydration. Hypernatremic (hypertonic) dehydration occurs with excessive fluid losses due to perspiration, respiration, and inadequate fluid intake. The nurse should note that the client's sodium is above the accepted reference range, while glucose, potassium, BUN, chloride, and creatinine are within the accepted reference ranges. The client's history, collapsing after activity on a hot day, and the sodium findings are consistent with dehydration due to water deficit.

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when they find that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

Dextrose 10% in water. Sudden withdrawal from TPN, which is a hypertonic solution that contains dextrose, vitamins, electrolytes and sometimes lipids, can result in a sudden drop in the client's blood glucose levels. Administering an infusion of 10% dextrose will prevent hypoglycemia.

A nurse is caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all.)

Education. Gender. Perception. The educational background of the client is an interpersonal variable that affects the communication process. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships. Gender is an interpersonal variable that affects the communication process. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships. Perception provides a uniquely personal view to a client's experience and is an interpersonal variable that affects communication. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships.

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following priority action by the nurse?

Elevate the head of the client's bed 30-45 degrees. A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all.)

Emptying urine from an indwelling urine collection bag. Providing oral care. Changing ostomy pouch. Standard precautions indicate that the nurse should wear gloves when in direct contact with bodily fluids. Standard precautions indicate that the nurse does not have to wear gloves unless in direct contact with bodily fluids.

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

Gloves. The greatest risk to safety is pathogen transmission. The gloves are the most contaminated item of PPE, so the nurse should remove them first. Failing to remove the most contaminated item first increases this risk.

A nurse is preparing to administer a cleaning enema to a client. Which of the following actions should the nurse take?

Hold the container of solution 30 cm (12 in) above the anus. The nurse should hold the container of solution 30 to 45 cm (12 to 18 in) above the anus when administering a cleansing enema to allow for a continuous, slow instillation of solution to promote evacuation of feces in the bowel.

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning?

Industry vs. inferiority. According to Erickson, a school-age child (6 to 12 years) is in this stage of development. In this stage, the child engages in tasks and activities that are carried through to completion.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Inhale slowly and evenly through her nose. The nurse should inhale slowly and evenly through her nose until chest expansion is maximized.

A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?

Instruct the client about methods to achieve goals. Instructing the client about methods to achieve goals describes the working phase, when the nurse and the client work together to solve problems and accomplish goals.

A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?

Integrity vs. despair. According to Erikson, integrity vs. despair is the developmental task of late adulthood, when adults must accept the worth and uniqueness of one's life and eventual death.

A nurse receives a client care assignment from the charge nurse and believes they are unfair. The nurse voices their concern to the charge nurse. The nurse is using which level of communication at this time?

Interpersonal. Interpersonal communication is face-to-face interaction with another person. It results in an exchange of ideas, problem solving, expression of feelings, decision-making and personal growth.

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment. (Select all that apply.)

Irrigating a client's abdominal wound. Suctioning a client's new tracheostomy tube. The nurse should wear protective eyewear when irrigating a wound because wound exudate and fluids could splash into her eyes. The nurse should wear protective eyewear when performing tracheal suctioning because the client's secretions could splash into her eyes.

A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen?

Left forearm. This site is in the antecubital fossa, which allows for easy access and does not interfere with the client's IV catheter and infusion. The nurse should use this site to obtain a blood specimen.

A nurse is teaching a class of older adults about the expected physiological changes of aging. Which of the following changes should the nurse include in the discussion? (Select all.)

More difficulty seeing due to a greater sensitivity to glare. Decrease cough reflex. Decrease bladder capacity. Dehydration of intervertebral discs. Older adults have an increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and alterations in color perception. Older adults have a decreased cough reflex, increased airway resistance, fewer alveoli, and a greater risk for respiratory infections. Older adults have a decreased bladder capacity and a reduction in renal blood flow. Older adults have dehydration of intervertebral discs, decreased muscle strength and mass, and decalcification of bones.

A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his TMJ. Based on these findings, to which of the following providers should the nurse request a referral for the client?

Oral surgeon. The temporomandibular joint connects the mandible to the temporal bone. The clinical manifestations of pain, crepitus, and a popping sound require further evaluation and assessment. Referral to an oral surgeon for evaluation and diagnosis is an appropriate intervention.

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain. If the client reports pain, the nurse should address managing the client's pain and postpone the learning session until the client reports pain relief.

A nurse is caring for who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for the client?

Protective. Clients whose immune system is compromised, such as from chemotherapy, AIDS, or after a stem-cell transplant, require a protective environment.

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

Reach around the pack & open the top flap away from the body. The nurse should pull the uppermost flap away from her body, grasping it from the side to avoid reaching over the sterile field and contaminating it.

A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" The nurse responds, "It must be very frustrating to encounter this kind of attitude." The nurse is using which of the following therapeutic communication techniques?

Reflection. Reflection involves responding to the content and emotional components of a message by restating the client's feelings.

As part of an annual physical examination, a nurse is preparing to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

Remove all metal necklaces. Metal objects block visualization of body structures and tissues, thus the client must remove them.

A nurse is auscultating a client's lung sounds and identifies crackles in the lower left lobe. Which of the following interventions should the nurse take?

Repeat auscultation after asking client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all.)

Report of feeling pressure. Tenderness over the symphysis pubis. Distended bladder. Voiding 30 mL frequently. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine.

A nurse is preparing to administer intramuscular (IM) injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

Respiratory rate. Airway, breathing, and circulation are the priority focus of the nurse at this time. Meperidine can cause respiratory depression and the client's respiratory rate should be monitored prior to administering this medication.

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

Rub all surfaces of your hands with an alcohol rub for 20-30 seconds. The staff should rub the product over all aspects of the hands and fingers until they are dry, which generally takes 20 to 30 seconds.

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

Scheduling a diagnostic study for a client. The LPN can schedule a diagnostic study as this does not involve assessment or nursing judgment as part of the nursing process.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure using quick-release tie. The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Shakiness and diaphoresis. When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

Sharing passwords with coworkers. This action violates client confidentiality by allowing coworkers to access information which they may not be authorized to view.

A nurse is caring for a client who is at 36 weeks of gestation and is on the antepartum unit for continuous close observation. The client confides to the nurse that she doesn't think she will ever be a mother and begins to cry. Which of the following responses should the nurse make?

Sit quietly with the client and follow her cues. This demonstrates using silence and active listening, therapeutic techniques that offer support and acceptance and encourage further communication.

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Urine output of 175 mL in the past 8 hr. The nurse should notify the provider if the client's urinary output is less than 30 mL/hr. This finding indicates a fluid imbalance, decreased circulating fluid volume, and possibly inadequate renal perfusion.

A nurse is admitting a client from a long-term care facility. The nurse should closed-ended questions when assessing which of the following factors?

When asking the client if medications were taken. A "yes" or "no" response is sufficient when asking if a client took his morning medications. If he did not take them and should have, the nurse might want to explore the issue further.