ATI Fundamentals Dynamic quiz
A nurse is teaching the parent of a child who is to take 10 mL of liquid medication the parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons how many teaspoons should the nurse instruct the parent to give the child?(fill in the blank with the numeric value only round to the nearest whole number and use a leading zero if applicable do not use a trailing zero.)
2 teaspoons - Step 1: what is the unit of measurement the nurse should calculate? Teaspoons - step 2: set up an equation and solve for X. 5mL/1 teaspoon = 10 mL/X tsp 5X = 10 X = 2 - step 3: round if necessary - step 4: determine whether the conversion to teaspoons makes sense If 5 mL = 1 tsp, then 10 mL = 2 tsp
The nurse is teaching a client how to use an albuterol metered dose inhaler after removing the cup from the inhaler and shaking the canister was sequence of instructions should the nurse give the client? (Move the steps into the box on the right placing them in the order of performance use all steps) 1. "tilt your head back slightly and open your mouth wide" 2. "hold your breath for 10 seconds" 3. "hold the mouthpiece 1 to 2 inches in front of your mouth" 4. "depress the canister while taking a slow deep breath"
3, 1, 4, 2 - The client should hold the mouthpiece 1-2 in from the mouth - the client should tell the head back slightly and then open the mouth - the client should depress the medication canister while taking a deep breath to facilitate the delivery of the medication through the airway - after holding this breath for 10 seconds the client should resume her usual breathing pattern
A nurse is calculating the protein needs of a young adult client who weighs 132 pounds the RDA for protein for an adult who has no medical conditions is 0.8 g per kilogram how many grams of protein per days of the nurse recommend for this client?
48 132/2.2 = 60 kg 60 kg x 0.8 g = 48 g
A nurse is caring for a client who's intake and output flow sheet for 0700 to 1500 indicates the following voided: x: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. what total output in milliliters should the nurse document for this 8 hour period? (Fill in the blank with the numeric value only round the answer to the nearest whole number and use a leading zero if applicable do not use a trailing zero)
770 Follow these steps to the conversions of TSP to ML step one: what is the unit of measurement the nurse should calculate? ML step two: set up an equation and solve for X 1 tsp/5mL = 2 tsp/X mL X = 10 Step three: round if necessary step four: determine if the conversion to milliliters makes sense if 1 tsp = 5 mL then 2 tsp = 10 mL follow these steps for the conversions of oz to mL Step one: what unit of measurement should the nurse calculate? mL Step two: set up an equation and solve for X 1 oz/30 mL = 2 oz/x mL X = 60 Step three: round if necessary Step four: determine whether the conversion to mL makes sense if 1 oz = 30 mL then 2 oz = 60 mL
A nurse is assessing a client for conductive hearing loss when using the rinne test which of the following results should the nurse identify as an indication that the client has conductive hearing loss to the left ear? A. Air conduction is less than bone conduction in the left ear B. air conduction is greater than bone conduction in the left ear C. sound is lateralizing to the right ear D. sound is lateralizing to the left ear
A. Air conduction is less than bone conduction in the left ear The finding indicates conductive hearing loss of the left ear
A nurse is caring for a client who has a terminal illness the client is restless and reports severe pain but refuses the prescribed opioid pain medication which of the following actions should the nurse take first? A. Ask why the client is refusing the pain medication B. administer a PRN anti-anxiety medication C. help the client change positions D. offer the client a heat or cold pack to place on painful areas
A. Ask why the client is refusing the pain medication Using the nursing process the nurse should first assess the reason for the clients refusal of the opioid medication
A nurse is caring for a client who reports not sleeping at night which interferes with her ability to function during the day which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. take a sleep medication regularly at bedtime C. watch television for 30 minutes in bed to relax prior to falling asleep D. advise the client to take several naps during the day
A. Avoid beverages that contain caffeine Caffeine is a stimulant the nurse should suggest that the client avoid caffeinated beverages
A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage the nurse notes no urine output in the past two hours which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. palpate the bladder C. obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. encourage the client to drink more fluids
A. Check to determine if the catheter tubing is kinked the nurse should apply the least invasive priority setting framework when caring for clients which assigns priority to nursing interventions that are least invasive to the client as long as those interventions do not jeopardize client safety this approach reduces the number of organisms introduced into the body decreasing the number of facility acquired infections hence the first action the nurse should take us to inspect the tubing carefully Straighten any kinks and ensure there are no dependent loops a lack of drainage is often due to a kink in the tubing or the client lying on it
A newly licensed nurse is preparing to administer medications to a client the nurse knows that the provider has prescribed a medication that is unfamiliar to him which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. ask a more experienced nurse for information about the medication C. call the clients provider and verify the prescription D. ask the client if she takes his medication at home
A. Consult the medication reference book available on the unit A nurse must have knowledge about medications to administer them safely the nurse should become familiar with the medication by looking it up in the medication reference on the unit
A nurse is preparing to administer eyedrops to a client following surgery which of the following actions should the nurse take one and stealing the eyedrops? A. Drop the eye medication into the lower conjunctival sac B. apply gentle pressure to the outer opening of the eye for 2 minutes C. hold the eye dropper 0.5 cm from the cornea D. instruct the client to close the eyes tightly after administration
A. Drop the eye medication into the lower conjunctival sac The nurse should drop the eye medication in the lower conjunctiva sack to avoid placing the drops on the cornea and causing damage
A nurse is admitting a client who is experiencing an exacerbation of heart failure at which of the following times should the nurse initiate discharge planning? A. During the admission process B. as soon as the clients condition is stable C. during the initial team conference D. on the day prior to discharge
A. During the admission process The nurse should initiate discharge planning as soon as the client is admitted to the facility this is intended to ensure they continuity of care and meet the clients care needs this process should include each member of the clients health care team
A nurse is teaching an assistive personnel how to obtain a capillary fingerstick blood sample which of the following actions by the AP requires the nurse to intervene? A. Elevating the finger above heart level B. rubbing the finger tip with an alcohol pad C. puncturing the side of the fingertip D. wrapping the finger and warm cloth
A. Elevating the finger above heart level The nurse should intervene if the client elevates the finger above the level of the heart holding the finger below the level of the heart in any dependent position will help increase blood flow to the area and ensure in adequate specimen for collection
A nurse is removing personal protective equipment after performing a procedure for a client who requires isolation precautions which of the following items of PPE should the nurse remove first? A. Gloves B. gown C. Eyewear D. mask
A. Gloves According to evidence-based practice the nurse should first remove the gloves because they are the most contaminated piece of PPE next the nurse should remove the goggles or face shield and then the gown finally the nurse to remove the respirator or mask because it is the least contaminated piece of PPE
A nurse is teaching a client who has low back pain about heat therapy which of the following statements by the client indicates an understanding of the teaching? A. I need to place a towel between the heating pad and my skin B. I'll need to turn up the temperature if I can't feel the heat C. I'll sleep on top of the heating pad to increase the heat penetration D. keeping the heat continuously on my back will help it heal
A. I need to place a towel between the heating pad and my skin The nurse should instruct the client to place a towel between the heating pad and the skin to reduce the risk of burns
A nurse is planning to assess the Abdomen of a client who reports feeling bloated for several weeks which of the following methods of assessment should the nurse use first? A. Inspection B. auscultation C. percussion D. palpation
A. Inspection according to evidence-based practice the nurse should inspect the abdomen first by observing the contour of the abdomen the condition of the skin in the position of the umbilicus findings from this step of assessment are used by the nurse in the subsequent steps
Nurse is assessing a client who is unconscious family members are present and answer the nurses questions about the clients medical history the nurse should document this information as which of the following types of data? A. secondary source data B. Experiential data C. primary source data D. quantitative data
A. secondary source data information provided by someone other than the client a secondary source data
A nurse and a rehabilitation facility is observing an assistive personnel help a client transfer from my bed to wheelchair which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client B. lowering the foot plates of the wheelchair before the transfer C. placing the wheelchair perpendicular to the bed D. placing the wheelchair on the clients weaker side prior to the transfer
A. Locking the brakes on the bed and the wheelchair before moving the client Prior to starting to transfer the AP should make sure that both the wheelchair and the bed or stationary and will not shift when the client moved into the chair
A nurse is preparing to provide a chest physiotherapy for a client who has left lower lobe atelectasis which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. perform percussions directly over the clients bear skin C. use a flat hand to perform percussions D. remind the client that chest percussions can cause mild pain
A. Place the client in the Trendelenburg position The nurse should place the client in a right sided Trendelenburg position to promote drainage from the clients left lower lobe
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for the use of restraints within 24 hours B. secure the restraint with the buccal side next to the client skin C. Ensure that 4 fingers can be inserted under the secured restraint D. remove the restraint every three hours
A. Renew the prescription for the use of restraints within 24 hours The nurse should plan to renew the prescription for the restraints within 24 hours only after the provider has evaluated the client
A nurse is caring for a client who has bilateral casts on her hands which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside while feeding the client B. order puréed foods C. make sure the feedings are provided at room temperature D. offer the client a drink of fluid after every bite
A. Sit at the bedside while feeding the client The nurse should avoid appearing to be in a hurry sitting at the bedside provide the client with the nurses full attention during the feeding
A nurse is preparing to administer medication to a client which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? A. Stat prescription B. PRN prescription C. standing prescription D. single prescription
A. Stat prescription A stat medication prescription is carried out immediately or as soon as possible and for one time only
A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day the client states that no one has spoken to her about the procedure before which of the following actions should the nurse take? A. Stop the teaching and check with the surgeon about informed consent B. continue the teaching but check afterward with the surgeon about informed consent C. stop the teaching and ask the client to sign an informed consent form D. continue the teaching and check the clients medical record afterward for a signed consent form
A. Stop the teaching and check with the surgeon about informed consent the client statement indicates that she has not given informed consent therefore the nurse should interrupt the teaching and notify the surgeon
A nurse on a medical surgical unit is caring for a client who is at risk of experiencing seizures which of the following pieces of equipment must be available at the clients bedside at all times? A. suction equipment B. clean gloves C. blankets D. oxygen
A. Suction equipment The the greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis therefore the nurse must have section equipment available for clearing the mouth of secretions or emesis to reduce the risk
A hospice nurse is visiting with the family member of a client family member states that the client has insomnia almost nightly which of the following practices should the nurse identify as contributing to the clients insomnia? A. The client watches television in her bed during the day B. the client drinks warm milk before bedtime C. the client goes to bed at 2200 every night D. the client gets up to use the bathroom once during the night
A. The client watches television in her bed during the day To promote sleep the client should avoid watching television in bed she should use the bed only for sleep or sexual activities
A nurse is assessing a client respiratory system which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A. Vesicular B. bronchial C. Rhonchi D. bronchovesicular
A. Vesicular The nurse will hear vesicular sounds over the periphery of the major lung fields the sounds are soft and low pitched Bronchial: over trachea, high pitched, hollow and loud Rhonchi: gurguling sounds over trachea, bronchi airways are narrow due to secretions or swelling Bronchovesicular: sternal border sides anteriorly and between scapulae posteriorly. Loud and medium pitch
A nurse is caring for a client who is postoperative following abdominal surgery which of the following actions should the nurse perform first after discovering that the clients wound has eviscerated? A. cover the incision with a moist sterile dressing B. have the client lay on his back with his knees flexed C. call the client surgeon D. reassure the client
A. cover the incision with a moist sterile dressing The nurse should apply the safety and risk reduction priority setting framework which assigns priority to the factor or situation posing the greatest safety risk for the client where there are several risk to client safety the one posing the greatest threat is the highest priority the nurse should use Maslow's hierarchy of needs the ABC priority setting framework and or nursing knowledge to identify which risk poses the greatest threat to the client
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool which of the following personal protective equipment items should the nurse don prior to providing client care? Select all that apply A. gown B. gloves C. mask D. hair cover E. goggles
A. gown B. gloves The nurse should follow standard precautions when caring for a client who has aids because the bed linens might be soiled the nurse should Don gown because the nurses hands will come in contact with the soiled bed linens the nurse should Don clean gloves in addition to other necessary PPE
A nurse is presenting an in-service training session about nutrition which of the following simple sugars should the nurse identify as the carbohydrate found in milk? A. lactose B. sucrose C. maltose D. fructose
A. lactose the nurse should identify that lactose as a form of sugar that is found in milk Sucrose is a table sugar and is also found in fruits and vegetables Maltose is found in germinating cereals such as barley fructose is found in honey and fruit
A nurse is caring for a group of clients which of the following tasks should the nurse assigned to an assistive personnel? A. provide oral care to a client who cannot take oral fluids B. check the clients IV insertion site for manifestations of infiltration C. assess the clients ability to ambulate D. demonstrate the use of a glucometer to a client who has diabetes mellitus
A. provide oral care to a client who cannot take oral fluids providing oral care to a client who cannot take oral fluids is within the range of function for an AP therefore the nurse can assign this task to the AP
A nurse is planning to perform passive range of motion exercises for a client which of the following actions should the nurse take? A. repeat each joint motion five times during each session B. move the joint to the point of considerable resistance C. sit approximately 2 feet from the side of the bed closest to the joint being exercised D. exercise the smaller joints first
A. repeat each joint motion five times during each session To maintain the clients joint mobility the nurse should repeat each motion 3 to 5 times.
A nurse is teaching a client who is postoperative about the importance of turning, coughing and breathing deeply. which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "If I do this often I wont experience muscle wasting" B. "if I do this often I won't get pneumonia" C. "If I do this often I won't get constipation" D. "if I do this often I won't have a fast heartbeat"
B. "if I do this often I won't get pneumonia" turning coughing and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal
Nurse is caring for a client who has injuries resulting from a motor vehicle crash which of the following client statements should the nurse address first? A. I'm afraid this injury will cause me to lose my job B. I can't sleep well because whenever I move in my sleep the pain wakes me up C. I don't know what I would do if my car isn't safe or even drivable after the crash D. I wonder how I'm going to be able to take care of my family
B. I can't sleep well because whenever I move in my sleep the pain wakes me up The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the clients physiological need for comfort the nurse should reevaluate the clients pain management plan immediately
A nurse is providing discharge teaching to an older dog client about personal safety which of the following statements by the client indicates an understanding of the teaching? A. I will have the steps to my house painted a dark color B. I will put a night light in the hallway C. I will put on socks when I get out of bed D. I will secure any wires in my home under rugs
B. I will put a night light in the hallway The nurse should instruct the client to use night lights in and around the home as an important safety measures to reduce the risk of falls in the home. physiological changes associated with aging can affect an older adult clients ability to see surroundings older adults and infants are at increased risk of serious injury from falls and most falls occur in the clients home
A nurse is performing a straight urinary catheterization for a female client who has urinary retention which of the following actions indicates the nurse is maintaining sterile technique? A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. spreading the labia with a dominant hand D. using a cotton ball to wipe the right and left labia majora
B. Wiping the labia minora in an anteroposterior direction The nurse should wipe anteroposteriorly both the right and left labia minora with separate cotton swabs to destroy any microorganisms in that area that would contaminate the catheter
A nurse is caring for a group of clients in a long-term care facility one of the client is walking along the hallway and bumping into walls and does not respond to his name which of the following actions should the nurse take first? A. Offer the client a nutritious snack B. accompany the client back to his room C. re-orient the client to his surroundings D. administer a PRN antianxiety medication
B. accompany the client back to his room The nurse should first escort the client back to his room to protect him from injury due to wandering
A nurse is performing an admission assessment for a client who has asthma and reports several food allergies which of the following actions should the nurse take first? A. Document the clients food allergies in the medical record B. ask the client to identify the specific food allergies B. monitor the client for indications of anaphylaxis D. have epinephrine available for administration
B. ask the client to identify the specific food allergies The nurse should apply the nursing process priority setting framework in order to plan client care and prioritize nursing actions each step of the nursing process builds on the previous step beginning with an assessment or data collection before the nurse can formulate a plan of action and implement a nursing intervention or notify the provider of a change in the client status the nurse must first collect adequate data from the client assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision therefore the nurse should first assess the clients allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals
A nurse is assessing a client vascular system which of the following techniques should the nurse use when evaluating the carotid artery's? A. Palpation of both carotid artery's simultaneously B. auscultation of the arteries for bruitts with the bell of the stethoscope C. palpation of the arteries for murmurs bilaterally D. auscultation of the arteries for thrills with the diaphragm of the stethoscope
B. auscultation of the arteries for bruitts with the bell of the stethoscope The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds such as those from turbulence in blood vessels
A nurse is implementing cold therapy for a client who has an ankle sprain which of the following actions should the nurse take? A. Apply a cold pack to the edematous area B. check capillary refill before applying an ice pack to the affected area C. Half fill an ice pack with crushed ice D. apply an ice pack for 60 minute intervals
B. check capillary refill before applying an ice pack to the affected area The nurse should check the affected area for adequate circulation by assessing pulses and capillary refill because a cold pack applied to an area of impaired circulation can further decrease the blood supply to the area
A nurse enters a clients room and find the client sitting on the floor and leaning against the side of the bed the client states she slipped while getting out of bed which of the following actions should the nurse take first? A. Complete an incident report B. check the client for injuries C. make sure the client has skid free footwear D. remind the client to ask for help when getting out of bed
B. check the client for injuries Using the nursing process the nurse should first evaluate the client for any injuries or physiological changes the nurse should also notify the provider to determine the need for any further examination or intervention
A nurse is providing teaching about proper care to a client who has a new colostomy which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. cleanse the skin around the stoma with warm water C. change the pouch every day D. place an aspirin in the ostomy pouch to decrease odor
B. cleanse the skin around the stoma with warm water The nurse should instruct the client to cleanse the skin around the stoma with warm water as using soap can leave a residue on the skin and cause poor adherence of the pouch
A nurse is assessing a client which of the following findings should the nurse identify as an indication of protein calorie Malnourishment? select all that apply A. Gingivitis B. dry brittle hair C. edema D. spoon shaped nails E. poor wound healing
B. dry brittle hair C. edema E. poor wound healing Dry brittle hair that falls out easily suggests inadequate protein intake and Malnutrition edema can occur when albumin levels are lower than the expected reference range and indicates protein calorie malnutrition adequate wound healing depends on the ingestion of sufficient protein and calories water vitamins especially C and A, iron and zinc
A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye this manifestation is consistent with which of the following eye disorders? A. Retinopathy B. glaucoma C. cataracts D. macular degeneration
B. glaucoma The nurse should identify that an obstruction of the flow of the vitreous humor of the eye as a manifestation of glaucoma this obstruction leads to an increase in intraocular pressure resulting in damage to the eye
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer which of the following pieces of information should the nurse include in the teaching? A. Exhale slowly to reach the goal volume B. hold the breath for five seconds after the goal volume is reached C. continue to breathe deeply between each cycle D. limit the repeat pattern of breathing to five breath's
B. hold the breath for five seconds after the goal volume is reached The nurse should instruct the client to hold their breath for 3 to 5 seconds after reached maximum inspiratory volume this decreases the collapse of alveoli which helps prevent the risk of atelectasis and pneumonia
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation for pain management the client asked the nurse how a tens unit helps relieve pain which of the following responses should the nurse make? A. it provides a distraction from the pain B. it modulates the transmission of the pain impulse C. it promotes increased circulation to the painful area D. It elicits a relaxation response
B. it modulates the transmission of the pain impulse The nurse should inform the client that a tens unit applies low voltage electrical stimulation directly over location of pain at and acupressure joint. it modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief
A nurse is performing an admission assessment for a client which of the following responses by the nurse reflects the communication technique of clarifying? A. Now that we have talked about your medications let's talk about your pain B. are you having other symptoms B. it sounds like your pain is intermittent D. it seems as though you have really had a rough time these past few weeks
B. it sounds like your pain is intermittent This response by the nurse reflects the communication technique of clarifying the nurse should use this technique to ensure an understanding of the clients message
A nurse is caring for a client who has a temperature of 101.7°F which of the following actions should the nurse take? A. Apply and alcohol water solution to the clients skin B. keep the clients bed linens dry C. apply ice packs to the groin D. limit the clients fluid intake to 40 ounces of fluid per day
B. keep the clients bed linens dry The nurse should maximize the clients heat loss by keeping the clients clothes and bed linens dry the nurse should also reduce external coverings on the clients bed without causing shivering
A nurse is measuring a clients vital signs the clients resting radial pulse rate is 55 per minute which of the following actions should the nurse take next? A. Document the finding B. measure the clients apical pulse rate C. talk with the client about factors that can affect the pulse rate D. notify the provider about the clients radial pulse rate
B. measure the clients apical pulse rate The first action the nurse should take using the nursing process is to assess or collect data from the client the pulse rate is below the expected reference range for an adult the nurse and coworker should measure the apical and radial pulse rates simultaneously to determine if there is a post deficit if the clients radial pulse rate is lower than the apical rate the client might have a Cardiovascular disorder
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has gastrostomy tube for enteral feedings which pieces of information are critical to communicate to the next nurse who will be caring for this client? Select all that apply A. room temperature B. new prescriptions C. number of visitors D. arterial blood gas results E. Tracheal secretion characteristics
B. new prescriptions D. arterial blood gas results E. Tracheal secretion characteristics The nurse should report any changes in the clients treatment in the nursing handoff report for a client who is receiving mechanical ventilation the latest arterial blood gas results reflect the clients current Respiratory and ventilatory status and are an essential part of the nursing handoff report additionally tracheal secretion characteristics provide important information about the clients current respiratory and ventilatory status and are an essential part of the nursing handoff report
A nurse is monitoring her clients laboratory results which of the following results should the nurse report to the provider? A. sodium 140 meq/L B. potassium 3.0 meq/L C. chloride 100 meq/L D. magnesium 2.0 meq/L
B. potassium 3.0 meq/L This potassium level is below the expected reference range indicating hypokalemia the nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration
A nurse is planning care for a client who has a single lumen NG tube for gastric decompression which of the following actions should the nurse include in the plan of care? (select all that apply) A. set the suction machine at 120 mmHg B. provide oral hygiene frequently C. measure the amount of drainage from the NG tube every shift D. secure the NG tube to the clients gown E. Apply petroleum jelly to the client snares
B. provide oral hygiene frequently C. measure the amount of drainage from the NG tube every shift D. secure the NG tube to the clients gown Frequent oral hygiene provides comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment that you can also be dislodged if not secured appropriately
A nurse is preparing to insert an NG tube for a client who requires enteral feedings which of the following instructions should the nurse give the client before beginning the procedure? A. Inhale forcefully during insertion B. raise your index finger if you need to pause during the insertion C. bear down during insertion D. avoid making any swallowing motions during the insertion
B. raise your index finger if you need to pause during the insertion The nurse should instruct the client that the insertion of an NG tube is uncomfortable and the gag reflex will be activated during the procedure the nurse should establish a communication techniques such as having the client raise a finger or hand to indicate distress and the need to pause the insertion process
As part of a neurological examination a nurse instructed client to keep his eyes closed place an object in his hand and asks him to identify the object which of the following abilities is the nurse evaluating with this technique? A. gustation B. stereognosis C proprioception D. kinesthesia
B. stereognosis Stereognosis is the ability to identify an object size shape and texture via tactile sensation
A nurse in an oncology clinic Is assessing a client who is undergoing treatment for ovarian cancer which of the following statements by the client indicates she is experiencing psychological distress? A. My parents are retired and they have come to help with our children B. I am going to ask my husband to go to counseling with me C. I keep having nightmares about my upcoming surgery D. my girlfriends brought me a nice wig
C. I keep having nightmares about my upcoming surgery Nightmares and sleep disturbances are manifestations of anxiety and post traumatic stress disorder these indicate a risk of experiencing psychological distress
A nurse is planning care for an adult client who has fluid volume access which of the following interventions should the nurse plan to include to monitor the clients weight? A. Calibrate the scales weekly B. use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing
C. Weigh the client on arising The nurse should weigh the client on arising each day after voiding and before breakfast an accurate weight requires the client to be weighed wearing the same garments and on the same carefully calibrated scale balance to zero before each use accurate daily weights provide the easiest measurement of volume status an increase of 1KG is equal to 1000 mL/1 L of retained fluid
A nurse is caring for a client who has stage III pressure ulcer On the heel when preparing to irrigate the wound which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. check the clients pain level D. place a waterproof pad under the clients extremity
C. check the clients pain level
A nurse is preparing to administer medications to a client who is unconscious the nurse should bring the medication administration record to the clients bed and perform which of the following verification procedures? A. Check the clients name and medical record number on the MAR against the room and bed number B. call the client by name and check the name on their identification band against the MAR C. compare the medical record number and name on the MAR with the clients identification band D. Ask the clients visitor to identify the client by name and to state the clients birthday
C. compare the medical record number and name on the MAR with the clients identification band The joint commission requires the use of two client identifiers when administering medications the nurse should compare the medical record number and name on the MAR with the clients identification band
A nurse is planning care for a young adult client who has a terminal illness which of the following concepts of deaths of the nurse consider for this client? A. Death is unacceptable under any circumstances B. magical thinking helps avoid thoughts of death C. death is viewed as an interruption of what might have been D. death is a natural consequence of deteriorating body
C. death is viewed as an interruption of what might have been Young adults tend to see a whole life ahead of them so death is often seen as interrupting that life. young adults do not typically welcome death at this time
A nurse is preparing to insert an NG tube to a client who has bowel obstruction which of the following actions should the nurse take first? A. Give the client a glass of water B. assist the client in to a sitting position C. explain the procedure to the client D. measure the length of tubing to be inserted
C. explain the procedure to the client
A nurse is assessing a client who is experiencing stress following a near fall out of bed which of the following psychological responses should the nurse expect due to the fight or flight response? A. Decreased respiratory rate B. pinpoint pupils C. increased blood pressure D. bronchiolar construction
C. increased blood pressure The nurse should expect a client who is experiencing a fight or flight response to manifest an increase in arterial blood pressure heart rate and cardiac output due to arousal of the central nervous system
A nurse is caring for a client who had a stroke and is at risk of falling which of the following actions should the nurse take? A. Assign the client to a private room B. keep 4 side rails up while the client is in bed C. monitor the client at least once every hour D. request a PRN prescription for restraints restraints
C. monitor the client at least once every hour The nurse should monitor the client frequently as a means of reducing the clients fall risk other measures can include keeping the client bed at a low position creating elimination schedules and using a gait belt when the client is ambulating
A nurse is using the breeding scale to predict the pressure ulcer risk of a client in a long-term care facility using the scale which of the following parameters should the nurse evaluate? Al Incontinence B. mental state C. nutrition D. general physical condition
C. nutrition nutrition, sensory perception, moisture, activity, mobility, and friction and sheer are the parameters on the Braden scale for determining a clients risk of developing pressure ulcers
A nurse is initiating seizure precautions for a client who has a seizure disorder which of the following pieces of equipment shut the nurse have readily available at the clients bedside? A. Vest restraint B. tongue blade C. oxygen equipment D. neck brace
C. oxygen equipment The nurse should have oxygen equipment at the bedside of a client who is on seizure precautions the nurse should be able to apply oxygen via mask or nasal cannula to a client who experience as a seizure
A nurse is assessing a client peripheral pulses which of the following descriptions should the nurse used to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60 per minute B. Radial, brachial and pedal pulses bilaterally weak C. peripheral pulses bilaterally symmetric equal and strong in all four extremities D. Brachial, radial, popliteal and dorsalis pedis pulses regular 58 and bilaterally palpable
C. peripheral pulses bilaterally symmetric equal and strong in all four extremities The nurse does not evaluate the peripheral pulses routinely when measuring vital signs peripheral pulses evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination a full evaluation of peripheral pulses typically includes palpation of the radial brachial ulnar femoral popliteal tibial and dorsalis pedis pulses documentation of peripheral pulses evaluation should include the strength of pulsations as well as their equality and symmetry in all four extremities
A nurse is caring for a client who has xerostomia with the lack of saliva which of the following nutrients will be affected by the lack of salivary amylase? A. Fat B. protein C. starch C. fiber
C. starch Salivary amylase begins the process of digestion in the mouth with the initial breakdown of starches the majority of starch break down occurs in the small intestine with pancreatic Amylase
A nurse is performing an abdominal assessment of a client which of the following positions should the nurse tell the client to see him for this examination? A. Lithotomy B. lateral C. supine D. Sims
C. supine The nurse should tell the client to assume the supine position to promote relaxation of the abdominal muscles having the client bend the knees and has his relaxation of the stomach muscles
A nurse delegated the task of emptying it indwelling urinary catheter drainage bag to an assistive personnel the nurse later observes the AP emptying the bag without wearing gloves which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. insist that the AP attend an in-service training about standard precautions C. talk with the AP about the technique used D. observe the AP a second time and intervene if the technique remains the same
C. talk with the AP about the technique used The nurse who delegates a task is responsible for providing the right supervision and evaluation the nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP which includes wearing gloves
An adolescent client at an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him which of the following statements should the nurse make? A. Don't worry teenagers often have friends who give bad advice B. I think you should stop seeing those friends since they discourage you from following your treatment plan C. tell me more about how your friends discourage you D. where did you meet these friends?
C. tell me more about how your friends discourage you The nurse should ask an open ended questions to encourage the client to elaborate on these problems
A nurse is planning care for a client who reports abdominal pain an assessment by the nurse reveals the client has a temperature of 39.2°C or 102.6°F a heart rate of 105 per minute a soft nontender abdomen and menses overdue by two days which of the following findings should be the nurses priority? A. Heart rate of 105/Min B. Soft nontender Abdomen C. temperature D. overdue manses
C. temperature Elevated temperature is an emergent physiological needs that requires priority intervention by the nurse the nurse should consider Maslow's hierarchy of needs which includes five levels of priority the levels are as follows - physiological needs safety security needs love and belonging needs personal achievement and self-esteem needs and an achievement to full potential and the ability to perform solve and cope with life situations
A nurse is providing discharge teaching for a client who has type two diabetes mellitus and will be caring for herself at home The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences which of the following responses should the nurse offer? A. The home health dietitian will visit and help you learn to cook all over again B. the dietitian will give you a list of foods and dietary choices to keep your diabetes under control C. the dietitian will help you choose foods you are used to that also meet your health needs D. it might be difficult but I know you can change your eating and cooking habits with some help from the dietitian
C. the dietitian will help you choose foods you are used to that also meet your health needs This response shows respect for the clients food preferences and cultural needs by offering choices from among the clients usual food
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure the client states you're not putting that hose down my throat which of the following statements should the nurse make? A. Let's get the process over with because you won't get better without this tube B. you should talk to your provider about your fears C. why don't you want to tube inserted? D. I can see that this is upsetting you
D. I can see that this is upsetting you This response uses the therapeutic communication techniques of reflecting and restating which encourages further communication by the client
A nurse is teaching a client who is using a patient controlled analgesia pump (PCA) to deliver morphine for pain management which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I'll limit pushing the button so I don't get an overdose B. if I push the button and still have pain after two minutes I'll push it again C. I'll ask my niece to push the button when I am sleeping D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button
D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation while using a PCA pump to reduce the amount of opioid dosing the client needs
A Nurse is reviewing measures to prevent back injuries with assistive personnel which of the following instructions should the nurse include? A. stand 3 feet from the client when assisting with lifting B. Lock your knees when standing for long periods C. lift up to 22.6 kg/50 lbs without the use of assistive devices D. When lifting an object spread your feet apart to provide a wide base for support
D. When lifting an object spread your feet apart to provide a wide base for support The AP should spread the feet apart because a wide base of support increases stability
A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. allow the client to remain in bed until her pain subsides C. instruct the family to perform ADLs for the client D. advise the client to perform range of motion exercises while in bed
D. advise the client to perform range of motion exercises while in bed performing range of motion exercises will help the client maintain mobility and tell her pain is under control and she is able to ambulate without excessive discomfort
A nurse is caring for a client who had a mastectomy and has a self suction drainage evacuator in place which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift B. cleanse the opening with soap and water after emptying C. maintain the tubing above the level of the surgical incision D. collapse the device to remove air after emptying
D. collapse the device to remove air after emptying The nurse should collapse the device to remove air after emptying the contents periodically this will create enough suction to pull fluid excudate into the collection area of the device
A nurse is caring for a client who is 48 hours postoperative following a small bowel resection the client reports gas pains in the pre-umbilical area the nurse should plan care based on which of the following factors contributing to this postoperative complications? A. Blood loss B. NPO status after surgery C. nasogastric tube suctioning D. impaired peristalsis of the intestines
D. impaired peristalsis of the intestines Normal bowel function is delayed for up to several days following a bowel resection when peristalsis is absent or sluggish intestinal gas builds up producing pain and abdominal distention the nurse should plan to help the client ambulate to promote peristalsis
A nurse is reviewing a clients laboratory results and notes a white blood cell count of 3600/MM dinner should identify this result as which of the following conditions? A. Leukoplakia B. leukemia C. leukocytosis D. leukopenia
D. leukopenia Leukopenia occurs when there is a decrease in the production of white blood cells this alteration place is a client at an increased risk of infection
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room the client states she is no longer wants to have the surgery which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled B. telephone the operating room and cancel the surgery C. inform the clients family about the situation D. notify the provider of the clients decision
D. notify the provider of the clients decision Well acting as the clients advocate the nurse should support her decision and notify the provider
A nurse in a long-term care facility is in the dining room while residents are eating lunch one resident begins to choke and is coughing strongly which of the following actions should the nurse take? A. Assist the client to the floor B. perform an abdominal thrust C. open the airway with the head chin tilt D. observed the client closely
D. observed the client closely The nurse should observe the client closely at this point in time as long as the client is able to cough strongly the nurse does not need to intervene
A nurse is preparing to provide tracheostomy care for a client. which of the following actions should the nurse perform first? a. open all sterile supplies and solutions. b. stabilize the tracheostomy tube. c. put on sterile gloves d. perform hand hygiene.
D. perform hand hygiene according to evidence based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. this is vital because
A nurse is leading an education session about disposing of biohazardous material which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean blood spills B. discard empty blood bags in a bedside trashcan C. break use needles before discarding D. place soiled linen in a single linen bag
D. place soiled linen in a single linen bag Soiled linen should be placed in a single bag that is tightly secured to reduce the risk of transmission of micro organisms Chlorine bleach is used to clean blood spills
A nurse is planning to obtain the vital signs of a two-year-old child who is experiencing diarrhea and may have a right ear infection which of the following routes should the nurse use to obtain the child's temperature? A. Rectal B. Tympanic C. oral D. temporal
D. temporal The temporal artery route while not as accurate as a rectal route for obtaining a precise body temperature is non-invasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea the nurse should place the probe behind the ear if the client is diaphoretic but should avoid placing it over an area covered with hair
A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis which of the following actions should the nurse take when applying the stockings? A. roll the stocking partially down if too long B. remove the stocking once per day C. bunch and pull the stocking halfway up the calf D. turn the stocking inside out up to the heel before applying
D. turn the stocking inside out up to the heel before applying The nurse should turn the stocking inside out up to the clients heel to make the application of the stocking easier and cost if you were constrictive wrinkles
a nurse is planning weight loss strategies for a group of clients who are obese. which of the following actions by the nurse will improve the clients commitment to a long term goal of weight loss? a. attempt to increase the clients self motivation b. keep detailed records of each clients progress c. test client learning after each teaching session d. avoid discussing topics that might increase clients anxiety
a. attempt to increase the clients self motivation motivation to learn is a key part of improving a clients commitment to achieving a health goal, as well as increasing the amount and speed of learning
a nurse is preparing a sterile field for a procedure the provider will perform at the clients bedside. which of the following actions should the nurse take? a. hold the sterile drape above the waist and away from the body b. drop sterile objects towards the edges of the sterile field c. hold packaged supplies 7.6 cm (3 in) above the sterile field d. hold sterile objects over the field before setting them down on the field
a. hold the sterile drape above the waist and away from the body contamination occurs when the nurse holds any object that will be part of the sterile field below the waist or allows it to touch anything other than a sterile object.
a nurse is performing suctioning for a client who has a tracheostomy. which of the following actions should the nurse take? a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing b. allow 30 sec between suctioning passes c. hyperventilate the client with 50% oxygen for 30 sec d. perform a maximum of 4 passes with the suction catheter.
a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing the nurse should pull the suction catheter back 1 cm when the client starts to cough or resistance is met. this will remove the catheter from the mucosal wall of the trachea prior to suctioning.
A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? a. speech language pathologist b. social worker c. physical therapist d. occupational therapist
a. speech language pathologist a speech language pathologist can perform a thorough evaluation of the client for dysphagia and help the client learn to eat safely. For example, a speech language pathologist can instruct the client in learning the supraglottic swallow: take a breath, hold the breath while swallowing, cough after swallowing and swallow again to clear the mouth.
A nurse on a telemetry unit is caring for a client who had a myocardial infarction. the client states "all this equipment is making me nervous" which of the following responses should the nurse offer? a. " you wont need the equipment for very long" b. "all of this equipment can be frightening" c. "why does the equipment bother you" d. "let me tell you about what each mechine does"
b. "all of this equipment can be frightening" this statement is therapeutic because the nurse is reflecting the clients statement. the client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more.
a nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. which of the following pieces of information should the nurse include in the teaching? a. clients who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients b. clients who are age 65 or older are reluctant to report pain c. clients who are age 65 or older should not receive opioid narcotics. d. clients who are age 65 or older experience a shorter duration of action with medications than young adult clients.
b. clients who are age 65 or older are reluctant to report pain the nurse should instruct the newly licensed nurse that clients age 65 and older frequently can be reluctant to report pain because they might not want to bother or anger caregivers and might believe the pain is expected.
a nurse is changing the dressings for a client who has 2 penrose drains near an abdominal incision. which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? a. abdominal binder b. montgomery straps c. hypoallergenic tape d. plastic tape
b. montgomery straps the nurse should apply the least restrictive priority setting framework, which assigns priority to nursing interventions that are the least restrictive to the client, as long as those interventions do not jeopardize client safety. least restrictive interventions promote client safety without using restraints. the nurse should only use physical or chemical restraints when the safety of the client, staff members or others is at risk. the nurse should plan to use montgomery straps to minimize irritation of the skin near the incisional area. montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. the adhesive strips have holes for using gauze to tie the dressing securely. when the dressing is changed the ties are released, the dressing is replaced and the ties are secured again without removing the adhesive first.
a nurse is developing a plan of care for a client. which of the following pieces of information should the nurse consider when planning care that is culturally congruent? a. illness is not influenced by culture b. the meaning of disease can vary widely across cultures. c. assigning clients to specific cultural categories facilitates communication d. predetermined criteria should generate client care activities
b. the meaning of disease can vary widely across cultures. a client may define and react to disease based on his or her unique cultural perspective. the nurse should seek to understand a clients culture and life experiences in order to provide care that is effective based and culturally congruent.
a nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. which of the following client statements indicates an understanding of the teaching? a. "i should rinse my mouth out right before i use the inhaler" b. "after the first puff, i will wait 10 seconds before taking the second puff" c. "i will shake the inhaler well right before i use it" d. "i will tilt my head forward while inhaling the medication"
c. "i will shake the inhaler well right before i use it" the nurse should instruct the client to shake their inhaler vigorously for 3-5 seconds, which will mix the medication within the inhaler evenly.
a nurse in the emergency department is caring for a client who has abdominal trauma. which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? a. warm, dry skin b. increased urinary output c. tachycardia d. bradypnea
c. tachycardia due to the decreased circulating blood volume that occurs with internal bleeding, the oxygen carrying capacity of the blood is reduced. the body attempts to relieve the hypoxia by increasing the heart rate and cardiac output while increasing the respiratory rate.
a nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular sized cuff for a client who is obese. which of the following explanations should the nurse give the AP? a. "the reading will be inaudible if the cuff is too small for the client" b. "the width of the cuff bladder should be 75% of the circumference of the clients arm" c. "as long as the cuff will circle the arm, the reading will be accurate" d. "using a cuff that is too small will result in an inaccurately high reading"
d. "using a cuff that is too small will result in an inaccurately high reading" blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. blood pressure readings can be falsely high if the cuff is too small for the client.
a nurse is obtaining the blood pressure in a clients lower extremity. which of the following actions should the nurse take? a. auscultate the blood pressure at the dorsalis pedis artery b. measure the blood pressure with the client sitting on the side of the bed c. place the cuff 7.6 cm (3in) above the popliteal artery d. place the bladder of the cuff over the posterior aspect of the thigh.
d. place the bladder of the cuff over the posterior aspect of the thigh. this is correct position for the bladder of the cuff when the nurse is measuring a lower extremity blood pressure.
a nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? a. change the tube feeding bag every 48 hours b. chill the formula prior to administration c. increase the infusion rate d. request a prescription for an isotonic enteral nutrition formula
d. request a prescription for an isotonic enteral nutrition formula the nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the clients formula to an isotonic formula. This formulation can be easier for the client to digest and can decrease diarrhea.
a nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. at which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? a. fifth intercostal space just medial to the mid-clavicular line b. second intercostal space to the left of the sternum c. fifth intercostal space to the left of the sternum d. second intercostal space to the right of the sternum
d. second intercostal space to the right of the sternum the aortic valve is located in the second intercostal space to the right of the sternum. aortic stenosis produces a mid systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.
