Final Exam Review #2

The provider orders furosemide 20 mg IV STAT. Available is furosemide 40 mg/mL. How many mL will the nurse administer?

0.5 mL

A client with a bacterial infection is prescribed amoxicillin 500 mg every 8 hours. The available medication is in liquid form, with a concentration of 250 mg/5 mL. How many milliliters should the nurse administer for each dose?

10 mL

The nurse is preparing to administer two types of eye drop medications to a client. The nurse instills the first eye medication at 1315. What time should the nurse administer the second eye medication?

1320

The nurse is caring for a client that is being prepped for a CT (computed tomography) scan with contrast media. What assessment should the nurse perform on the client prior to the examination?

Assess allergy to iodine.

The nurse is assisting with collecting data from a client. The client states, "I hurt all over." How will the nurse document this form of data?

Subjective.

A nurse is caring for a client that has an order for strict intake and output. The client has soiled linen from incontinence. How will the nurse obtain this client's output?

Subtract the weight of the soiled linen from the weight of a similar dry item.

A nurse is collecting data on a client who has a wound that is healing by first intention. Which finding should the nurse expect?

Surgical incision closed with staples.

The LPN is delegated a task by the RN and is not sure it is within the scope of practice to perform. Which document will the LPN access to make this determination?

State Nurse Practice Act.

A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops a fever, chills, and headache. Which action should the nurse take first?

Stop the infusion.

The nurse is caring for a client following a bronchoscopy and the client has maintained NPO for two hours. Which assessment will indicate to the nurse that this client's risk for aspiration has decreased?

The client's gag reflex has returned.

When the nurse instructs a nursing assistant to place a client in a low fowler position, which description indicates the nursing assistant has performed the task correctly?

The client's head and torso are elevated to 30 degrees.

A nurse is reinforcing education to a family member who's loved one is currently in rehabilitation and will be transitioning to hospice care. Which will the nurse explain about the focus of change in care from rehabilitation to hospice care?

The focus of care will change to maintaining comfort as death approaches.

A newly licensed nurse is preparing a medication from an ampule. Which action would require the charge nurse to intervene?

The newly licensed nurse leaves the filtered needle on for injection.

Once a nurse empties the drainage from a Jackson-Pratt drainage device. What nursing action is crucial to restore negative pressure?

The nurse should compress the bulb before closing the vent.

A nurse is preparing a client for an MRI (Magnetic Resonance Imaging) procedure. Which action should the nurse take to ensure the client's safety during the MRI?

The nurse should ensure that the client removes all metal objects.

A nurse is preparing to lift a heavy object. Which action made by the nurse indicates an understanding of body mechanics?

The nurse stands close to the object being moved.

A nurse is discussing potential barriers to the nurse-client relationship with a newly licensed nurse. Which barrier should the nurse include?

The nurse went on break without delegating the client's care.

A newly licensed nurse is precepting in the operating room. The charge nurse should explain the preoperative period is best described by which statement?

The period leading up to the surgical procedure, encompassing assessment, education, and preparation.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which purpose?

To confirm the placement of the NG tube.

The nurse recognizes that making rounds on the client, changing their position, providing skin care, and offering fluids are part of a nurse's responsibility. Which is the reason for these interventions?

To provide safety and prevention.

The nurse is caring for a client that is experiencing a sickle cell crisis and the provider has ordered patient-controlled analgesia. The nurse is setting the infusion pump. The nurse should know the provider ordered a loading dose for which reason?

To reduce the severity of the pain.

A nurse is providing education for a client that will be receiving bolus tube feedings. The client is curious about potential complications and side effects. Which explanation should the nurse provide on what causes dumping syndrome?

Too rapid infusion of highly concentrated feedings.

A nurse is providing an intervention for a client who has a superficial wound with no exudate. Which dressing should the nurse recommend to cover the wound?

Transparent dressing.

The nurse is caring for a client that has severe dysphagia. The client has excessive oral secretions in the mouth. Which device should the nurse use to perform oral suctioning?

Yankauer

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?

joint flexibility

A nurse is reinforcing education to a client on when to perform a self-breast exam as part of her breast health routine. Which statement made by the client indicates an understanding of the teaching?

"I should examine myself about a week after my menstrual cycle."

A nurse is assisting with evaluating teaching with a client who reports insomnia. Which statement made by the client indicates an understanding of the teaching?

"I should keep a consistent sleep schedule, going to bed and waking up at the same time every day."

A nurse creates a discharge education plan for a client diagnosed with narcolepsy. Which statement made by the client indicates an understanding of the teaching?

"I should not drive a motor vehicle."

The nurse is caring for a client that has been experiencing lower back pain. Which statement made by the client would indicate this pain is chronic?

"I've been experiencing this pain for about 8 months now."

The nurse is reinforcing education to a client that has been placed on contact precautions. Which statement made by the client indicates further teaching is needed?

"My family can come visit me as long as they wear their mask."

A nurse is reinforcing teaching on coughing and deep breathing with a client who is scheduled for abdominal surgery. Which statement should the nurse make?

"Splint your incision with a pillow when coughing."

The nurse is reinforcing education to a client's wife with a cuffed tracheostomy that is inflated intermittently. Which statement by the wife indicates teaching was effective?

"The cuff is inflated intermittently to prevent aspiration when eating."

A friend of a client comes to visit in the hospital and asks the nurse about the client's diagnosis. Which statement made by the nurse would be identified as a violation of the Health Insurance Portability and Accountability Act?

"Your friend has diabetes and needs to take better care of themselves."

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. Available is digoxin 0.125 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies.

2

The nurse encourages a client who has been vomiting, to drink fluids because the body fluid lost daily must match the amount of fluid taken in to maintain homeostasis. Which is the recommended daily amount of fluid for an adult?

2500 mL

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which pH level should the nurse identify as an indication of correct placement of the tube?

4.0

A nurse receives an order to administer Hydromorphone 2mg IM STAT. Upon administration, which angle will the nurse administer this medication?

90-degree angle.

A nurse is planning care for a client who has anorexia and has manifestations of malnutrition. When reviewing the client's laboratory values, which test result should the nurse expect to be low?

Albumin

The nurse in preparing to discuss birth control options for a Catholic client. Which is the most appropriate method for the nurse to discuss with the client?

Abstinence

The nurse is sitting in a chair near the client's bed, leaning forward to hear what the client is saying and does not interrupt. Which technique is the nurse demonstrating?

Active listening

A client with chronic lower back pain is considering a CAM intervention called acupuncture therapy. Which statement is accurate regarding acupuncture?

Acupuncture involves the insertion of small needles.

A client in the operating room is exhibiting signs of an overdose on anesthesia, including a respiratory rate of 6 breaths/min. What is the nurse's priority intervention in this situation?

Administering the reversal agent for the specific anesthesia used.

A nurse is explaining unintentional torts to a group of nursing students. Which example should the nurse provide to illustrate an unintentional tort?

Administering the wrong medication due to a medication administration error.

The client demands to be discharged without a health care provider's order and is leaving the unit with their belongings. Which document will the nurse ask the client to sign?

Against medical advice form.

Prior to starting a surgical procedure, a time-out is held. This prevents performing surgery on the wrong client, wrong site, and/or wrong procedure. What team members are involved in the time-out?

All of the procedure team.

A nurse is assisting with teaching a newly licensed nurse about anesthesia. The nurse should include that an epidural is an example of which type of anesthesia?

Spinal

The nurse is providing care for a client involved in a motor vehicle crash and requires collaborative teamwork from different disciplines within the facility. Which will be used to best meet those needs?

An individualized care plan.

A nurse is assisting with teaching a newly licensed nurse about incident reports. The nurse should include that which event would require an incident report?

An intramuscular medication was administered via an oral route.

The nurse is preparing a client for a diagnostic examination. What intervention can the nurse implement to assist with reducing anxiety?

Answer questions for clarification.

While performing a head-to-toe physical assessment, you notice pitting edema in a client's lower extremities. To estimate the severity of the edema, which assessment should be performed?

Applying pressure to the edematous area and assessing the depth and duration of the resulting indentation.

A nurse is caring for a newly admitted client that speaks a different language. Which action should the nurse take?

Arrange for a certified interpreter.

A nurse is caring for a client who was born in Japan but has lived in the U.S for 20 years. The client speaks English and has family members at the bedside. Which action should the nurse take?

Assess for any special cultural beliefs or practices.

A nurse is preparing to administer a soapsuds enema to an adult client. Which action should the nurse take?

Assist the client to the left Sims' position.

During a physical assessment of a client's respiratory system, which assessment technique should the nursing student prioritize for assessing lung sounds?

Auscultation of lung sounds with a stethoscope.

A nurse is assisting with the care of a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which ethical principle should the nurse uphold for the client?

Autonomy

A nurse is preparing to administer intravenous fluids via an infusion pump to a client. Which action should the nurse take to prevent an electrical hazard?

Avoid rolling equipment over extension cords

A client is scheduled to undergo a minor dermatological procedure, and the provider plans to use topical anesthesia. What would be a priority consideration for the nurse to take when using topical anesthesia?

Confirm that the client does not have any allergies to the topical anesthesia agent.

A terminally ill client has recently been informed of their prognosis. The client is expressing a desire to live long enough to attend a special family event in the coming weeks and has begun making promises to be more involved in community service if granted this request. The nurse should recognize this client is experiencing which phase of dying?

Bargaining

A nurse is reinforcing teaching with a client who has a prescription for home oxygen therapy. Which instructions should the nurse include?

Be sure to store oxygen tanks upright.

A client requires a clean catch urine specimen for diagnostic testing. Which action should the nurse instruct the client to take to obtain a clean catch urine specimen?

Begin urinating, stop midstream, and then continue urinating into the collection cup.

The nurse is providing care to a client postoperatively. Which nursing intervention will help prevent venous stasis and other circulatory complications in a client who has had surgery?

Encourage the client to move their legs frequently and do leg exercises.

You are the nurse on a medical-surgical unit and are caring for four client's. Which client should you prioritize for immediate assessment and intervention?

Blood pressure 90/58 mm Hg, heart rate 110 bpm, respiratory rate 24 breaths/min, oxygen saturation 91% on room air.

The nurse is completing a physical assessment and notes the client's heart rate is 56 beats/min. Which will the nurse document the client is experiencing?

Bradycardia

When providing oral care for an unconscious client, which practice is essential for maintaining oral hygiene?

Brushing the client's teeth and gums at least twice daily.

The nurse who is documenting the client's morning assessment, is called to the client's room. What action will the nurse take to ensure the privacy of the client's electronic medical record while being away from the computer?

Log off the computer.

While caring for a client, the healthcare provider has issued an order to discontinue the indwelling foley catheter. As the nurse responsible for this client's care, what is the priority assessment after removing the foley catheter?

Characteristics of next void.

A nurse is preparing to administer an oral antibiotic medication to a client. Which action should the nurse take first?

Check the client's allergies.

A nurse is caring for a client who is postoperative that received general anesthesia. The client has a peripheral IV and is requesting ice chips. Which action should the nurse take first?

Check the client's gag reflex.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. Which action is the nurse's priority?

Check to see if the suction equipment is working.

The nurse is providing care for a Muslim client. Which dietary selection will the nurse serve to this client?

Chicken and rice.

A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. The client refuses to take the medication. Which action should the nurse take?

Discard the opened unit-dose and document the client's refusal.

A nurse is caring for a client who is experiencing fluid volume deficit. Which manifestation should the nurse suspect?

Dark yellow urine.

A nurse is caring for a client who requires contact precautions. Which action should the nurse take?

Dedicate equipment and supplies for use only by this client.

The nurse is inserting a foley catheter on a client that requires strict input and output. During insertion of a foley catheter, the client grimaces as the balloon is inflated. Which action should the nurse take?

Deflate the balloon and advance the catheter into the bladder.

Mr. Johnson has recently been diagnosed with an advanced and aggressive form of cancer that has metastasized extensively. When the oncologist attempts to discuss the prognosis and the potential benefits of palliative care, Mr. Johnson insists that the medical team has made a mistake in the diagnosis. The nurse should identify that Mr. Johnson is in which phase of dying?

Denial

A nurse has received report from a physician's office on a client that is being admitted for hypertensive urgency. The client should arrive to the medical surgical floor within 1 hour and orders will be faxed from the physician's office. Which type of admission should the nurse document this as?

Direct

A nurse is reinforcing teaching with a client who is to self-administer regular insulin and NPH insulin from the same syringe. Which instructions should the nurse provide?

Discard regular insulin if it appears cloudy.

A nurse is reinforcing education on accidental poisoning to a client that has a 2-year-old. Which should the nurse include in the teaching?

Do not refer to medication as candy.

An 80-year-old male client has been admitted to the acute care facility with the diagnosis of pneumonia. The client is receiving oxygen via nasal cannula at 2 L/min. The nurse assesses respirations at 22 breaths/min, PaO2 level is 88 mm Hg, and pink skin tone. Which action will the nurse implement?

Document the PaO2 level.

A nurse is caring for a client with congestive heart failure. During the physical assessment, the nurse notes the client is experiencing difficulty breathing. Which will the nurse document the client is experiencing?

Dyspnea

A 17-year-old female presents to the emergency department seeking treatment for a gynecological issue. She provides documentation of emancipation. The healthcare provider recommends a surgical procedure to address the issue. Which statement regarding the minor's ability to sign informed consent is accurate?

Emancipated minors have the legal right to provide informed consent for their medical treatment, including surgical procedures.

A family is preparing for the impending loss of a loved one due to a terminal illness. The family members are experiencing anticipatory grief. What is a characteristic feature of anticipatory grief?

Emotional reactions and mourning occurring before the actual loss.

A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which statement should be included as a responsibility of the nurse in this process?

Ensure the client has the capacity, able to comprehend, and can voluntarily sign the consent.

A nurse is reinforcing teaching about informed consent with a newly licensed nurse. Which should be included as a responsibility of the nurse in this process?

Ensuring the consent is on the chart prior to the procedure.

Which nursing theory was developed by Florence Nightingale?

Environmental Theory.

A nurse is caring for a 4-year-old client that is experiencing acute pain. Which pain scale will the nurse use to assess this client's pain level?

FACES scale.

A nurse is caring for a client who is desiring their wound care to be provided at 1500. The nurse returns at 1500 to perform wound care for the client. Which ethical principle is the nurse demonstrating?

Fidelity

A nurse is preparing to administer an IV push medication to a client. What is the correct sequence of actions?

Flush with saline, administer the medication, and then flush with saline again.

A nurse is reinforcing education to a client and family members on palliative care as this is an option that is available for this client. How should the nurse explain the primary purpose of palliative care?

Focusing on comfort and quality of life for client's.

The nurse is preparing to insert an NG tube. Which is the correct measurement to insert the tube correctly?

From tip of nose to earlobe to xiphoid process.

A nurse is caring for a client who requires a clear liquid diet. Which food should the nurse allow the client to have?

Grape juice.

A nurse is performing cardiopulmonary resuscitation on a client experiencing a hemorrhagic stroke. What room furnishing would the nurse employ to assist in performing cardiopulmonary resuscitation?

Headboard of the bed.

A nurse is documenting postmortem care for a client. Which information should the nurse include?

Location of the client's belongings.

A nurse is assisting with teaching a newly licensed nurse about massage therapy. The nurse should include that a massage is contraindicated for clients who have which condition?

Impaired skin integrity.

A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection?

Indirect contact

A nurse is collecting data from a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which complication?

Infiltration

A client presents to the emergency department with a blood pressure of 82/48mmHg and is experiencing symptoms of shock resulting from intravascular fluid depletion. What should the nurse prioritize in the initial management of this client's condition?

Initiating IV fluids.

The nurse is preparing to gather data from a newly admitted client. Which primary methods used to collect data will provide the most accurate information?

Interview and physical examination.

A nurse is assisting with teaching a class about routes of medication administration. The nurse should include that which route has the fastest rate of absorption?

Intravenous

A client has expired under circumstances that require a forensic autopsy. The healthcare team is preparing the body for postmortem examination. Considering the need for forensic investigation, what is the appropriate action regarding tubes, dressings, and IVs?

Leave the tubes, dressings, and IVs in place, as their removal may compromise forensic evidence.

A client's blood glucose is 224 mg/dL. The nurse is preparing to administer Humalog 4 units subq per the sliding scale ordered. Which site will the nurse use for injection of the insulin?

Lower abdomen, 2 inches away from umbilicus.

A nurse is preparing to perform a physical assessment on a client and wants to ensure the client's comfort and safety while maintaining their modesty. Which action should the nurse prioritize for achieving these goals?

Maintain appropriate draping to cover and expose only the necessary areas.

The nurse is caring for a preschool child. Which body language presented by the nurse may be perceived as non-threatening to the child?

Maintaining an open posture.

A nurse is assisting with teaching a class about sleep. The nurse should include that which hormone regulates the sleep-wake cycle?

Melatonin

A nurse enters into a client's room and discovers a small fire in the corner of the room. Which action should the nurse take first?

Move the client out of the room.

A nurse is caring for a client who had an above the knee amputation and is experiencing phantom limb pain. The nurse should identify that the client is experiencing which type of pain?

Neuropathic pain.

A nurse is collecting data from a client who has a urine output of 250 mL in a 24-hr period. Which term should the nurse use to document this finding in the electronic record?

Oliguria

The nurse is providing care for a client and identifies the client is very angry. The nurse ask, "Can you tell me about the cause of your anger?" Which therapeutic communication technique is the nurse demonstrating

Open-ended questioning.

The client ask the nurse what is the slowest and safest route to administer medications. Which response by nurse is most accurate?

Oral

A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test (FOBT). What should the nurse instruct the client to avoid for at least 3 days before the test?

Orange juice.

A nurse is assisting with obtaining an ABG. When the nurse performs the Allen test, the palm has continued blanching upon release. What action should the nurse take next?

Perform the Allen test on the opposite hand.

The nurse is assisting a client with completing a bed bath. Suddenly the client states, "I feel like my incision just pulled apart." The nurse assesses the incision and finds the wound has eviscerated. Which action should the nurse take first?

Place a sterile moist gauze over the site.

A nurse is preparing to administer Nitroglycerin 0.4mg sublingual to a client experiencing chest pain. How should the nurse instruct the client to take this medication?

Place the tablet under the tongue.

A nurse is caring for a client who acquired hepatitis A from consuming contaminated food. The client's mouth is an example of which of the following links in the chain of infection?

Portal of entry.

During a physical assessment, you decide to perform a whisper test to assess the client's hearing acuity. Which action represents the correct technique for conducting a whisper test?

Position yourself 2 feet behind the client and whisper a color toward the uncovered ear.

A nurse is caring for a client that is receiving furosemide 20mg IV BID. The client had a basic metabolic panel drawn at the beginning of the shift. Which result would be a priority to report to the physician?

Potassium level of 2.7mEq/L.

A client who is scheduled for surgery is considering options for preoperative blood donation to prepare for potential blood transfusions during the procedure. Which statement accurately compares preoperative blood donation from a direct donor to autologous donation?

Preoperative autologous blood donation is when a client donates blood for their own use, while direct donation involves receiving blood from a family member or friend.

A nurse is collecting data on a client who has a stage 2 pressure injury. Which finding should the nurse expect?

Presence of a shallow open pink wound bed and ruptured blister.

A nurse is caring for a client who is at the end of life. Which action should the nurse take to support the client's dignity?

Provide privacy when providing care.

A nurse is preparing to clean a client's dentures. Which action should the nurse plan to take?

Pull dentures from client's mouth with gloves.

A nurse is reinforcing education to a 20-year old client that has been prescribed bilateral eardrop medication. Which instructions should the nurse include in the teaching?

Pull the ear up and back.

Two nurses are obtaining an apical-radial pulse rate on a client. The apical pulse rate is 70 beats/min, while the radial pulse rate is 62 beats/min. How should the nurse document this finding?

Pulse deficit of 8.

A nurse is performing a neurological assessment on a client and is assessing the pupils for their response to light. Which finding would be considered normal when assessing the pupils?

Pupils constrict briskly when exposed to light.

While providing care for a client diagnosed with pneumonia, their current oxygen saturation level is at 85%. What immediate intervention should the nurse prioritize?

Raise the head of the bed.

A nurse is reinforcing education to a client that has just completed a lumbar puncture. Which intervention should the nurse recommend to decrease severity of a headache?

Recommend that the client lie flat for several hours.

A nurse is collecting data on a client following administration of an opioid narcotic. Which finding indicates a decrease in the client's pain?

Reduced grimacing.

A client is complaining of pain in the left arm, secondary to coronary insufficiency. The nurse should identify this as which type of pain?

Referred pain.

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should document that the client is experiencing which type of urinary incontinence?

Reflex incontinence.

The dying bill of rights emphasizes the importance of providing comprehensive and compassionate care to individuals nearing the end of life. Which statement aligns with the principles of the dying bill of rights?

Respect the client's wishes regarding the level of information they want to receive about their condition.

A nurse is assisting with teaching a newly licensed nurse about end-of- life care. The nurse should include that which service provides support for a client's caregiver?

Respite care.

A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP). The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

Retie the restraint straps with a quick release knot.

The nurse is preparing to call the provider regarding the client. Which is the correct communication model that supports The Joint Commission as a part of safety as the standardize communication method for health care workers?

SBAR

A client presents with an itchy rash that consists of small, raised, red bumps with itching between the web spaces of the fingers. Which skin condition is most likely causing these symptoms?

Scabies

A nurse is preparing to administer an inhaler medication to a client. Which action should the nurse take?

Shake the inhaler prior to administration.

The charge nurse is precepting a new nurse on the floor. What should the charge nurse teach the new nurse regarding when discharge planning begins?

Shortly after admission.

The nurse is performing a fecal occult blood test on a client with a suspected gastrointestinal bleed. Which would be the correct action for the nurse to take?

Take a sample from the center of the stool.

During an admission assessment, the nurse collects objective and subjective data. Which is an example of objective data?

The client is observed to be short of breath with exertion.

A nursing student is preparing to measure a client's blood pressure using a manual sphygmomanometer and stethoscope. Which statement about blood pressure measurement is correct?

The client should be seated with their arm at heart level during blood pressure measurement.

A client presents to the emergency department and is experiencing a gastrointestinal hemorrhage. The physician has ordered 3 units of packed red blood cells STAT. Which blood type should the nurse suspect this client will receive?

Type O.

A 45-year-old client is admitted to the emergency department with severe abdominal pain, vomiting, and distention. On examination, the client presents with rebound tenderness, guarding, and a rigid abdomen. The physician suggests that the client needs surgery today, but no later than tomorrow. Which type of surgery would this be classified as?

Urgent

A nurse is preparing to assist with sharp debridement on a client's wound. Which action is appropriate for the nurse to take for this procedure?

Use a sterile scalpel blade for the procedure.

A nurse is preparing to administer medications to the assigned client. Which action will be followed to prevent medication errors?

Use two methods to identify the client.

A nurse is assisting with reinforcing education on water soluble vitamins. Which vitamin should the nurse include in the teaching?

Vitamin C.

A nurse is reinforcing teaching with a client who has a respiratory infection. The nurse should have the client lie on the left side with a pillow placed under the left hip to help mobilize secretions from which of the lung segments?

​Posterior segment of the right lower lobe.