ATI RN fundamentals Practice Assessment

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? 1. Critical pathway 2. SBAR 3. Transfer report 4. MAR

2. SBAR rationale: SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply).

Assist the client with a partial bed bath, Measure the client's BP after the nurse administers an antihypertensive medication, and use a communication board to ask what the client wants for lunch rationale: Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function, measuring a client's BP poses minimal risk to the client and is within the AP's range of function, and using a communication board poses minimal risk to the client and is within the AP's range of function.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply)

pupil clarity, visual fields, and visual acuity

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? 1. Press gently on the tragus of the client's ear 2. Pack a small piece of cotton deep into the client's ear canal 3. Move the client's auricle down and back toward her head 4. Tilt the client's head backward for 5 minutes

1. Press gently on the tragus of the client's ear rationale: Pressing gently on the tragus of the ear will help the medication get into the inner ear

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? 1. Bladder distention 2. Decreased blood pressure 3. Calf swelling 4. diminished bowel sounds

3. Calf swelling rationale: Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? 1. Assist the client into a prone position 2. Place a sleeve over the top of each leg with the opening at the knee 3. Make sure two fingers can fit under the sleeves 4. Set the ankle pressure at 65 mm Hg

3. Make sure two fingers can fit under the sleeves rationale: The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? 1. Biofeedback 2. Aloe 3. Feverfew 4. Acupuncture

4. Acupuncture rationale: The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection

A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds. 1. Crackles (discontinuous sounds heard during inhalation) 2. Rhonchi (low-pitched, snore-like noise) 3. Friction rub (Scratching or squeaking sound) 4. Normal breath sounds

4. Normal breath sounds rationale: These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? 1. Bend at the waist 2. Keep his feet close together 3. Use his back muscles for lifting 4. Stand close to the cabinet when lifting it

4. Stand close to the cabinet when lifting it rationale: This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? 1. "Is your pain constant or intermittent?" 2. What would you rate your pain on a scale of 0 to 10?" 3. "Does the pain radiate?" 4. "Is your pain sharp or dull?"

4."Is your pain sharp or dull?" Rationale: Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

B rationale: The nurse should identify this image as assessing the client's patellar reflex.

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? 1. "I can concentrate best in the morning" 2. "It is difficult to read the instructions because my glasses are at home" 3. "I'm wondering why i need to lean this" 4. "You will have to talk to my wife about this"

1. "I can concentrate best in the morning" rationale: The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? 1. Administer the medication with the needle at a 45 degree angle 2. Administer the medication into the client's nondominant arm 3. Pull the client's skin laterally or downward prior to administration 4. Massage the injection site after administration

1. Administer the medication with the needle at a 45 degree angle rationale: The nurse should insert the needle at a 45 to 90 degree angle for a subcutaneous injection.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? 1. Ask another nurse to observe the medication wastage 2. Notify the pharmacy when wasting the medication 3. Lock the remaining medication in the controlled substances cabinet 4. Dispose of the vial with the remaining medication in sharps container

1. Ask another nurse to observe the medication wastage rationale: A second nurse must witness the disposal of any portion of a dose of a controlled substance

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? 1. A lesion with uniform pigmentation 2. New appearance of petechiae 3. A mole with an asymmetrical appearance 4. The presence of a papule

3. A mole with an symmetrical appearance. rationale: an uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. Obtain the pronouncement of death from the provider. 2. Remove tubes and indwelling lines. 3. Wash the client's body 4. Ask the client's family members if they would like to view the body 5. Place a name tag on the body. rationale: The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? 1. Use a bed exit alarm system 2. Raise four side rails while the client is in bed 3. Apply one soft wrist restraint 4. Dim the lights in the client's room

1. Use a bed exit alarm system rationale: The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? 1. Protective environment 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

4. Contact precautions rationale: Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? 1. Document the provider's statement in the medical record 2. Complete an incident report 3. Consult the facility's risk manager 4. Notify the nursing manager

4. Notify the nursing manager rationale: The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress? 1. Role ambiguity 2. Sick role 3. Role overload 4. Role conflict

3. Role overload rationale: The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? 1. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter 2. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min 3. Make sure the reservoir bag of a partial rebreathing mask remains deflated 4. Use petroleum jelly to lubricate the client's nares, face, and lips

2. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min rationale: Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2)

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? 1. The client uses a wool blanket on their bed 2. The client identifies the location of a fire extinguisher 3. The client stores an extra oxygen tank on its side under their bed 4. The client has a weekly inspection checklist for oxygen equipment

2. The client identifies the location of a fire extinguisher rationale: The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? 1. "I will return shortly after I document this in your record" 2. "Most men live a long time with prostate cancer" 3. "I am available to talk if you should change your mind" 4. "I will make a referral to a cancer support group for you"

3. "I am available to talk if you should change your mind" rationale: When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? 1. "I think I should take my pain medication more often, since it is not controlling my pain" 2. "Breathing faster will help my keep my mind off of the pain" 3. " It might help me to listen to music while I'm lying in bed" 4. "I don't want to walk today because I have some pain"

3. "It might help me listen to music while I'm lying in bed" rationale: Listening to music is an effective non-pharmacological intervention for the management of mild pain

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? 1. Insert the needle at a 15 degree angle 2. aspirate for blood return prior to administration 3. Administer the medication into the abdomen 4. Massage the site following the injection

3. Administer the medication into the abdomen rationale: The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? 1. Numbness of the extremities 2. Bradycardia 3. Positive Chvostek's sign 4. Abdominal cramping

4. Abdominal cramping rationale: This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 1. Discuss the risk factors for colon cancer 2. Focus teaching on what the client will need to do in the future to manage his illness 3. Provide the client with written information about the phases of loss and grief 4. Reassure the client that this is an expected response to grief

4. Reassure the client that this is an expected response to grief rationale: During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is and expected reaction to a cancer diagnosis

A nurse is preparing an education program for a staff about advocacy. Which of the following information should the nurse include? 1. Advocacy ensures clients' safety, health, and rights 2. Advocacy ensures that nurses are able to explain their own actions 3. Advocacy ensures that nurses follow through on their promises to clients 4. Advocacy ensures fairness in client care delivery and use of resources

1. Advocacy ensures clients' safety, health, and rights rationale: Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? 1. Check the client for injuries 2. Move hazardous objects away from the client 3. Notify the provider 4. Ask the client to describe how she felt prior to the fall

1. Check the client for injuries rationale: The first action the nurse should take when using the nursing process is to assess the client for injuries

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 1. Verify the client's name on their identification bracelet with the medication administration 2. Call the pharmacy to determine whether the client's medications are available 3. Compare the client's home medications with the provider's prescriptions 4. Place the client's home medication bottles in a secure location

3. Compare the client's home medications with the provider's prescriptions rationale: The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? 1. The top of the cane is parallel to the client's waist 2. When walking, the client moves the cane 46 cm (18 in) forward 3. The client holds the cane on the stronger side of her body 4. The client moves her stronger limb forward with the cane

3. The client holds the cane on the stronger side of her body rationale: The client should hold the cane on the stronger side of her body to increase support and maintain alignment

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L

Potassium 5.4 mEq/L rationale: This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? 1. "Use the complete name of the medication magnesium sulfate" 2. "Delete the space between the numerical dose and the unit of measure" 3. "Write the letter U when noting the dosage of insulin" 4. "Use the abbreviation SC when indicating an injection"

1. "Use the complete name of the medication magnesium sulfate" rationale: The institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? 1. During the admission process 2. As soon as the client's condition is stable 3. During the initial team conference 4. After consulting with the client's family

1. During the admission process rationale: Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? 1. Examine personal values about the issue 2. Tell the parents that this is a necessary procedure 3. Inform the parents that the staff does not require their consent 4. Contact a spiritual support person to explain the importance of the procedure

1. Examine personal values about the issue rationale: Nurses should examine their own personal values about the issue in question in order to provide care that is without bias

A nurse on a medical-surgical unit is caring for a client for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? 1. Pad the client's wrist before applying the restraints 2. Evaluate the client's circulation every 8 hours after application 3. Remove the restraints every 4 hours to evaluate the client's status 4. Secure the restraint ties to the bed's side rails

1. Pad the client's wrist before applying the restraints rationale: The use of restraints without padding can abrade the client's skin, resulting in client injury

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? 1. Turn the client every 2 hours 2. Administer an antiemetic every 6 hours 3. Hold oral care 4. Increase the room's temperature

1. Turn the client every 2 hr rationale: The nurse should turn the client at least once every 2 hours to break up the secretions in the client's lungs and prevent noisy respirations

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

107 mL/hr rationale: 750/7 = 107 mL/hr

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? 1. "I am not worried because I still have hope that he will be okay" 2. "I am relying on support from our family during this time" 3. "We can plan our family reunion once he recovers and comes home" 4. "We don't see any reason to start discussing funeral arrangements right now"

2. "I am relying on support from our family during this time" rationale: This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 1. "I can place an extension cord across my living room to plug in my television" 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" 3. "I will place my alarm clock on my bedroom dresser across the room" 4. "I will replace the old throw rug in my kitchen with a new one"

2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" rationale: Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? 1. "They allow the court to overrule and adult client's refusal of medical treatment 2. "They indicate the form of treatment a client is willing to accept in the event of a serious illness" 3. "They permit a client to withhold medical information from health care personnel" 4. "They allow health care personnel in the emergency department to stabilize a client's condition"

2. "They indicate the form of treatment a client is willing to accept in the event of a serious illness" rationale: Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? 1. "We would consult the person appointed by your health care proxy to make decisions" 2. "We would give you oxygen through a tube in your nose" 3. "You would be unable to change your previous wishes about your care" 4. "We would insert a breathing tube while we evaluate your condition"

2. "We would give you oxygen through a tube in your nose" rationale: Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? 1. Insert the suction catheter while the client is swallowing 2. Apply intermittent suction when withdrawing the catheter 3. Place the catheter in a location that is clean and dry for later use 4. Hold the suction catheter with her clean, nondominant hand

2. Apply intermittent suction when withdrawing the catheter. rationale: The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? 1. Request that a respiratory therapist discuss the technique for incentive spirometry with the client 2. Determine the reasons why the client is refusing to use the incentive spirometer 3. document the client's refusal to participate in health restorative activities 4. Administer a pain medication to the client

2. Determine the reasons why the client is refusing to use the incentive spirometer. rationale: The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? 1. Contact 2. Droplet 3. Airborne 4. Protective

2. Droplet rationale: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? 1. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain 2. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm 3. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum 4. Palpate the client's abdomen before auscultating bowel sounds

2. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm rationale: The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 1. Make sure the client's room has at least six air exchanges per hour 2. Make sure the client wears a mask when outside her room if there is construction in the area 3. Place the client in a private room with negative-pressure airflow 4. Wear an N95 respirator when giving the client direct care

2. Make sure the client wears a mask when outside her room if there is construction in the area rationale: An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? 1. Carry a client's soiled linens out of the room in a mesh linen bag 2. place a client who has TB in a room with negative-pressure airflow 3. Provide disposable plates and utensils for a client who is HIV-positive 4. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag

2. Place a client who has tuberculosis in a room with negative-pressure airflow rationale: A client who has TB requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? 1. Insert the catheter at a 45 degree angle 2. Place the client's arm in a dependent position 3. Shave excess hair from the insertion site 4. Initiate IV therapy in the veins of the hand

2. Place the client's arm in a dependent position rationale: The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? 1. Remove the outer cannula cautiously for routine cleaning 2. Use tracheostomy covers when outdoors 3. Use sterile technique when performing tracheostomy care at home 4. Cleanse irritated skin with full-strength hydrogen peroxide

2. Use tracheostomy covers when outdoors. rationale: Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? 1. "You would have so much more time to spend with your family" 2. "You should consider getting a part-time job or doing volunteer work" 3. "Let's talk about how the change in your job status will affect you" 4. "Why wouldn't you want to retire and relax?"

3. "Let's talk about how the change in your job status will affect you" rationale: This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? 1. Increase in hematocrit 2. Increase in respiratory rate 3. Decrease in heart rate 4. Decreases in capillary refill time

3. Decrease in heart rate rationale: Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range

A nurse is using an opening irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? 1. Place the client in a side-lying position 2. Instill 15 mL of irrigation fluid into the catheter with each flush 3. Subtract the amount of irrigant used from the client's urine output 4. Perform the irrigation using a 20 mL syringe.

3. Subtract the amount of irrigant used from the client's urine output rationale: The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? 1. The client is receiving formula at room temperature 2. The feedings infuse at a slow, continuous drip over 8 hours each night 3. The client's caregiver washes out the feeding bag with warm water once every 24 hours 4. The client's caregiver flushes the tubing with water before and after administering medications

3. The client's caregiver washes out the feeding bag with warm water once every 24 hr. rationale: Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hours to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? 1. Combine client care tasks when caring for multiple clients 2. Wait until the end of the shift to document client care 3. Use the planning step of the nursing process to prioritize client care delivery 4. Allow for interruptions in tasks to discuss client care issues with colleagues

3. Use the planning step of the nursing process to prioritize client care delivery rationale: Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? 1. Encourage the client to relax and take deep breaths during the dressing change 2. Educate the client about the importance of the dressing change to prevent infection 3. Assist the client to a comfortable position for the dressing change 4. Administer pain medication 45 min before changing the client's dressing

4. Administer pain medication 45 min before changing the client's dressing rationale: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first? 1. Reposition the client 2. Document the client's IV intake in the medical record 3. Request a new IV fluid prescription 4. Check the IV tubing for obstruction

4. Check the IV tube for obstruction rationale: The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 1. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube 2. Remove the NG tube if the client begins to gag or choke 3. Apply suction to the NG tube prior to insertion 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus

4. Have the client take sips of water to promote insertion of the NG tube into the esophagus rationale: Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid

4. Hydrocolloid rationale: Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? 1. Have the client wear a mask when receiving visitors 2. Limit the client's time with visitors to no more than 30 minutes per day 3. Assign the client to a room with negative-pressure airflow exchange 4. Wear a gown when caring for the client

4. Wear a gown when caring for the client rationale: The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces