cms quizlet

Obtaining cotton balls for the tracheostomy

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for the trachesotomy care. B. Obtainging cotton balls for the tracheostomy care .C. Obtaining sterile gloves for the tracheostomy care. D. Obtaining a sterile brush for the tracheostomy care.

Confirm unresponsiveness

A charge nurse is teaching adult cardiopulmonary resusciation (CPR) to a group of newly licensed nurses.Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assisstance B. Begin Chest compressions C. Confirm unresponsiveness. D. Give rescue breaths.

Occupational therapist

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist

Donning a mask to measure the vital signs of a client who has pertussis

A nurse has delegated various client care tasks to the assistive personnel on the care team. Which of the following actions by the AP should the nurse identify as correct?

elevate pedal pulses

A nurse is admitting a client who has decreased circulation in his left leg.Which of the following actions should the nurse take first? A. Evaluate pedal pulses. B. Obtain a medical history. C. Measure vital signs. D. Assess for leg pain.

"Describe your concerns about sleeping to me"

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

Compare the label of the medication container with the medication administration record three times.

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

Resolved health conditions

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report?

Teaching a client who has asthma to use a metered dose inhaler

An RN is making assignments for a PN at the beginning of the shift which of the following assignments should the PN question? A. Assisting a client who is 24 hour post operative to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered dose inhaler

Nonmaleficence definition

a commitment to do no harm

veracity

a commitment to tell the truth

intentional torts

assault, battery, false imprisonment

quasi-intentional torts

breach of confidentiality and defamation of character

justice defintion

fairness in care delivery and use of resources

fidelity

fulfillment of promises

battery

intentional and wrongful physical contact with a person that involves an injury or offensive contact

unintentional torts

negligence and malpractice

assault definition

the conduct of one person makes another person fearful and apprehensive

autonomy definition

the right to make one's own personal decisions, even when those decisions might not be in that person's own best interest

Release of personal belongings form

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

Inspection, Auscultation, Palpation, Percussion

Place in order: Inspection Palpation Percussion Auscultation

Choose a private room for the interview

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take

Pallor with scaly skin

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

1820 ml

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 ml/hr and had 4 oz of juice and 0.5 L of water. How many mL fluid should the nurse document as the client's intake for the last 8 hr.

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

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia .B. Place a heating pad at the child's neck for comfort. C. Administer analgesics to the child on a routine schedule throughout the day and night. D. Provide the child with ice cream when oral intake is initiated.

"Tell me what the afterlife means to you."

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs?

Remove the restraints one at a time

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints.Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails. B. Perform range-of-motion exercises to the wrists every 3 hrs. C. Remove the restraints one at a time. D. Obtain a PRN prescription for the restraints.

"This dressing allows the wound bed to breathe."

A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include?

Ensuring that healthcare providers comply with regulations

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administration to clients

intensive care unit oncology treatment center burn center

A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary? (Select all that apply) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home healthcare

medicare medicaid

A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following healthcare financing mechanisms are federally funded? (Select all that apply). A. Preferred provider organization (PPO) B. Medicare C. Long term care insurance D. Exclusive provider organization (EPO) E. Medicaid

Repeat the details of the prescription back to the provider Have another nurse listen to the telephone prescription Obtain providers signature on the prescription within 24 hours

A nurse is receiving a providers prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply) A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain providers signature on the prescription within 24 hours D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone.

1 cup of applesauce

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching?

"When lifting a heavy object, keep it close to your body."

A nurse is reinforcing teaching about stress injuries. Which of the following instructions should the nurse include?

"I will be sure to keep the crutch tips dry."

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?

"The living will directs my medical care when I am unable to make decisions."

A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching?

The client advances the unaffected leg first while climbing stairs.

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

Put the date and time on all entries Document objective data leaving out opinions

A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients record? (Select all that apply) A. Cover errors with correction fluid and write in the correct information B. Put the date and time on all entries C. Document objective data leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document

BUN 8 mg/dL

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess?

I will listen for background noises

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? A. I will get the caller off the phone as soon as possible so I can alert the staff B. I will begin evacuating clients using the elevators C. I will not ask any questions and just let the caller talk D. I will listen for background noises

Brush the chemical off the skin and clothing

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Wash the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive

Reassess the client to determine the reasons for an adequate pain relief

By the second postoperative day a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for an adequate pain relief B. Wait to see whether the pain lessons during the next 24 hours C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing his pain.

An older adult who is postoperative following a below the knee amputation

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients just the nurse assigned to the room closest to the nurses station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. Young adult who is postoperative following an open reduction internal fixation of the ankle D. An older adult who is postoperative following a below the knee amputation

Respiratory rate is 22/min with even, unlabored respirations. Skin is pink, warm, and dry The AP reports the client walked with a limp

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply) A. Respiratory rate is 22/min with even, unlabored respirations. B. The clients partner states, "he said he hurts after walking about 10 minutes." C. Pain rating is three on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The AP reports the client walked with a limp

Take vitamin D supplements.

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend?

Remove polish from the client's fingernail before applying the oximetry probe.

A charge nurse is reinforcing teaching with an assistive personnel about performing pulse oximetry. Which of the following information should the nurse include in the teaching

Showing a client how to use progressive muscle relaxation Performing a daily bath after the evening meal Re-positioning a client every two hours to reduce pressure ulcer risk.

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include? (Select all that apply) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG tube) to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Re-positioning a client every two hours to reduce pressure ulcer risk.

Speech-language pathologist

A client who has had a CVA (cerebrovascular accident) has persistent problems with dysphasia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist

Carbon monoxide binds with hemoglobin in the body

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every five years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body

Immunocompromised individuals are at risk for complications from food poisoning Clients who are at high-risk should eat or drink only pasteurized dairy foods Handling raw and fresh food separately can prevent food poisoning

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply) A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high-risk should eat or drink only pasteurized dairy foods D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw and fresh food separately can prevent food poisoning

Removing the client's dentures

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Hypotension

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

The lower my center of gravity the more stability I have To broaden my base of support I should spread my feet apart When I lived an object I should hold it as close to my body as possible

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements shit the nurse identify as an indication that an attendee understands the teaching? (Select all that apply) A. My line of gravity should fall outside my base of support B. The lower my center of gravity the more stability I have C. To broaden my base of support I should spread my feet apart D. When I lived an object I should hold it as close to my body as possible E. When pulling an object, I should move my front foot forward

The flap farthest from the body

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation of an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

autonomy

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

Mild soap

A nurse is caring for a client who has a C. diff infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client?

a thready pulse

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

The client's output was 60 mL for the past 3 hr.

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

guided imagery

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting?

Instruct the client to tilt their head forward while eating.

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

Orthopneic

A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions?

Absent Val sounds with distention

A nurse is caring for a client who is postoperative and has parlytic ileus.Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus. B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea. D. Normal bowel sounds with increased peristalsis.

Cool extremities Orthostatic hypotension Flat neck veins

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit?

Wash hands after removing gloves. Use antimicrobial hand gel after refilling a client's water pitcher. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care associated infections for these clients? (Select all that apply.)

A client who has terminal cancer requests hospice care in her home A client asks about community resources available for older adults A client requests an electric wheelchair for use after discharge

A nurse is caring for a group of clients on a medical surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply) A. A client who has terminal cancer requests hospice care in her home B. A client asks about community resources available for older adults C. A client states that she wants her child baptized before surgery D. A client requests an electric wheelchair for use after discharge E. A client states that he does not understand how to use a nebulizer

Keep the family updated about the client's status is correct. Encourage the family to comb the client's hair is correct. Tell the client's family what to expect as the client's death nears is correct.

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.)

"Do you consume pork products?

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences?

A client who has measles

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

Family members should provide a code prior to receiving client health information Communication of client information can occur at the nurses station. A client can request a copy of her medical record A nurse my photo copy a clients medical record for transferred to another facility

A nurse is discussing the HIPAA Privacy rule with nurses during new employee orientation. Which of the following information should the nurse include? (Select all that apply) A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station. D. A client can request a copy of her medical record E. A nurse my photo copy a clients medical record for transferred to another facility

"Became short of breath when ambulating."

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation?

Three-point

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight o their right leg. Which of the following is the proper crutch gait for this client?

place the bladder of the cuff over the posterior aspect of the thigh

A nurse is obtaining the blood pressure in a client's lower extremity.Which of the following action should the nurse take? A. Auscultate for the blood presure at the dorsalis pedis artery. B. Measure the blood pressure with the client sitting on the side of the bed. C. Place the cuff 7.6cm (3in) above the popliteal artery. D. Place the bladder of the cuff over the posterior aspect of the thigh.

Orient a client to his room

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient a client to his room B. Conduct a client care conference C. Review medical prescriptions D. Develop a plan of care

Ensure that the client is wearing nonskid slippers is correct. Place the client in a room near the nurses' station is correct Reinforce teaching about how to use the call bell is correct.

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.)

Performance of a paracentesis

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

Remove the cover gown in the client's room after providing care.

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Bone scan scheduled for today

A nurse is preparing information for a change of shift report; which of the following information should the nurse include in the report? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record

13.6

A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

donate autologous blood before the surgery

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion.The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should ask your provider about taking iron supplements prior to the surgery." C. Request a family member to donate blood for you." D. "Donate autologous blood before the surgery.

"You should cover your mouth with a tissue when you cough."

A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching

"I will place a gel pad directly above your pubic area before I place the probe."

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching

Use printed materials written in the client's language

A nurse is reinforcing teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

"I will remove all stuffed animals from my baby's crib."

A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching?

"Provide mouth care to them at least every 2 hours."

A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse provide?

Collaborating with providers to perform obesity screenings during routine office visits

A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary healthcare strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. Educating acute care nurses on post operative complications related to obesity

assessment

A nurse on a medical-surgical unit is admitting a client.Which of the following information should the nurse document in the client's record first? A. Assessment B. Plan of care C. Nursing interventions performed. D. Evaulation of progress.

Obtain client information

A nurse on a medical-surgical unit is caring for a client.Which of the following actions should the nurse take first when using the nursing process? A. Identify goals for client care. B. Obtain client information. C. Document nursing care needs. D. Evaluate the effectiveness of nurse care.

Nonmaleficence

A nurse questions a medication prescription as too extreme in light of the clients advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

Any difficulty swallowing

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the clients family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing

malpractice

a nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies

negligence

a nurse fails to implement safety measures for a client at risk for falls

breach of confidentiality

a nurse releases a client's medical diagnosis to a member of the press

defamation of character

a nurse tells a coworker that they believe the client has been unfaithful to their partner

false imprisonment

a person is confined or restrained against their will

beneficence

action that promotes good for others, without any self-interest

Notify the charge nurse of the client's concerns.

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

Apply thromboembolic stockings.

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel?

"Stand with your feet together and your arms at your sides."

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

Young adults should receive a dental assessment every 6 months.

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?

Request assistance when repositioning a client Avoid twisting your spine or bending at the waist Use smooth movements when lifting and moving clients

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instruction should the nurse manager include? (Select all that apply) A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waist C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2 to 3 hrs to flex and stretch her joints and muscles

provider pharmacist registered nurse

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medications affects? (Select all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

Report the observations to the nurse manager on the unit

A nurse has noticed several occasions in the past week on another nurse on the unit seem drowsy and unable to focus on the issue at hand. Today, she found the nurses sleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Alert the ANA B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep

Testicular examination

A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

Ask the client close-ended questions.

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?

Assist a client to get out of bed after a breathing treatment.

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel?

"Have you had small liquid stools?"

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Document the client's refusal of the treatment.

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

"This can help prevent pneumonia."

A nurse is reinforcing preoperative teaching with a client about how to turn, cough and deep breathe? Which of the following statements by the clients indicates an understanding of the teaching?

Place a wheelchair at 45° angle to the bed

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to wheelchair.Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45degree angle to the bed. D. Assume a narrow stance with feet 15 cm (6in) apart.

Discipline

A nurse uses a head-to-toe approach to conduct a physical assessment of a client who undergoes surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline

Ego integrity vs. despair

A nurse working in a community clinic is talking with an older adult client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?

Place a mask on the client to limit the spread of micro-organisms into the surgical wound

When entering a clients room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 feet away from the clients bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound D. Keep a box of facial tissues nearby for the client to use during the dressing change

A client who has just experienced the death of their child

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

Administer an analgesic 30 min before starting the procedure.

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Provide handouts written in the client's primary language.

A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

assault

A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

use warm water when bathing the client.

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Wash hands with soap and water for at least 15 seconds Use a clean paper towel to turn off hand faucets

A nurse is reviewing hand hygiene techniques with a group of AP. which of the following instructions should the nurse include when discussing handwashing? (Select all that apply) A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash hands with soap and water for at least 15 seconds C. Rinse the hands with hot water D. Use a clean paper towel to turn off hand faucets E. Allow the hands to air dry after

A client who is scheduled for elective surgery A client who has chronic hypertension and blood pressure 135/85 mm hemoglobin

A nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply) A. A client who is dehydrated and receiving IV fluids and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm hemoglobin E. A client who has acute appendicitis and is scheduled for an appendectomy

Pericardial friction rub

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration.The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border.Which of the following heart sounds should the nurse document? A. Audible Click B. Murmur C. Third heart sound D. Pericardial friction rub

Count the client's radial and apical pulses simultaneously with another nurse.

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

Autonomy

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

Fever Malaise Increase in pulse and respiratory rate

A nurse educator is reviewing was a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

"Perform muscle relaxation before bedtime."

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

Ensure that the client wears a surgical mask during transportation throughout the facility.

A nurse is contributing to the plan of care for a client who has positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?

A physical therapist who is involved in the client's care

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities?

I will go to the nurses station for assistance

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. I will place the client on his side B. I will go to the nurses station for assistance C. I will administer his medications D. I will prepare to insert an airway

RN

A nurse manager of a medical surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assigned the client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)

"The reduced muscle tone has relaxed the jaw muscles."

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

actual loss

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following

A client who has partial-thickness and full-thickness burns to his face neck and chest

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4 inch laceration to the head C. A client who has partial-thickness and full-thickness burns to his face neck and chest D. A client who has a fractured fibula and tibia

Provide privacy for the client.

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?

Once my infant starts to push up, I will remove the mobile from over the crib.

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. I will set my water heater at 130°F B. Once my baby can sit up he should be safe in the bathtub C. I will place my baby on his stomach to sleep D. Once my infant starts to push up, I will remove the mobile from over the crib.

Place blankets over clients who are confined to bed Move beds away from the windows Instruct ambulatory clients in the hallways to return to the rooms

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply) A. Open doors to client rooms B. Place blankets over clients who are confined to bed C. Move beds away from the windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to the rooms

The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field The procedure is delayed one hour because the provider receives an emergency call The nurse turns to speak to someone who enters through the door behind the nurse

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply) A. The provider drops a sterile instruments onto the near side of the sterile field B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field C. The procedure is delayed one hour because the provider receives an emergency call D. The nurse turns to speak to someone who enters through the door behind the nurse E. The clients hand brushes against the outer edge of the sterile field

I plan to write that I don't want them to keep me on a breathing machine.

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. I'd rather have my brother make decisions for me, but I know it has to be my wife. B. I know they won't go ahead with the surgery unless I prepare these forms. C. I plan to write that I don't want them to keep me on a breathing machine. D. I will get my regular doctor to approve my plan before I hand it in at the hospital.

Explain the roles of other care delivery staff Begin discharge planning Document the clients wishes about organ donation Introduce the client to his roommate

A nurse is admitting a client who has a cholecystitis to a medical surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply) A. Explain the roles of other care delivery staff B. Begin discharge planning C. Inform the client that advanced directives are required for hospital admission D. Document the clients wishes about organ donation E. Introduce the client to his roommate

latex

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

Planning and evaluating control and prevention strategies Determining public health priorities Ensuring proper medical treatment Monitoring for common-source outbreaks

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS), the nurse is aware that healthcare professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks

Make sure that the clients call light is within reach Provide the client with nonskid footwear Complete a fall-risk assessment

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply) A. Place a belt restraint on the client when he is sitting on the bedside commode B. Keep the bed in its lowest position with side rails up C. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment

Ensure that the client has possession of his valuables Confirm that the rehabilitation center has a room available at the time of transfer Give a verbal transfer report via telephone Complete a transfer form for the receiving facility.

A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply) A. Ensure that the client has possession of his valuables B. Confirm that the rehabilitation center has a room available at the time of transfer C. Assess how the client tolerates the transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility.

Complete a fall-risk assessment

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurses priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the clients environment D. Make sure the client uses assistive aids in his possession

Providing client information to another nurse at change of shift

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

knowledge

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electric database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence

Attach a humidifier to the base of the flow meter.

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety?

Clean the perineal area at least once a day.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

The client is non-adherent with coughing, deep breathing, and dangling The client may have pain medication every 4 to 6 hrs but accepts it every 6 to 7 hrs. The clients vital signs are heart rate 124/min, respiratory rate 22/min, temperature 37°C (98°F), and blood pressure 156/80 mm Hg

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the clients acute pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply) A. The client seems easily agitated B. The client is non-adherent with coughing, deep breathing, and dangling C. The client may have pain medication every 4 to 6 hrs but accepts it every 6 to 7 hrs. D. The client reports tenderness in his right lower leg E. The clients vital signs are heart rate 124/min, respiratory rate 22/min, temperature 37°C (98°F), and blood pressure 156/80 mm Hg

Make sure the surgeon obtained the clients consent Witness the client signature on the consent form

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply) A. Make sure the surgeon obtained the clients consent B. Witness the client signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery

Semi-Fowler's

A nurse is caring for a client who is receiving enteral tube feedings due to dysphasia. Which of the following bed position should the nurse cues for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg

Measure the client's gastric residual before each feeding

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

"It must be difficult facing this type of surgery."

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

Determine the clients ability to help with the transfer

A nurse is caring for a client who is sitting in a chair and asked to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed B. Call for additional staff to assist with the transfer C. Use a transfer belt and assist the client back into bed D. Determine the clients ability to help with the transfer

Herpes zoster

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster

Client states, "I started to itch after taking that medication."

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

False imprisonment

A nurse is caring for a competent adult client who tells the nurse that he's thinking about leaving the hospital against medical advice. The nurse believes that this is not in the clients best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

basic

A nurse is caring for a patient who is 24 hrpostoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a deal for "real food. " The nurse told the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. the nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity

headache

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

the client has tenderness and warmth in their calf.

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?

A purple-colored stoma

A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider?

Sit on the side of her bed and rest her arms over pillows on top of her bedside table

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow B. Lie flat on her stomach with her head to one side C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her

Wear a mask when providing care within 3 ft of client Place a surgical mask on the client if transportation to another department is unavoidable Wear a gown when performing care that might result in contamination from secretions

A nurse is contributing to the plan of care for a client who has been admitted to the facility with a suspected diagnosis of pertussis. Which of the following intervention should the nurse include in the plan of care? (Select all that apply) A. Place client in a room that has negative air pressure of at least six exchanges per hour B. Wear a mask when providing care within 3 ft of client C. Place a surgical mask on the client if transportation to another department is unavoidable D. You sterile gloves when handling soiled linens E. Wear a gown when performing care that might result in contamination from secretions

Support the client's feet with foot boots.

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan?

The client ambulates with his slippers on over his antiembolic stockings. The client uses a front-wheeled walker when ambulating The client had pain medication 30 minutes ago

A nurse is delegating the ambulation of a client who had knee arthroplasty five days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply) A. The roommate ambulates independently B. The client ambulates with his slippers on over his antiembolic stockings. C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 minutes ago

medication error needle sticks omission of prescription

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply) A. Medication error B. Needle sticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribe laboratory test

I will determine the most important client problems that we should address

A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. I will determine the most important client problems that we should address B. I will review the past medical history on the clients record to get more information C. I will go carry out the new prescriptions from the provider D. I will ask the client if his nausea has resolved

bathing ambulating toileting measuring vital signs

A nurse is equating a group of newly licensed nurses with the roles of the various members of the healthcare team they will encounter on a medical surgical unit. When she gives examples of the types of tasks CNAs may perform which of the following client activities should she include? (Select all that apply) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical surgical unit demonstrate signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.

justice

A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the nurse should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

Perform a bladder scan.

A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?

Right supervision and evaluation Right direction and communication Right circumstances

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances

Follow-up care Instructions for diet and medications Contact information for the home healthcare agency

A nurse is preparing the discharge summary for a client who has had any arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply) A. Advance directive status B. Follow-up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home healthcare agency

3+ pitting edema

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?

Turn off the faucet with a clean paper towel after drying hands.

A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands?

A piston syringe

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use?

Remove the staple from the skin after both sides are visible

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

"Please don't tell my doctor, but I am taking my partner's oxycodone."

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

Nail polish should not be used near a client who is receiving oxygen A "no smoking" sign should be placed on the front door If I or extinguisher should be readily available in the home

A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply) A. Family members who smoke must be at least 10 feet from the client when oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "no smoking" sign should be placed on the front door D. Cotton bedding and clothing should be replaced with items made of wool E. If I or extinguisher should be readily available in the home

Assess the client's gag reflex Position the client on their side with their head turned to the side Place a towel under the client's head with an emesis basin under their chin Separate the client's upper and lower teeth with an oral airway device Cleanse the client's mouth using a toothbrush

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

"I know that I can change my advance directives if I need to in the future."

A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?

Ask the client what they already know about meal planning

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?

"We will keep her room cool to help her breathe better."

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching?

"You should cleanse your eye from the inner to the outer edge prior to putting in the drops."

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

"I should remove constrictive clothing prior to measuring my blood pressure."

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

"Tighten your stomach muscles."

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

The inner wrapping of an item on the sterile field An irrigation syringe on the sterile field One gloved hand with the other gloved hand

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

Move clients who are nearby

A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurses priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit

D. Beneficence

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

Reapplying a condom catheter for a client who has urinary incontinence

A nurse on a medical surgical unit has received change of shift report and will care for four clients. Which of the following clients needs should the nurse assigned to an AP? A. Updating the plan of care for a client who is post operative B. Reinforcing teaching with a client who is learning to walk using a quad C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer

Tell the nurses to change the topic of conversation.

A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.)

Screening groups of older adults and nursing care facilities for early influencer manifestations

A community health nurse is preparing a campaign about seasonal influenza.Which of the following plans should the nurse include as a secondary prevention. A. Holding a community clinic to adminster influenza immunizations. B. Screening groups of older adults in nursing care facilites for early influenza manifestations. C. Educating parents of young children about dangers of influenza. D. Finding rehabilitation programs for older adults who have complications from influenza.

Speak with the client about their condition after visitors have left.

A nurse at a long term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

Dorsalis pedis

A nurse is preparing to palpate a client's pulse/ The nurse should recognize that which of the following pulses is located on top of the client's foot?

Let the client know that, as their nurse, they are available and willing to listen.

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

Raise the level of the bed

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep.

Evacuate clients from the area is the first step. Pull the lever on the fire alarm box is second step. Close the fire doors on the unit is the third step. Use a fire extinguisher to put out the fire is the fourth step.

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the

Second intercostal space to the right of the sternum

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis.At which of the following anatomical areas should the nurse place the stethescope to auscultate the aortic valve? A. Fifth intercostal space just medical to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum.

Grasp a skinfold on chest under clavicle, release, and note whether it's springs back.

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days.Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skinfold on chest under clavicle, release, and note whether is springs back. C. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. D. Measure the skin fold thickness at the upper arm using a pair of calbrated skinfold calipers.

I keep having nightmares about my upcoming surgery

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. My parents are retired, and they have come to help out with our children. B. I am going to ask my husband to go to counseling with me. C. I keep having nightmares about my upcoming surgery. D. My girlfriends bought me a nice wig.

Circulation becomes less efficient with age.

A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes?

Assign the client to a negative-pressure airflow room.

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?

Compare the medications the provider has prescribed with the client's medications from home.

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

Clean soiled areas of the body.

A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?

Administer acetaminophen.

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9 degrees C (102 F). Which of the following interventions should the nurse include in the plan of care to treat the fever?

Beneficence

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?

Drain urine from the tubing before ambulation.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent UTIs?

The client's face should be turned toward Mecca.

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

"When I look at myself in the mirror, I don't know if I can go on."

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

Encourage the client to express his thoughts about death and dying

A nurse is caring for a client who has terminal illness.The client asks several questions about the nurse's religion beliefs related to death and dying.Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse. B. Encourage the client to express his thoughts about death and dying. C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain.

Tell me what I can do to help you overcome your fear of giving yourself injections

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin.Which of the following statements should the nurse make? A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I am sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections."

Sit and hold the clients hand

A nurse is caring for a client who is in the terminal stage of cancer.Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask them to stay with the client. B. Offer to call client's minister. C. Sit and hold the client's hand. D. Leave the room and allow the client to cry privately.

Decrease the rate of the feeding.

A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take?

Disconnect the machine, and measure the blood pressure manually every 15 min

A nurse is caring for a client who is unstable and has vital signs measured every 15 min 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? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only blood pressure readings needed for the 15-min intervals. C. Obtain manural and automatic readings and compare them/. D. Disconnect the machine, and measure the blood pressure manually every 15 min.

Clamp the infusion tubing.

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first?

Identify the client using to identifiers

A nurse is caring for a client who requires a chest x-ray.Prior to the client being transported for the procedure, which of the following actions should the nurse take first? A. Explain the x-ray procedure to the client. B. Help the client into a wheelchair before the transporter arrives. C. Ask if the client has any questions. D. Identify the client using two identifiers.

What worries you about being without your teeth?

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse .make? A.It's for your safety. Dentures can slip and block your airway during surgery. B. You wouldn't want your teeth to be lost or broken during surgery, would you? C. The anesthesiologist requires everyone to remove their dentures. D. What worries you about being without your teeth?

An 18-year-old client who has acute appendicitis

A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent?

Positive Chvostek's sign

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?

The client reports urinary incontinence.

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?

Urine output of 200 mL over 8 hr

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

Pad bony prominences on the wrist.

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Compare the client's pedal pulses bilaterally every 4 hr.

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

The client reports severe

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercise. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery.

home health care rehabilitation centers skilled nursing facilities

A nurse is discussing restorative Health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply). A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers

Carefully remove the gloves and follow with hand hygiene

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand.The client has no documented bloodstream infection.Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carfefully remove the gloves and follow with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection.

Count the apical pulse rate for one full minute and describe the written in the chart

A nurse is measuring vital signs for a client and notices an irregularity in the pulse.Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope. B. Check the client's pedal pulses. C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds.

Place feet apart with the foot nearest the head of the client's bed in front of the other foot.

A nurse is moving a client up in bed with the assistance of a second nurse? Which of the following actions should the nurse take?

Temperature

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 (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days.Which of the following findings should be the nurse's priority. A. Heart rate 105/min B. soft, nontender abdomen C. temperature D. overdue menses

Temporal

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? A. Rectal B. Tympanic C. Oral D. Temporal

Attempt to increase the clients self motivation

A nurse is planning weight loss strategies for a group of clients who are obese.Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? A. Attempt to increase the client's self motivation B. Keep detailed records of each client's progress. C. Test client learning after each teaching session. D. Avoid discussing areas that might cause client anxiety.

Notify the provider about the clients decision

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room, when the client states she no longer wants to have the surgery.Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider about the client's decision.

Check the pH of the gastric aspirate.

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG Tube?

Nonrebreather mask

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?

The involvement of the client in planning the change

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? A. The involvement of the client in planning the change. B. The emphasis the provider places on the dietary changes. C. The learning theory the nurse uses to teach the dietary changes. D. The extent of the dietary changes planned for the client.

Sit on the toilet 30 minutes after eating a meal

A nurse is providing teaching to an older adult client who has constipation.Which of the following statements should the nurse include in the teaching. A. "Drink a min. of 1,000 mL of fluid daily." B. "Increase your intake of refined-fiber foods" C. "Sit on the toilet 30 min after eating a meal. D. "Take a laxative every day to maintain regularity."

A stage 3 pressure injury on the coccyx

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention?

lock the wheels on the bed and stretcher

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse make to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5cm (1in) above the height of the bed. D. Log roll the client.

Precontemplation

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change?

flashing smoke alarm

A nurse is reinforcing teaching with a client who has partial hearing loss about how to modify the home environment. Which of following is a priority modification that the nurse should include?

Internally rotate the client's hips by using a trochanter roll.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury?

A client who has a pulse rate of 110/min

A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse?

"I see that you are angry. Let's sit down and talk."

A nurse is speaking with a client who has type 2 DM and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

Shred the paper in a secure container.

A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper?

I should expect my heart rate to take longer to return to normal after exercise as I get older

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? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older."

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

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? A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands I will dry them from the elbows down."

Attend an exercise program.

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?

Using a cuff that is too small will result in an inaccurately high rating

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. As long as the cuff will circle the arm the reading will be accurate. D. "Using a cuff that is too small will result in an inaccurately high reading."

The nurse washes her hands held higher than her elbow

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? A. The nurse washes each part of her hands with 5 strokes. B. The nurse washes from the elbows down to the hands. C. the nurse washes with her hands held higher than her elbows. D. The nurse uses minimal friction when washing her hands.