ATI fundamentals practice test B
A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has a myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
0.3 mg: The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family?
1) check the cord routinely for frays or tearing 2) consider purchasing a generator for power backup 3) observe for signs of hypoxia
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure
1) inject 10 units of air into the bottle of NPH insulin 2) inject 5 units of air into the bottle of regular insulin 3) withdraw the correct dose of regular insulin from the bottle 4) withdraw the correct dose of NPH insulin from the bottle
A nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? select all that apply
1)place the client in a room with negative-pressure airflow 2) wear gloves when assisting the client with oral care 3) use antimicrobial sanitizer for hand hygiene
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. at what rate should the nurse set the infusion pump?
8 mL/hr
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea
8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. 1 oz = 30 mL; 8 oz = 1 cup 2 cups = 480 mL 1 quart water = 960-1,000 mL 6 oz = 180 mL
A nurse is preparing to delegate client care tasks to an assistive personnel. which of the following tasks should the nurse delegate? a. Ambulating a client who is postoperative b. Inserting an indwelling urinary catheter for a client c. Demonstrating the use of an incentive spirometer to a client d. Confirming that a client's pain has decreased after receiving an analgesic
Ambulating a client who is postoperative: The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.
1200:Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation.1230:Client transported for abdominal x-ray.1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema.1300:Procedure explained to client who verbalized understanding. Diagnostic Results 1245:Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed.
Assist the client to a left side-lying position with the right knee flexed is correct. (Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure.) Administer a cleansing enema is correct. (A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray.) Auscultate the client's bowel sounds is correct. (The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract.) Perform a manual digital examination of the client's rectum is correct. (The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract.)
Nurses' Notes 1100:Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile.1110:Provider at bedside; prescriptions received.1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.1200:Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities. Medication Administration Record 1115:Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F) Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Vital Signs 1100:Temperature 39.2° C (102.6° F) Pulse rate 118/min Respiratory rate 18/min Blood pressure 92/68 mm Hg Oxygen saturation 95% Weight 44.9 kg (99 lb)BMI 17
Cachectic, with flaccid muscle tone is correct. (The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition.) Skin dry and scaly with bruises on extremities is correct. Pulse rate 118/min is correct. (The client's tachycardia can be an indication of malnutrition.) Abdomen distended is correct. BMI 17 is correct. A BMI of 17 is considered underweight and can be an indication of malnutrition.
A nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statements indicates an understanding of herbal supplement use?
I can take echinacea to improve my immune system: Feverfew is taken to promote wound healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress. Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion.
A nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client?
N95 respirator
Nurses' Notes Day 1:Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Day 5:Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.
Passive range-of-motion exercises to lower extremities performed once each day (The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures.) Plantar flexion contractures noted bilaterally is correct. The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact is correct. The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing.
Nurses' Notes 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Vital Signs 1030: Blood pressure 110/68 mm Hg Heart rate 110/min Respiratory rate 24/min Temperature 38.6° C (101.5° F) Oxygen saturation 91% on room air
Place the client on droplet isolation precautions and Remain 1 m (3 feet) from the client Apply oxygen at 2 L/min via nasal cannula (The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia.) Request a prescription for an antipyretic medication (The nurse should identify that the client has a temperature of 36.6° C (101.5° F), indicating a fever.)
Nurses' Notes 1000:Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. Vital Signs 1000: Blood pressure 132/68 mm Hg Heart rate 99/min Respiratory rate 20/min Temperature 38.3° C (101° F) Oxygen saturation 96% on room air Diagnostic Results 1100:Positive throat culture for streptococci bacteria.
Request a prescription for an antibiotic medication Initiate droplet precautions Wear a mask within 1 m of the client Apply a mask in the client when they leave the room
Nurses' Notes 0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Diagnostic Results 1200:Hgb 19 g/dL (12 to 16 g/dL) Hct 46% (37% to 47%)
Stoma color is correct. (The greatest risk to the client is the necrosis of the bowel. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel; therefore, the nurse should notify the provider immediately about the color of the client's stoma.) Skin around the stoma is correct. (The nurse should identify that the skin condition around the stoma is the next priority finding to address because it places the client at risk for infection.)
Nurses' Notes Day 1:Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Day 4:Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Vital Signs Day 4: Temperature 38.3° C (101° F) Pulse rate 80/min Respiratory rate 20/min Blood pressure 128/64 mm Hg Oxygen saturation 93% on room air Diagnostic Results Day 4: Potassium 4.2 mEq/L (3.5 to 5 mEq/L) Hgb 13 g/dL (12 to 16 g/dL) Hct 38% (37% to 47%) WBC count 12,000/mm3 (5,000 to 10,000/mm3) Prealbumin12 mg/dL (15 to 36 mg/dL)
Temperature WBC count Prealbumin (This is a manifestation of malnutrition, which contributes to delayed wound healing.) Pain level Odor of wound
Medical History Client is receiving chemotherapy for treatment of breast cancer. Diagnostic Results Week 1: Hct 42% (37% to 47%) Hgb 15 g/dL (12 g/dL to 16 g/dL) WBC count 8,000/mm3 (5,000 to 10,000/mm3) Platelet count 350,000/mm3 (150,000 to 400,000/mm3) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2: Hct 37% (37% to 47%) Hgb 12 g/dL (12 g/dL to 16 g/dL) WBC count 6,000/mm3 (5,000 to 10,000/mm3) Platelet count 100,000/mm3 (150,000 to 400,000/mm3) Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
The client is at risk for bleeding as evidenced by the client's platelet count.
Nurses' Notes 0800: Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis. Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed. Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed. Client 4: Client is admitted with a new diagnosis of heart failure. Client 5: Client has a stage 2 pressure injury on the left heel. Client 6: Client is admitted with a new diagnosis of diabetes mellitus. Diagnostic Results 0900: Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL) Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL) Client 3: Oxygen saturation 88% (95% to 100%) Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL) Client 6: Glycosylated hemoglobin 8% (less than 7%)
The first client the nurse should assess is Client 3 followed by Client 4 Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess. The client has a potassium level that is less than the expected reference range, which places the client at risk for dysrhythmias.
A nurse is caring for a group of medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity?
a client is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively
A community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension?
a client who smokes one pack of cigarettes each day
A nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
a nurse asks a nurse from another unit to assist with documentation for a client
A nurse is caring for a client who has terminal liver cancer. which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. "What could i have done to deserve this illness?" b. "I blame medical science for not curing me." c. "Where is my daughter at a time like this?" d. "Will I ever begin to feel in charge of my life again?"
a. "What could i have done to deserve this illness?"： The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them. D is a statement reflects the client's feelings of powerlessness but does not indicate a conflict of a spiritual nature.
A nurse is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "When descending stairs, I will first shift my weight to my right leg." b. "I should place my crutches 12 inches in front and to the side of each foot." c. "As I sit down, I will hold one crutch in each hand." d. "I will make sure the shoulder rests are snug against my armpits."
a. "When descending stairs, I will first shift my weight to my right leg.": To descend stairs, the client should first shift his body weight to the unaffected leg. The client should place crutches 15 cm in front and to the side of each foot. Just before sitting down, the client should hold both crutches by their hand bars in one hand. To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae.
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend? a. Walking briskly b. Riding a bicycle c. Performing isometric exercise d. Engaging in high-impact aerobics
a. Walking briskly: Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.
A nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement?
an x-ray shows the end of the tube above the pylorus
A nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
apply an ankle-foot orthotic device to the client's feet
A nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
auscultate lung sounds: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.
A nurse is caring for a client who reports pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild pain." b. "The pain is like a dull ache in my stomach." c. "I notice that the pain gets worse after I eat." d. "The pain makes me feel nauseous."
b. "The pain is like a dull ache in my stomach.": The client is describing the quality of the pain, which is how the pain feels in the client's own words. the nurse should obtain a description of how the pain feels or specify the intensity.
A nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make? a. "Drink a cup of hot cocoa before bedtime." b. "Maintain a consistent time to wake up each day." c. "Exercise 1 hour before going to bed." d. "Watching a television program in bed before going to sleep to reduce stimulation in order to promote rest."
b. Maintain a consistent time to wake up each day: The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client. Not c because exercising within 2 hr of bedtime can interfere with sleep.
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. which of the following actions should the nurse plan to take? a. Use a resuscitation bag with 80% oxygen prior ti the procedure b. Select a suction catheter that is half the size of the lumen c. Place the end of the suction catheter in water-soluble lubricant d. Adjust the wall suction apparatus to a pressure of 170mmHg
b. Select a suction catheter that is half the size of the lumen: To prevent hypoxemia and trauma to the muscosa. The nurse should preoxygenate the client the client with 100% oxygen before suctioning to prevent hypoxemia. The nurse should lubricate the end of the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation solution to decrease trauma to the mucosa. The nurse should adjust the suction pressure to approximately 120 mmHg and no higher 150 mmHg to prevent hypoxemia and trauma to the mucosa.
A nurse is caring for a client who has an indwelling catheter. which of the following findings indicates that the catheter requires irrigation?
bladder scan shows 525 mL of urine
A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide?
breath sounds： When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.
A nurse is caring for a client who requires a 24 hr urine collection. which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine." b. "I have a specimen in the bathroom from about 30 minutes ago." c. "I flushed what I urinated at 7:00 am and have saved all urine since." d. "I drink a lot, so I will fill up the bottle and complete the test quickly."
c. "I flushed what I urinated at 7:00 am and have saved all urine since.": For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voiding. Urine should be free of feces. Urine should be placed in the container immediately and kept on ice or in the refrigerator.
A nurse is preparing to transfer a client who can bear weight on lone leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next? a. Rock the client up to a standing position b. Pivot on the foot that is the furthest from the chair c. Assess the client for orthostatic hypotension d. Apply a gait belt to the client
c. Assess the client for orthostatic hypotension: The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair. All other actions are appropriate however not a priority.
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include? a. Client flow sheet b. Acuity ratings c. Current medications d. Incident reports
c. Current medications: The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect? a. Neck vein distention b. Urine specific gravity 1.010 c. Rapid heart rate d. Blood pressure 144/82 mmHg
c. Rapid heart rate: Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Typically, a client's specific gravity is greater than 1.030 in the presence of fluid volume deficit. JVD is a manifestation of fluid volume excess.
A nurse is caring for a client who has a prescription for wound irrigation. which of the following actions should the nurse take?
cleanse the wound from the center outward: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation.
A nurse enters a client's room and finds her on the floor. the client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident?
client found lying on floor: The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause.
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
compare prescriptions with medications the client received while are the facility
A nurse is teaching a group of nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. A client who has history of physical abuse b. A client who has a permanent pacemaker c. A client who has ulcerative colitis d. A client who has asthma
d. A client who has asthma: Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.
A nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. Assign a staff member to feed the client b. Provide small-handed utensils for the client c. Thicken liquids on the client's tray d. Arrange food in a consistent pattern on the client's plate
d. Arrange food in a consistent pattern on the client's plate
A nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess? a. Hypotension b. Weak, thready pulse c. Slow capillary refill d. Distended neck veins
d. Distended neck veins: Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure. Hypotension, weak thready pulse, decrease in capillary refill = fluid volume deficit.
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting
d. Have family members wear a gown and gloves when visiting The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores.
A nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice? a. Insert an implanted port. b. Close a laceration with sutures. c. Place an endotracheal tube. d. Initiate an enteral feeding through a gastrotomy tube.
d. Initiate an enteral feeding through a gastrotomy tube: implanted ports and other central venous devices requires insertion by a physician, surgeon, or advanced practice nurse. Surgeons and other physicians close wounds with sutures. Physicians and clinicians with special training insert endotracheal tubes.
A middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? a. "Most people are happy when their children grow up and leave home." b. "You should be proud that your children are becoming independent." c. "Maybe you should consider why you are feeling useless." d. "People in middle adulthood often find satisfaction in nurturing and guiding young people."
d. People in middle adulthood often find satisfaction in nurturing and guiding young people.: According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse? a. The caregiver is the client's financial power of attorney b. The client is in a wheelchair with the wheels locked c. The client reports receiving a full bath twice each week d. The caregiver insists on remaining in the room
d. The caregiver insists on remaining in the room: A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment. A is necessary. B is a matter of safety. C is sufficient.
A nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate?
droplet: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies.
A nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene?
erythema on pressure points: Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
evacuate the client
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take?
flush the tube with 15 mL of sterile water
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take?
gently shake the container of medication prior to administration: The nurse should gently shake the liquid medication to ensure that the medication is mixed.
A nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use?
have the client stand with their arms at their sides and their feet together: A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.
a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown?
have the client use a trapeze bar when changing position: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.
A nurse is caring for a client who has recently started using a behind the ear hearing aid. which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?
i will be sure to remove my hearing aid before taking a shower
A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia pump. which of the following actions should the nurse take?
instruct the family to refrain from pushing the button for the client while she is asleep: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.
A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider?
medication dose: In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.
A nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. the sound indicates which of the following?
narrowed arterial lumen: Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.
A nurse is planning on teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a pyschomotor approach to learning?
practice sessions: Practice sessions require psychomotor skills when learning.
A nurse is caring for a client who is receiving fluids through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration?
skin blanching: Skin blanching, edema, and coolness at the IV site indicate infiltration. Exudate indicates infection, not infiltration. Warmth indicates phlebitis, not infiltration. Bleeding can have a mechanical cause or can occur as the result of anticoagulation. It is not a sign of infiltration.
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actions should the nurse take first?
tell the client to keep the head of the bed elevated at least 30 degrees: the first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?
the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field: Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.
A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining blood pressure?
the one close to 120 mm Hg: To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advance directives. which of the following responses should the nurse make?
we can talk about advance directives, and i can also give you some brochures about them
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take?
withhold the blood transfusion: The principle of autonomy ensures that a client who is competent has the right to refuse treatment.
A nurse is caring for a client who requires consent for a surgical procedure. which of the following actions is the nurse's responsibility?
witness the client's signature on the consent form
A nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care?
wrap blankets around all four sides of the bed: The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take?
wrap monitoring cords with stockinette and tape them in place: Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.
A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since i am at an average risk for colon cancer, i should have a routine screening. what does this involve?" which of the following responses should the nurse make?
you should have a fecal occult blood test every year： Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.
A nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include?
you should receive a pneumococcal immunization every 10 years: 1. Older adults should have an eye examination every year. Older adults should receive a tetanus booster every 10 years. Older adult clients will receive a shingles vaccine when they are 60 years old. Older adult clients will receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.
