exam 3
41. A nurse is caring for a toddler who has otitis media and a temperature of 39.1 ℃ (102.4 ℉ ). Which of the following actions should the nurse take first? a. Reduce the temperature of the child's room b. Redress the child in minimal clothing c. Apply cool compresses to the child's forehead d. Administer an antipyretic to the chil
Administer an antipyretic to the chil
A nurse is reviewing a client's laboratory values. Which of the following information is correct regarding albumin levels and nutritional status? a. Albumin level is a poor short-term indicator of protein status b. Hydration status does not affect a client's albumin level c. An albumin level of 3.2 g/dL is within the expected reference range d. Albumin level is calculated by keeping a 24-hr record of protein intake
Albumin level is a poor short-term indicator of protein status
A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which of the following foods? a. Beef liver b. Oranges c. Turnips d. Whole milk
BEEF LIVER
A nurse is providing discharge instructions for a client who had a cesarean birth 4 days ago. The client's hemoglobin level is 9.2 g/dL, and the provider has prescribed an iron supplement. Which of the following foods should the nurse recommend to help increase the client's iron intake? a. Spinach b. Citrus fruit c. Milke d. Whole-grain bread
CITRUS FRUIT
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding? a. Vanilla pudding b. Apple juice c. Diet ginger ale d. Clear liquids
CLEAR LIQUIDS
A home health nurse is visiting an older adult client who has anemia. Which of the following foods should the nurse recommend to increase the client's iron intake? a. Greek yogurt b. Bran muffin c. Peanut butter sandwich d. Dried fruitDRIED FRUIT
DRIED FRUIT
While admitting a client to the medical unit, the nurse asks him is he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? a. Informed consent form b. Living will document c. Do-not-resuscitate (DNR) directive d. Durable power of attorney documet
Durable power of attorney documet
A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? a. Diarrhea b. Gastric ulcer c. Dilated pupils d. Dysrhythmias
Dysrhythmias
A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? a. Modular b. Elemental c. Polymeric d. Specialty
ELEMENTAL
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? a. Instruct the client to defecate into a toilet bowl b. Transfer the specimen to a sterile container c. Refrigerate the collected specimen d. Place the stool specimen in a biohazard bag
Place the stool specimen in a biohazard bag
A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? a. Deliver the formula at a slower rate b. Request a lower-fat formula c. Provide more water with feedings d. Instill a lactose-free formula
Provide more water with feedings
A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? a. Vastus lateralis b. Dorsogluteal c. Deltoid d. Abdomen 5 cm (2 in) from the umbilic
Vastus lateralis
Why is medication reconciliation necessary? a. To compare the list with new prescriptions and reconcile it to resolve any discrepancies b. To get an idea of how many illnesses a person has c. To ensure they are administering the medication to the correct patient d. To ensure the administration of the correct dose for new prescriptions
To compare the list with new prescriptions and reconcile it to resolve any discrepancies
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central line. Which of the following actions should the nurse perform? a. Change the tubing every 12 hr b. Check the client's blood glucose every 8 hr c. Apply a new dressing to the IV site every 76 hr d. Weigh the client daily
WEIGH THE CLIENT DAILY
A nurse is providing teaching about a living will for a client who has end-stage breast cancer. Which of the following pieces of information should the nurse include in the teaching? a. The client has the right to change the living will at any time b. The client should be certain of the decision because the document establishes guidelines for refusing resuscitation c. A durable power of attorney is required with a living will d. The handwritten living will is not a legal document and cannot be included in the client's medical record
a. The client has the right to change the living will at any time
A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. Wrist b. Great toe c. Index finger d. Heel
b. Great toe
A nurse is to administer ear drops into the right ear of a 5-year-old child. Which of the following actions by the nurse is appropriate? a. Nurse rubs the area behind the ear after administering the medication b. Nurse has the child lie supine for one-half hr after administering the medication c. Nurse pulls the pinna of the ear up and back d. Nurse warms the medication in the microwav
c. Nurse pulls the pinna of the ear up and back
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? a. "The reading will be inaudible if the cuff is too small for the client" b. "The width of the cuff bladder should be 75% of the circumference of the 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"
d. "Using a cuff that is too small will result in an inaccurately high reading"
A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? a. Tell the client the provider does not want her to remain in bed b. Allow the client to remain in bed until her pain subsides c. Instruct the family to perform ADLs for the client d. Advise the client to perform range-of-motion exercises while in bed
d. Advise the client to perform range-of-motion exercises while in bed
A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? a. Pulse rate 90/min b. Rectal temperature 38℃ (100.4℉) c. Pulse oximetry 95% d. BP 145/90 mmHg
d. BP 145/90 mmHg
A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? a. Raise the enema bag if the client experiences cramping b. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion c. Place the client in a left Sims' position d. Don sterile gloves prior to the procedure
place the client in a left sims position
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature? a. Rectal b. Tympanic c. Oral d. Temporal (forehead)
temporal
A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the high protein content? a. Medium baked potato b. Wheat bagel with 1 tbsp of apricot jam c. Large orange d. ½ cup of peanut butter with apple slices
½ cup of peanut butter with apple slices
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experiencing social isolation. Which of the following interventions should the nurse recommend? a. Encourage the client to go to the dining room at meal times to talk with other clients b. Suggest that the client watch television while feedings are being administered c. Remind the client that they can have visitors after feeding administration times d. Ask the facility chaplain to speak with the client
Encourage the client to go to the dining room at meal times to talk with other clients
Which of the following rights of delegation describes the consideration of the appropriate patient setting, available resources, and other relevant factors? a. Right person b. Right supervision c. Right circumstance d. Right communication
RIGHT CIRCUMSTANCE
The nurse delegates the collection of the client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? a. Right task b. Right circumstance c. Right person d. Right communication
RIGHT COMMUNICATION
Which of the following rights of delegation describes the giving of a clear, concise description of a task, including its objective, limits, and expectations? a. Right communication b. Right circumstance c. Right person d. Right task
RIGHT COMMUNICATION
Which of the following rights of delegation describes the delegation of the right tasks to the right person to be performed on the right person? a. Right person b. Right communication c. Right task d. Right supervision
RIGHT PERSON
Which of the following rights of delegation describes the provision of appropriate monitoring, evaluation, interventions as needed, and feedback? a. Right task b. Right supervision c. Right circumstance d. Right person
RIGHT SUPERVISION
Which of the following rights of delegation describes tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have potential minimal risk? a. Right circumstance b. Right task c. Right communication d. Right supervision
RIGHT TASK
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this central venous access device? ( Select all that apply ) a. Use a 5 mL syringe to flush the line b. Cleanse the insertion site with half-strength hydrogen peroxide c. Flush the line with sterile 0.9% sodium chloride before and after medication administration d. Access the PICC for blood sampling e. Perform a heparin flush of the line at least daily when not in use
Flush the line with sterile 0.9% sodium chloride before and after medication administration d. Access the PICC for blood sampling e. Perform a heparin flush of the line at least daily when not in use
A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase her consumption of which of the following foods? a. Lentils b. Avocados c. Cabbage d. Broccoli
LENTILS
A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? a. Administer antipyretics to the child every 4 to 6 hr b. Position the child on a cooling blanket and cover her with a sheet c. Place the child in the tub filled with water cooled to 26.7° to 29.4 ℃ (80° to 85 ℉ ) d. Assess the child's temperature every 2 hr during the cooling proces
Position the child on a cooling blanket and cover her with a sheet
A nurse is assisting a client who has right-sided weakness while ambulating with a cane. Which of the following action should indicate to the nurse that the client understands the procedure of cane walking? a. The client holds the cane on the affected side b. The client advances the unaffected leg followed by the cane c. The client supports his weight on the unaffected leg when moving the cane forward d. The client keeps 2 points of support on the ground
d. The client keeps 2 points of support on the ground
A nurse is reviewing informed consent with a client for a cardiac catheterization. Which of the following is the responsibility of the nurse? a.Explaining the procedure to the client b.Offering alternative treatments c.Informing the client of the consequences of refusing the procedure d.Verifying the client's understanding of the procedure being performed
d.Verifying the client's understanding of the procedure being performed
A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide? a. "Crushing the medication might cause you to have a stomachache or indigestion" b. "Crushing the medication is a good idea, and I can mix it in some ice cream for you" c. "Crushing the medication would release all the medication at once, rather than over time" d. "Crushing it is unsafe, as it destroys the ingredients of the medication
a. "Crushing the medication might cause you to have a stomachache or indigestion"
A nurse is caring for a client who has osteoporosis and a new prescription for calcium supplements. Which of the following foods should the nurse recommend to promote calcium absorption? a. Fortified milk b. Ripe bananas c. Steamed broccoli d. Green leafy vegetable
a. Fortified milk
A nurse is changing a dressing on a client's wound. When the soiled dressings is removed, it is saturated with blood. Which of the following best describes the most appropriate method of disposal? a. Place the dressing in a red biohazard bag b. Throw the dressing in a standard trash bin c. Place the dressing in a bag and then double bag the item d. Wearing gloves, squeeze excess blood into the sink and then place the dressing in a biohazard bag
a. Place the dressing in a red biohazard bag
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? a. Stop the instillation b. Ask the patient to take deep breaths to decrease the pain c. Tell the patient to bear down as he would when having a bowel movement d. Continue the instillation; then administer a pain medication
a. Stop the instillation
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? a. Earlobe b. Skin fold c. Finger d. Toe
a. Earlobe
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
a. Evaluate pedal pulses
A nurse is teaching the guardian of an 18-month-old toddler about otic medication administration. Which of the following statements should the nurse make? a. "Administer the drops immediately after removing the medication from the refrigerator" b. "Place the child in a seated position with the head tilted to the side for administration" c. "Gently pull the ear cartilage down and back when administering the medication" d. "Position the medication bottle so the drops do not touch the side of the ear canal
"Gently pull the ear cartilage down and back when administering the medication"
46. A charge nurse received notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? ( Select all that apply ) a. Assign the client to a private room with negative-pressure airflow b. Add contact precautions to the client's plan of care c. Wear an N95 respirator when entering the client's room d. Ensure the client's environment provides 4 exchanges of fresh air per minute e. Institute protective environment precautions as soon as the client arrives at the unit
Assign the client to a private room with negative-pressure airflow Wear an N95 respirator when entering the client's room
A nurse is caring for a client who is receiving TPN, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? a. Administer 20% dextrose in water IV until the next bag is available b. Slow the infusion rate of the current bag until the solution is available c. Monitor for hyperglycemia d. Monitor for hyperosmolar diuresis
COLLARD GREENS
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings? a. Hypertension b. Excessive thirst c. Fever d. Diaphoresis
Diaphoresis
A nurse will administer several medications to a patient who is receiving enteral feeding through a small bore nasogastric tube. The nurse administers the medication correctly by: a. Adding crushed medications to the enteral tube feedings and infusing via an electronic pump b. Infusing each medication by gravity and flushing with water before and after instillation c. Administering medication through a large bulb syringe d. Lowering the syringe to promote instillation of medication
Infusing each medication by gravity and flushing with water before and after instillation
A nurse is preparing to administer meperidine to a client who is postoperative and reports a pain level of 8 on a scale of 0 to 10. Which of the following routes of administration will deliver the medication with the shortest time of onset? a. Oral b. Intravenous c. Intramuscular d. Subcutaneous
Intravenous
A nurse is caring for a client who has a temperature of 38.7 ℃ (101.7 ℉ ). Which of the following actions should the nurse take? a. Apply an alcohol-water solution to the client's skin b. Keep the client's bed linens dry c. Apply ice packs to the groin d. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day
Keep the client's bed linens dry
A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? a. Simple face mask b. Nonrebreather mask c. Bag-valve-mask device d. Nasal cannula
NASAL CANNULA
A nurse is reviewing the laboratory findings of an older adult client. The nurse should identify which of the following findings as an indication of malnutrition? a. RBC count 5 million/mm3 b. Hemoglobin 15 g/dL c. Prealbumin 10 mg/dL d. WBC count 7,000/mm3
Prealbumin 10 mg/dL
49. A nurse is providing teaching to a client who has psoriasis and a new prescription for the topicalcorticosteroid cream betamethasone valerate. Which of the following information should the nurse include in the teaching? a. The medication should be applied in a thick layer to completely cover the lesions b. The medication should be applied every 2 hr c. Rubbing the medication vigorously into the lesions will increase its absorption d. Wrapping plastic around the site can increase the medication's effectiveness
Wrapping plastic around the site can increase the medication's effectiveness
A nurse is caring for a client who has a new prescription for levothyroidism. Which of the following findings should the nurse identify as an indication that the client requires intervention? a. Heart rate 106/min b. Dry skin c. Oral temperature 36.8℃ (98.2℉) d. Lethargy (lack of energy enthusiasm)
a. Heart rate 106/min
Which instructions do you include when educating a person with chronic constipation? (Select all that apply) a. Increase fiber and fluids in the diet b. Use a low-volume enema daily c. Avoid gluten in the diet d. Take laxatives twice a day e. Exercise for 30 minutes every day f. Schedule time to use the toilet at the same time every day g. Take probiotics 5 times a week
a. Increase fiber and fluids in the diet e. Exercise for 30 minutes every day f. Schedule time to use the toilet at the same time every day
A nurse is admitting a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority? a. Initiate airborne precautions b. Administer antimicrobial therapy c. Tell the client that the infection will be communicable for 2-3 weeks from the start of medication therapy d. Teach the client about the manifestations of tuberculosis
a. Initiate airborne precautions
A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? a. The client holds the cane on the unaffected side b. The client walks by stepping with the unaffected leg before the affected leg c. The client holds the cane directly next to the foot d. The client holds the cane with a straight elbow
a. The client holds the cane on the unaffected side
A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patient's health history or admission assessment: (Select all that apply) a. The patient is an elderly woman b. The patient reports rare laxative use c. The patient takes opioids for chronic back pain d. The patient eats who grains, raw fruits, and green leafy vegetables e. The patient takes daily iron and calcium supplements f. The patient reports daily exercise and remains active
a. The patient is an elderly woman c. The patient takes opioids for chronic back pain e. The patient takes daily iron and calcium supplements
A nurse is providing teaching to a parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? a. Withhold the medication if the infant's heart rate is less than 110/min b. Mix the medication in 120 mL (4 oz) of infant formula c. Expect the infant to vomit frequently while taking this medication d. Double the dose if the infant has increased edema
a. Withhold the medication if the infant's heart rate is less than 110/min
Pre-operative assessment is necessary to:
a.Ensure that the patient is fit to undergo surgery b. To highlight issues that the surgical/anesthetic team need to be aware of during the peri-operative period c. To ensure the patient's safety during their journey To obtain baseline data
A nurse is delegating tasks to an assistive personnel (AP) for the care of a group of clients. Which of the following directions should the nurse provide? a. "Take the temperature of the client in room 200" b. "Transport the client in room 203 to the radiology department at 1000" c. "Obtain the vital signs of the client in room 205 when he returns from surgery" d. "Contact the provider of the client in room 208 regarding her decreased hemoglobin level
b. "Transport the client in room 203 to the radiology department at 1000"
A nurse is preparing to administer meperidine 100 mg IM to a client who has a BMI of 23. Which of the following needle lengths should the nurse use to administer the medication? a. ½ inch b. 1 ½ inch c. 2 ½ inch d. 3 inch
b. 1 ½ inch
73. A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? a. Discard the dressing in the bedside trash receptacle b. Dispose of the dressing in a biohazardous waste container c. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle d. Double-bag the dressing in clear bags and label it "biohazardous
b. Dispose of the dressing in a biohazardous waste container
which of the following dietary modifications should an adolescent who participates in sports implement? a. Increase fats to 30% to 40% of daily kilocalories b. Drink water before and after sports activities c. Keep protein intake at the same level d. Decrease carbohydrates to 30% to 40% of daily kilocalorie
b. Drink water before and after sports activities
A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? a. Warm the feeding in a microwave oven b. Elevate the head of the client's bed c. Flush the tube with 0.9% sodium chloride for irrigation d. Verify that the client's gastric pH is above 4
b. Elevate the head of the client's bed
A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take? a. Administer pancrelipase to the child prior to each meal b. Supplement the child's feedings with enteral feedings c. Provide the child with a low-protein meal d. Perform dressing changes 10 min prior to the child's meals
b. Supplement the child's feedings with enteral feedings
A nurse in a long-term care facility is teaching an older adult client about ambulating with a quad-cane. Which of the following statements should the nurse include in the teaching? a. "Adjust the height of the cane so you can flex your flex at 45 degrees" b. "Hold the cane in the hand on the stronger side of your body" c. "Place the flat side of the cane away from your foot" d. "Move the cane and your stronger leg at the same time"
b. "Hold the cane in the hand on the stronger side of your body"
A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include? a. "When you go up a flight of stairs, place your right foot on the first step" (up with the good, down with the bad) b. "Keep the rubber crutch tips securely in place" c. "When standing, keep the crutches 12 inches in front of you and 12 inches to the side" (6 inches in front & 6 inches to side) d. "Place your weight on the crutch pads at your armpits" (arms bear weight of body; not armpits)
b. "Keep the rubber crutch tips securely in place"
A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure? a. 142/85 mmHg b. 116/70 mmHg c. 130/76 mmHg d. 124/82 mmHg
b. 116/70 mmHg
A nurse is caring for a group of clients who has mobility issues. Which of the following clients is at the greatest risk for a complication? a. A 3-year-old client who has a burned foot b. An 80-year-old client who has a fractured hip c. A 30-year-old client who has a cast applied for a fractured ankle d. A 42-year-old client who has an indwelling urinary catheter
b. An 80-year-old client who has a fractured hip
A nurse is assessing the vital signs of a 3-month-old infant. Which of the following actions should the nurse perform regarding the infant's heart rate? a. Assess the radial pulse for 1 full minute while the infant is sleeping b. Assess the apical pulse for 1 full minute while the infant is sleeping c. Assess the radial pulse for 1 full minute while the infant is awake d. Assess the apical pulse for 1 full minute while the infant is awake
b. Assess the apical pulse for 1 full minute while the infant is sleeping
A nurse is caring for a client who has a fractured hip and was placed on Buck's traction (type of skin traction used to immobilize and maintain alignment of the lower extremities) 4 hr ago. Which of the following actions should the nurse take? a. Inspect the client's skin underneath the boot every 12 hr b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr c. Remove the weights from the traction while repositioning the client in bed d. Loosen the ropes if the client reports muscle spasms in the affected extremit
b. Encourage the client to perform dorsiflexion of the affected extremity every 2 hr
A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? a. Document the finding b. Measure the client's apical pulse rate c. Talk with the client about factors that can affect the pulse rate d. Notify the provider about the client's radial pulse rate
b. Measure the client's apical pulse rate
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. This client is experiencing which of the following complications? a. Pneumonia (fever, chest pain, Fatigue. sweating and shaking chills. b. Pulmonary embolus (shortness of breath, chest pain, and cough.) c. Tension pneumothorax (Severe shortness of breath. Shallow breathing.) d. Tuberculosis (weakness, weight loss, fever, and night sweats
b. Pulmonary embolus
A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? a. Oral temperature 37.8℃ (100℉) b. Respirations 30/min c. BP 148/88 mmHg d. Radial pulse rate 45 beats/30 seconds
b. Respirations 30/min
A nurse is providing teaching to a client about a surgical procedure for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following action should the nurse take? a. Continue the teaching, but check afterward with the surgeon about informed consent b. Stop the teaching and check with the surgeon about informed consent c. Stop the teaching and ask the client to sign an informed consent form d. Continue the teaching and check the client's medical record afterward for a signed consent form
b. Stop the teaching and check with the surgeon about informed consent
5. A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? a. Family member b. Surgeon c. Nurse d. Nurse manager
b. Surgeon
A nurse is teaching an older adult client who had a total hip arthroplasty about ambulating with a standard walker. Which of the following actions by the client indicates an understanding of the teaching? a. The client adjusts the height of the walker so the hand grips are at the level of his waist b. The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker c. The client uses the walker to pull himself from a sitting to a standing position d. The client uses the walker to climb the stairs
b. The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker
While your patient is ambulating with crutches he moves both crutches forward along with the injured leg and then moves the non-injured leg forward. When documenting, you will note that the patient used what type of gait while ambulating with crutches? a. Two-point gait b. Three-point gait c. Four-point gait d. Swing-to-gai
b. Three-point gait
A nurse is teaching a client who has a new prescription for enteric-coated aspirin as stroke prophylaxis. The client asks the nurse why the provider prescribed an enteric-coated medication. Which of the following responses should the nurse give? a. "The enteric coating allows a lower dosage to be given" b. "Enteric-coated medications have better absorption in the body" c. "Enteric-coated medications cause less gastric irritation" d. "The enteric coating provides a steady release of the medication over time
c. "Enteric-coated medications cause less gastric irritation"
A nurse is preparing to administer the first injection of diphtheria, tetanus, and pertussis (DTaP) to an infant. Which of the following pieces of information should the nurse tell the guardian prior to administering the immunization? a. "Your child might develop diarrhea or vomiting within 24 hours of receiving this vaccine" b. "I can either give your child all of the injections in this series at once or individually" c. "The vaccine will be injected into the infant's thigh" d. "This injection contains a live viru
c. "The vaccine will be injected into the infant's thigh"
A nurse is teaching a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs nasogastric tube intubation for gastric decompression? a. A 6-year-old child who ingested a toxic substance b. A 60-year-old client who has a gastrointestinal hemorrhage c. A 40-year-old client who has a postoperative bowel obstruction d. A 20-year-old client who has malabsorption syndrome
c. A 40-year-old client who has a postoperative bowel obstruction
A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? a. A client who has a paralytic ileus b. A client who has recently experienced facial trauma c. A client who has dysphagia d. A client who has a decreased appetite
c. A client who has dysphagia
A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions should the nurse take? a. Assist the client into a semi-sitting position b. Have the client lean slightly backward c. Advise the client to tuck his chin downward d. Instruct the client to tilt his head slightly backward
c. Advise the client to tuck his chin downward
A client is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse implement when the next scheduled TPN solution is temporarily unavailable? a. Monitor the client for symptoms of shakiness and confusion b. Encourage the client to increase oral intake of fluids to 4 oz every hour c. Infuse dextrose 10% in water (D10W) until the TPN solution is available d. Increase the rate of infusion when the next TPN solution becomes availablE
c. Infuse dextrose 10% in water (D10W) until the TPN solution is available
48. A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? ( Select all that apply ) a. Verifying tube placement after medications are given b. Mixing all medications together to give all at once c. Using an enteral tube syringe to administer medications d. Flushing tube with 30 to 60 mL of water after the last dose of medication e. Checking for gastric residual before giving the medications f. Keeping the head of the be elevated 30 to 60 minutes after the medications are given
c. Using an enteral tube syringe to administer medications d. Flushing tube with 30 to 60 mL of water after the last dose of medication e. Checking for gastric residual before giving the medications f. Keeping the head of the be elevated 30 to 60 minutes after the medications are given
A nurse is assessing the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform? a. Use a cuff to auscultate blood pressure b. Determine heart rate by taking the radial pulse c. Count respirations before taking other vital signs d. Measure temperature by placing the thermometer in the infant's ear
c. Count respirations before taking other vital signs
A nurse is measuring a client's vital signs 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 for 1 full min and describe the rhythm in the chart d. Take the pulse at each peripheral site and count the rate for 30 sec
c. Count the apical pulse for 1 full min and describe the rhythm in the chart
A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? a. Pull the infant's pinna up and back when examining the ears b. Palpate and count the infant's radial pulse for 15 seconds c. Examine the infant's throat at the end of the examination d. Check the infant's blood pressure in both arms
c. Examine the infant's throat at the end of the examination
A nurse is preparing to administer digoxin (used to treat heart failure) to a client. Which of the following findings should the nurse identify as a contraindication to the client receiving this medication? a. Blood pressure 180/70 mmHg b. Oxygen saturation rate 94% c. Heart rate 51/min d. Respiratory rate 21/min
c. Heart rate 51/min
The nurse records the following subjective data in the client's medical record: a. Breath sounds clear to auscultation b. Amber urine in sufficient quantities c. Pain intensity 8 out of 10 d. Skin warm and dry
c. Pain intensity 8 out of 10
You're observing your patient using crutches. She is using the three-point gait. Which finding requires you to re-educate the patient on how to use the crutches? a. There is a 1.5-inch gap between the axillae and crutch rest pad during ambulation with the crutches b. The patient starts in the tripod position before ambulating with the crutches c. The patient leans on the crutch rest pads during ambulation d. The patient does not let the injured leg touch the ground while ambulating with the crutches
c. The patient leans on the crutch rest pads during ambulation
A nurse in the emergency department is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as digoxin toxicity (overdose)? Toxicity causes anorexia,nausea,vomitting a. Irritability b. Diaphoresis c. Vomiting d. Tachycardia
c. Vomiting
nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? a. Administer vitamin K subcutaneously b. Administer erythromycin eye ointment within 12 hours c. Administer erythromycin eye ointment from the outer canthus toward the inner canthus d. Administer vitamin K in the newborn's thigh
d. Administer vitamin K in the newborn's thigh
A nurse is completing medication reconciliation for an older adult client who is receiving multiple medications. Which of the following actions should the nurse perform first? a. Clarify the client's list of medications with the pharmacist b. Compare the current list against the new medication prescriptions c. Investigate any discrepancies on the list d. Ask the client about any over-the-counter medications she is taking
d. Ask the client about any over-the-counter medications she is taking
A nurse is working with an assistive personnel (AP) in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks? a. Whether the AP has consented to the performance of delegated tasks b. The client's willingness to consent to care from the AP c. Whether the task can be more efficiently completed by the nurse d. The degree of supervision that the AP will require to complete the tasK
d. The degree of supervision that the AP will require to complete the tasK
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? a. "Have you eaten more high-fiber foods lately?" b. "Have you taken antibiotics recently?" c. "Do you have gluten intolerance?" d. "Have you experienced frequent, small liquid stools recently?"
d. "Have you experienced frequent, small liquid stools recently?"
A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygen? a. Restlessness b. Retractions c. Dependent edema d. Clubbing of the fingers
d. Clubbing of the fingers
A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe use of the equipment? a. The client places a crutch on each side when assuming a sitting position (together in one hand & use other hand to grasp chair) b. The client moves the unaffected leg onto the step first when descending stairs (up with the good, down with the bad) c. The client places weight on the axillae when walking (arms bear weight of body; not armpits) d. The client has slightly flexed elbows when ambulating with the crutches
d. The client has slightly flexed elbows when ambulating with the crutches
A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? a. Gloves b. Gown c. Eyewear d. Mask
gown
A nurse is assessing a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? a. IV b. I c. III d. II
ii
Which of the following strategies for enhancing the intake of healthy foods is appropriate for an adolescent? a. Encouraging the adolescent to consume snack foods from the grains food group b. Permitting the adolescent to skip breakfast to enhance appetite at later meals c. Making healthful food choices more convenient and available for the adolescent d. Allowing the adolescent complete autonomy in making food choice
scurvy
