ATI Quiz: Fundamentals 1, 2 & final

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?

"I am going to listen to your abdomen." a common reason why client's experience nausea and vomiting after a surgery is bc of delayed gastric emptying time or decreased peristalsis determine presence of bowel sounds before liquids can be administered

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after excessive as I get older."

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than alcohol based hand rub to clean my hands."

nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask.

A nurse is changing the dressings for a client recovering form an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin. Rationale: The nurse should report to the provider when the client has a ring of erythema on the surrounding skin, which might indicate underlying infection. This and any other manifestion of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's 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 when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks 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, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

A. Daily weight According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement.

A nurse is preparing to provide 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 Trendelenburg's position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain

A. Place the client in Trendelenburg's position The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the client's mouth open. C. Rinse the client's mouth with an alcohol-based mouth wash following the procedure D. Cleanse the client's mucous membranes with lemon-glycerin sponges

A. Place the client in a lateral position with the head turned to the side before beginning the procedure The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? A. WBC 15,000 mm3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063

A. WBC 15,000 mm3 This finding is above the expected reference range and is an indication of infection.

A nurse is caring for a client who has clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest.

A. Wear gloves when changing the client's gown The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.

A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect?

Absent bowel sounds with distention

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administe analgesics to the child on a routine schedule throughout the day and night.

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouth piece with an alcohol swab after each use D. Use the spirometer every 8 hr.

B. Cough deeply after each use Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs.

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

B. Edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration.

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles. B. Educating clients about the recommended immunization schedule for adults. C. Teaching clients who have type 1 diabetes mellitus about care of the feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually

B. Educating clients about the recommended immunization schedule for adults. Primary prevention includes health education about disease prevention.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

B. Fidelity The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? A. Place a padded tongue blade in the client's head. B. Lower the client to the floor and place a pad under the clients head. C. Seek the help of a coworker and life the client back to bed. D. Use an oropharyngeal airway to keep upper airway passages open.

B. Lower the client to the floor and place a pad under the clients head. To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head.

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations. C. Prepare to administer oxygen. D. Give the client a back rub to help her relax.

B. Observe the rate, depth, and character of the client's respirations. The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status.

A. nurse is planning care for a client who has a single-lumen nasogastric (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 mm HG B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares.

B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed B. Tie the restraint with a quick-release knot C. Allow one finger's breadth between the restraint and the client's chest. D. Place the restraint under the client's clothing

B. Tie the restraint with a quick-release knot The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints.

A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked. first apply least invasive framework

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? A. "Support the majority of your weight on the axillae." B. "Keep your elbows extended." C. "Bear weight on both of your legs." D. "Move both crutches forward at the same time."

C. "Bear weight on both of your legs." The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs.

A hospice nurse is reviewing religious practices of a group of clients with newly licensed nurse indicates an understanding of the teaching? A. "People who practice the islamic faith pray over the decreased for a period of 5 days before burial." B. "People who practice the Hindu faith bury the deceased with their head facing north." C. "People who practice Judaism stay with the body of the deceased until burial." D. "People who are practicing the Buddhist faith have the female family members prepare the body following death."

C. "People who practice Judaism stay with the body of the deceased until burial." In the Jewish faith, a family member often stays with the body until burial occurs.

An adolescent client in an outpatient mental health facility tells the nurse that it is hard 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 them 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. "Tell me where you met these friends."

C. "Tell me more about how your friends discourage you."

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? A. Pain level B. Hydration status C. Airway D. Urinary output

C. Airway The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them; therefore, the nurse should first assess the client's airway.

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream

C. Gelatin Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature.

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning. A. Ask the client if he want to self-administer his insulin. B. Have the client list the steps of the procedure. C. Have the client demonstrates the procedure. D. Ask the client if he understands the purpose of insulin.

C. Have the client demonstrates the procedure. Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning.

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? A. BT for bedtime B. SC for subcutaneously C. PC for after meals D. HS for half-strength

C. PC for after meals The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation.

A nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port. Rationale: The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.

nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port. Rationale: The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching.

Cleanse the skin around the stoma with warm water. using soap can leave a residue and cause poor adherence of pouch

A nurse is caring for a client who has 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.

Collapse the device of air after emptying. Rationale: The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device.

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen upon arising in the morning. in the morning it's easier to cough up secretions deepest specimens are usually collected in morning try to collect before breakfast prior to coughing into container: rinse mouth and deep breathe

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? A. "I would try to get it over with because you won't get better without this tube." B. "You should talk to your provider about it." C. "Why don't you want the tube inserted?" D. "I can see that this is upsetting you."

D. "I can see that this is upsetting you." The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? A. Sunken eye balls B. Hypotension C. Poor skin turgor D. Bounding pulse

D. Bounding pulse Bounding pulse is an expected finding of fluid volume excess.

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pain in the periumbilical area. The nurse should plan care bases 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 assist the client to ambulate to promote peristalsis.

A nurse in a provider's office is collecting information form an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects. A. Constipation B. Gastric ulcers C. Respiratory depression D. Liver damage

D. Liver damage Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500 mg/day of vitamin E C. Limit fluid intake to 20 ml/kg of body weight per day D. Provide a protein intake to 1.5g/kg of the body weight per day.

D. Provide a protein intake to 1.5g/kg of the body weight per day. A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes

D. Washing dishes Washing dishes requires a low level of activity and is appropriate for this client.

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? A. Use battery-operated equipment for personal care B. Apply mineral oil to protect the facial skin from irritation C. Remove the television set from the client's bedroom D. Wear cotton clothing to avoid static electricity

D. Wear cotton clothing to avoid static electricity

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?

Lower abdomen. Rationale: The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and tissue injury.

A nurse is changing the dressings for a client who has two 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.

Montgomery straps. Rationale: The nurse should apply the least restrictive priority-setting framework. MS straps are adhesive strips applied to the skin on either side of the surgical wound. They have holes for using gauze to tie the dressing securely.

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart or sour foods first. Rationale: , The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level. Rationale: Consider Maslow's hierarchy. To meet the pt's Physiological needs, the 1st action the nurse should take is to begin pain management by asking the client to describe her pain.

nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C and Zinc. both help fight wound infection

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising. on rising, after voiding, and before breakfast accurate weight - same garments, same scale,

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? "

What do you think caused the onset of your pan" Rationale: The nurse is using an opne-ended question that allows the client to respond with a wide range of information by using more than one or two words.

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?

Wipes the labia minor in an anteroposterior direction. The nurse should wipe anteroposterior both the right & left labia minora w/ sperate cotton swabs to destroy any microorganisms in the area that would contaminate.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Pull suction catheter back 1 cm if the client starts coughing. will remove catheter from mucosal wall

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum.

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance. A. Two-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg Test

D. Romberg Test When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test.

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells. B. A client who is being transported for a radiography of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization

A. A client who has a prescription for a transfusion of packed red blood cells. Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation

A. Assessment The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings.

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider had prescribed a medication that is unfamiliar to her. 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 client's provider and verify the prescription D. Ask the client if she takes this 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 it in the medication reference on the unit.

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decrease calcium B. Decreased potassium C. Increased potassium D. Increased calcium

A. Decrease calcium Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary bag. The nurse recognizes these manifestations as which of the following types of transfusion reaction? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

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, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps.

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A. Loss B. Trust C. Self-disclosure D. Risk-taking

A. Loss At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.

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 client's joint mobility the nurse should repeat each motion three to five times.

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 pureed foods. C. Make sure feeding are 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 provides the client with the nurse's full attention during the feeding.

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Ventrogluteal

D. Ventrogluteal According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels.

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 make? A. "You won't need the equipment 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 machine does."

B. "All of this equipment can be frightening." This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include> A. A 2-month-old can turn from his abdomen to his back B. A 10-month-old infant can pull up to a standing position C. A 4-month-old infant can sit up without support D. A 6-month-old infant can crawl on his hands and knees.

B. A 10-month-old infant can pull up to a standing position An 8 to 10-month-old infant can pull himself to a standing position.

A nurse is caring for a client who has a terminal illness. which of the following findings indicates that the client's death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia

B. Cold extremities Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent.

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min. B. Fill the bag two-thirds full with ice. C. Place the ice bag uncovered on the client's ankle. D. Tell the client that it is expected to feel numbness when the ice bag is in place.

B. Fill the bag two-thirds full with ice. The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle.

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). 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 (50lbs) without the use of assistive devices D. When lifting an object, spread your feet apart to provide a wide base of support.

D. When lifting an object, spread your feet apart to provide a wide base of support. The AP should spread his feet apart because a wide base of support increases stability.

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes and apologizes for smell. Which of the following responses should the nurse make? A. " A lot of clients who are cared for at home have the same problem." B. "Don't worry about it. He will get a bath, and that will tae care of the odor." C. It must be difficult to care for someone who is confined to bed." D. "When was the last time that he has a bath?"

C. It must be difficult to care for someone who is confined to bed." This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.

A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A.Carminative B. Hypertonic C. Oil retention D. Sodium polystyrene sulfate

C. Oil retention The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take. A. Insert the rectal tube 15.2 cm (6in.) B. Wear sterile gloves to insert the tubing. C. Position the client on his left side. D. Hold the solution bag 91 cm (36 in) above the client's rectum.

C. Position the client on his left side. Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pin from the extinguisher D. Sweep the hose from side to side to dispense material

C. Remove the safety pin from the extinguisher Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first.

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 decrease in 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, along with increasing the respiratory rate.

An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures that there are no kinks in the drainage tubing.

C. The AP hangs the collection bag at the level of the bladder. The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent exudate. Rationale: usually indicates wound sloughing or infection.

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe. before you can notify what is going on with the patient, you have to collect vital data from the patient

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Discontinue the machine, and measure the blood pressure manually every 15 min.

A nurse is replacing the surgical dressings on a client who has abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves to remove the old dressing. Rationale: The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication in the outer third of the lower conjunctival sac.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? .

Elevate the client's head of bed 45 degrees before the feeding. Rationale: the nurse should do this to prevent aspiration

A nurse is preforming eye irrigation for a client who has exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open. Rationale: The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching.

Granulation tissue fills the wound during healing. Rationale: The nurse should include in the teaching that a beefy, red tussie called granulation fills the wound during healing. The wound is left open to drain & heal by secondary intention that should occur w/in 5-21 days. Open wounds place the client at an increased risk for wound infection.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?

Hold breath for 5 seconds after goal volume is reached. Rationale: decreases collapse of alveoli, which helps prevent risk of atelectasis and pneumonia

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?

Hold the linens away from the body and clothing.

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability of the toddle to cry or speak. bc no sounds passing through vocal cords use heimliech maneuver

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm. will prevent dislodging of the tubing during the procedure and injury to rectal mucosa

nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube. decreases risk of aspiration of any GI contents

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag.

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?

Renew the prescription for the use of restraints within 24 hours. after provider has evaluated condition

nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

taut the skin around the IV catheter site that is cool to the touch. stop infusion, elevate extremity, and apply warm moist compress

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions. give priority to the factor or situation posing the greatest safety risk.

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 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?

Temporal

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

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?

Turn the stockings inside out up to the heel before applying. Rationale: The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse to decrease the risk of a fall?

Use a gait belt during ambulation. The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall.

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection. .

the side hip between the iliac crest and anterior iliac spine Forms the boundaries for ventrogluteal injection

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

face the client when speaking.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take?

remove the sleeve of the gown from the arm without the IV line. do line arm last bc that will allow least amount of disruption to the line