Fundamentals ATI

A nurse is assessing a client who reports nausea and vomiting for 2 days . Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit ?

Increased heart rate

A nurse in a provider's office is assessing a client who has heart failure . The client has gained weight since her last visit , and her ankles are edematous . Which of the following findings is another clinical manifestation of fluid volume

Bounding pulse

A nurse is reviewing the use of side rails with an assistive personnel ( AP ) . Which of the following statements by the AP indicates that further teaching is required

the client seems confused , I'll raise all 4 side rails so that he doesn't hurt himself

information should the nurse collect during the introductory phase of the interview A nurse is conducting an admission interview with a client Which the following pieces of assessment

the nurse collect during the Client's level of comfort the interview

A nurse is caring for a client who is hospitalized and has a new tracheostomy . Which of the following actions should the nurse take when performing tracheostomy care for the client ?

Soak the inner cannula of the tracheostomy tube in normal saline

A nurse is instructing a client about collecting a 24 - hr urine specimen for creatinine clearance . Which of the following statements should the nurse identify as an indication that the client understands the procedure ?

" I'll make sure to keep the collection bottle in the container of ice they gave me . "

A nurse is caring for a client who is immobile . The nurse should recognize that immobility places the client at risk of which of the following health alterations ?

Decreased cardiac output

A nurse is performing an otoscopic examination of a client's right ear . The light reflex is visible in the right lower quadrant of the tympanic membrane . Which of the following actions should the nurse take in response to this finding ?

Document this as an expected finding

A nurse is performing a comprehensive physical assessment of a client . The nurse should use inspection to assess which of the following ?

Gait

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye . This manifestation is consistent with which of the following eye disorders ?

Glaucoma

A nurse is caring for an adult client who communicates an unmet spiritual need . Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress

God is punishing me for something . "

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding . The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status . Which of the following actions should the nurse take ?

Instruct the guard to ask the inmate

While in the hospital , a client who has a terminal illness tells the people in the world are healthy , and here I am dying ! " Which of the following nurse , " I can't believe I'm dying . Which responses should the nurse provide ?

Tell me more how u feel about dying

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

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

A nurse is applying an ice bag to the ankle of a client following a sports injury . Which of the following actions should the nurse take ?

for 45 Fill the bag 2/3 full with ice

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation ( TENS ) for pain management . The client asks the nurse how a TENS unit helps relieve pain . Which of the following responses should the nurse make ?

modulates the transmission of the pain impulse . "

A nurse in a long - term care facility is admitting a client who is incontinent and smells strongly of urine . His partner , who has been caring for him at home , is embarrassed and apologizes for the smell . Which of the following responses should the nurse make ?

must be difficult to care for someone who is confined to bed . "

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

oven Elevate the head of the client's bed

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis . Which of the following actions should the nurse plan to take ?

should the nurse plan to take Place the client in the Trendelenburg position

A nurse is performing an admission assessment for a client . Which of the following responses by the nurse reflects the communication technique of clarifying ?

sounds like your pain is intermittent

A nurse is measuring the blood pressure of several clients . Which of the following results is within the expected reference range for blood pressure ?

116/70 mmHg

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

" I am going to listen to your abdomen . "

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure . The client states , " You are not putting that hose down my throat . " Which of the following statements should the nurse make ?

" I can see that this is upsetting you . "

A nurse is teaching a client who is using a patient - controlled analgesia ( PCA ) pump to deliver morphine for pain management . Which of the following statements should the nurse identify as an indication that the client understands the instructions ?

" I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button . "

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative . Which of the following clients should the nurse see first ?

. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red , bloody drainage postoperative following

A nurse in a long - term care facility is in the dining room while residents are eating lunch . One resident begins choke and is coughing strongly . Which of the following actions should the nurse take ?

. Observe the client closely

A nurse is inserting an NG tube into a client who begins to cough and gag . Which of the following actions should the nurse take ?

. Pull the NG tube back slightly

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis . Which of the following actions should the nurse take when applying the stockings ?

. Turn the stocking inside out up to the heel before applying

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy . Which of the following muscle groups is responsible for movement at the knee joint

Antagonistic

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

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

A nurse is assessing a client for conductive hearing loss . When using the Rinne test , which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear ?

A. Air conduction is less than bone conduction in the left ear .

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

A. Vitamin C and zinc

A nurse is caring for a group of clients in a long - term care facility . One of the clients is walking along the hallway and bumping into walls and does not respond to his name . Which of the following actions should the nurse take first ?

Accompany the client back to his room

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

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

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy . Which of the following actions by the newly licensed nurse indicates an understanding of the procedure ?

Administering high - flow oxygen prior to the procedure

A nurse is admitting a client who has measles . Which of the following types of transmission precautions should the nurse initiate ?

Airborne

A nurse is caring for a client who has a terminal illness . The client is restless and reports severe pain but refuses the prescribed opioid pain medication . Which of the following actions should the nurse take first ?

Ask why the client is refusing the pain medication

A nurse is supervising a newly licensed nurse who is administering a controlled substance Which of the following actions by the newly licensed nurse indicates an understanding of the procedure ?

Asking another nurse to observe the disposal of an unused portion of the medication

A nurse is assessing a client's vascular system . Which of the following techniques should the nurse use when evaluating the carotid arteries ?

Auscultation of the arteries for bruits with the bell of the stethoscope

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

C. Exert pressure on the bony prominences when holding the eyelids open

A nurse is caring for a client who is receiving total parenteral nutrition ( TPN ) . Which of the following actions should the nurse take ?

Check the client's capillary blood glucose level every 4 hr

nurse is caring for a client who has a stage III pressure ulcer on the heel . When preparing to irrigate the wound , which of the following actions should the nurse take first ?

Check the client's pain level

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

Check the client's perineum

A nurse is collecting a specimen for culture from a client's infected wound . Which of the following actions should the nurse perform ?

Cleanse the wound with 0.9 % sodium chloride irrigation

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older . Which of the following pieces of information should the nurse include in the teaching

Clients who are age 65 or older are reluctant to report pain

A nurse is preparing to insert an NG tube for a client . Which of the following actions will help facilitate the insertion of the tube ? ( Select all that apply

Coat the tip of the tube with a water - soluble lubricant Ask the client to swallow water while the tube enters her throat Tell the client to tilt her head backward as insertion begins

A newly licensed nurse is preparing to administer medications to a client . The nurse notes that the provider has prescribed a medication that is unfamiliar to him . Which of the following actions should the nurse take

Consult the medication reference book available on the unit

During a physical examination of a client , the nurse suspects strabismus . Which of the following tests should the nurse use to collect additional data ?

Corneal light reflex

A nurse is preparing to assess the function of the client's trigeminal nerve ( cranial nerve V ) . Which of the following items should the nurse gather ?

Cotton wisps

A nurse is teaching a client who is postoperative how to use a flow - oriented incentive spirometer . Which of the following instructions should the nurse include ?

Cough deeply after each use

A nurse is assessing a client who has a total calcium level of 12.7 mg / dL . Which of the following findings should the nurse expect

Depressed deep - tendon reflexes

A nurse is caring for client who has terminal pancreatic cancer . When the client states , " It's devastating that I will not be here to see my child graduate , " the nurse should identify that the client is in which of the following stages of grief as defined by Kubler - Ross ?

Depression

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight . Which of the following actions should the nurse take first ?

Determine the client's intention to change current eating habits

A nurse is caring for a client who has a methicillin - resistant Staphylococcus aureus ( MRSA ) infection . A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray . Which of the following instructions should the nurse give to the dietary assistant ?

Don gloves when entering the room and use hand sanitizer when exiting .

A nurse is teaching an assistive personnel ( AP ) how to obtain a capillary finger - stick blood sample . Which of the following actions by the AP requires the nurse to intervene ?

Elevating the finger above heart level

A nurse is admitting a client who has decreased circulation in his left leg . Which of the following actions should the nurse take first ?

Evaluate pedal pulses

A nurse is caring for an older adult client who has an in - the - canal hearing aid . The client states that the hearing aid is making a whistling sound . The nurse should identify which of the following factors as the source for this sound ?

Excessive wax in the ear canal

A nurse is teaching a middle - aged female client about disease prevention and health maintenance Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening ?

Eye examination every 2 years

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

Face the client when speaking

A nurse is assessing a client who is postoperative Which of the following findings should the nurse identify as an indication that the client is experiencing pain ?

Grimacing

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

Halo of erythema on the surrounding skin

A nurse is caring for a client with dehydration who has developed hypovolemic shock . Which of the following laboratory values should the nurse expect for this client ?

Hct 55 %

A nurse in a same - day procedure unit is caring for several clients who are undergoing different types of procedures The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging ( MRI ) ?

Hearing aids

A nurse is performing a breast exainination for a female client . Which of the following techniques should the nurse use first ?

Inspect both breasts simultaneously

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

Hold the breath for 5 sec after goal volume is reached

A nurse is teaching a client about how to remove a soiled dressing . Which of the following statements by the client indicates an understanding of the teaching ?

I'll wear nonsterile gloves .

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 ?

Identify the client using 2 identifiers .

A nurse is teaching a group of young adults . Which of the following should the nurse identify as an expected developmental task for this age group ?

Independent moral development

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 ?

Measure the client's apical pulse rate

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year . The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders ?

Osteoporosis

A nurse is assessing a client's peripheral pulses . Which of the following descriptions should the nurse use to document the findings ?

Peripheral pulses bilaterally symmetric , equal , and strong in all 4 extremities

A nurse is preparing to administer a tap water enema to a client . Which of the following actions should the nurse take ?

Place the client in a left Sims ' position

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision . On assessment , the nurse notes that the client's wound has eviscerated . Which of the following actions should the nurse take ? ( Select all that apply

Place the client in a supine position with the hips and knees flexed Cover the wound and intestine with a sterile , moistened dressing Monitor the client for manifestations of shock

A nurse has received a prescription for dextran to administer to a client . The nurse should recognize that dextran belongs in which of the following functional classifications ?

Plasma volume expanders

A nurse is monitoring a client's laboratory results . Which of the following results should the nurse report to the provider ?

Potassium 3.0 mEq / L

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake . Which of the following actions should the nurse include in the plan of care to promote wound healing ?

Provide a protein intake of 1.5 g / kg of body weight per day

A nurse is caring for a client in a long - term care facility . Which of the following findings should alert the nurse to the possibility that the client has developed delirium ?

Reduced level of consciousness

mEq / L . The nurse should determine that the client has which of the following acid base imbalances ? A nurse is reviewing a client's laboratory report . The client's ABG levels are pH 7.5 , PaCO2 32 mmHg , and HCO3-24

Respiratory alkalosis

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent . The team informs her that someone can come to initiate a new line in 30 min . Which of the following actions should the nurse take ?

Return the blood to the laboratory

A community health nurse is preparing a campaign about seasonal influenza . Which of the following plans should the nurse include as a form of secondary prevention ?

Screening groups of older adults in nursing care facilities for early influenza manifestations

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 stethoscope to auscultate the aortic valve ?

Second intercostal space to the right of the sternum

A nurse is examining a client for signs of costovertebral angle tenderness . The nurse should place the client in which of the following positions for evaluation ?

Sitting

A nurse is caring for a client who has a cuffed endotracheal tube in place . The nurse should identify that the purpose of inflating the cuff includes which of the following ? ( Select all that apply . )

Stabilizing the position of the tube Preventing aspiration of secretions Preventing tracheal injury

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

Start chest compressions

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day . The client states that no one has spoken to her about the procedure before . Which of the following actions should the nurse take ?

Stop the teaching and check with the surgeon about informed consent

A nurse on a medical - surgical unit is caring for a client who is at risk of experiencing seizures . Which of the following pieces of equipment must be available at the client's bedside at all times

Suction equipment

A nurse is caring for a client who has breast cancer . The client has been receiving radiation therapy for several to undergo further treatment . Which of the following actions should the nurse take ?

Support the client's decision

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 ?

Temporal

A nurse is providing nutritional teaching to a group of clients . Which of the following definitions for the recommended dietary allowance ( RDA ) should the nurse include in the teaching ?

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups .

A hospice nurse is visiting with the family member of a client . The family member states that the client has insomnia almost nightly . Which of the following practices should the nurse identify as contributing to the client's insomnia ?

The client watches television in her bed during the day .

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 handwashing technique ?

The nurse holds her hands higher than her elbows while washing .

A nurse is witnessing a client sign an informed consent form for surgery . What is the nurse affirming by this action ?

The signature on the preoperative consent form is the client's .

A nurse is caring for a client who has a prescription for a vest restraint . Which of the following actions should the take ?

Tie the restraint with a quick - release knot .

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

Use a gait belt during ambulation

A nurse is preparing to instill a vaginal medication in suppository form to a client . Which of the following actions should the nurse take during this procedure ?

Use the index finger to insert the suppository

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

Use the pain scale to determine the client's pain level

A client is being discharged home with oxygen therapy delivered through a nasal cannula . Which of the following instructions should the nurse provide to the client and family members ? .

Wear cotton clothing to avoid static electricity .

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

What do you think caused the onset of your pain ? "

when the nurse requests that the client's dentures be removed prior to surgery . Which of the following A nurse is caring for an older adult client who becomes agitated responses should the nurse provide

What worries you about being without your

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet ?

Whole milk

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life . Which of the following pieces of information should the nurse include ?

10 - month - old infant can pull up to a standing position .

A nurse in an urgent - care center is caring for a 15 - year - old client whose symptoms suggest a sexually transmitted infection ( STI ) . The client's parent is unavailable , but the client's grandmother accompanied the client to the clinic . Which of the following actions should the nurse take ?

Ask the adolescent to sign the consent form .

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood . Which of the following actions should the nurse take first ?

Ask the client about first aid performed at the scene

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies . Which of the following actions should the nurse take first ?

Ask the client to identify the specific food allergies

to convey empathy when using the therapeutic communication technique of active listening ? A nurse is beginning a therapeutic relationship with a client . Which of the following actions should the nurse take

Assume an open position

A nurse is caring for a middle - aged adult client . The nurse should evaluate the client for progress toward which of the following developmental tasks ?

Ceasing to compare personal identity with others

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury . The nurse should suspect injury to which of the following areas of the brain ?

Cerebellum

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury The nurse should suspect injury to which of the following areas of the brain ?

Cerebellum

A nurse is implementing cold therapy for a client who has an ankle sprain . Which of the following actions should nurse take ?

Check capillary refill before applying an ice pack to the affected area

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder . Before administering the medication , which of the following actions should the nurse take ?

Check the medication dose and the client's identification

A nurse is caring for a client who requires a peripheral IV insertion When choosing the site which of the following sites should the nurse select

Choose a vein that is soft on palpation

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema . Which of the following is the underlying cause of this finding ?

Chronic hypoxemia

A nurse is preparing to administer a tuberculin skin test to a client . After performing hand hygiene , which of the following actions should the nurse take ?

Circle the injection area with a pen

A nurse is performing a neurological assessment for a client . By asking the client to stick out his tongue , which of the following cranial nerves is the nurse testing ?

Cranial nerve XII

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration . Which of the following statements by the newly licensed nurse indicates an understanding of the teaching ?

D. " I will clip each suture close to the skin and pull it through from the other side . "

A nurse is assessing a client's nutritional status . The nurse determines the client is consuming 500 calories more per day than his energy level requires . If his dietary habits do not change , how long will it take the client to gain 4.5 kg ( 10 lb ) ?

D. 10 weeks

A nurse is caring for a client who requires a dressing change . Which of the following actions should the nurse take ?

D. Clean the drain site from the center outward

A nurse is performing a physical examination for a client . To evaluate the client's skin moisture , the nurse should use which of the following techniques ?

D. Palpation

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment . The should provide care that facilitates which of the following outcomes

D. Supports self - determination .

A nurse is caring for a client who has acute renal failure . Which of the following assessments provides the most accurate measure of the client's fluid status ?

Daily weight

A nurse is planning care for a young adult client who has a terminal illness . Which of the following concepts of death should the nurse consider for this client ?

Death is viewed as an interruption of what might have been .

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

Determine whether the client is able to breathe

A nurse is performing a mental - status examination on a client who has manifestations of dementia . Which of the following directions should the nurse give the client when evaluating the client's ability

Discuss the meaning of a common proverb

A nurse is working with the facility's language interpreter to explain a wound - care procedure to a client who does not speak the same language as the nurse . Which of the following actions should the nurse take when describing the procedure to the client ?

Ensure the interpreter and the client speak same dialect

nurse is admitting a client who will undergo a craniotomy . During the planning phase of the nursing process which of the following actions should the nurse take ?

Establish client outcomes .

A nurse is discussing fire safety with newly hired nurses . Which of the following actions is the priority if a fire occurs in the health care facility

Evacuate clients from the unit

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

Granulation tissue fills the wound during healing

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

Granulation tissue fills the wound during healing .

A nurse is teaching a client about lifestyle changes to manage a chronic illness . Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes ?

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is caring for a client who is receiving a blood transfusion . The client reports flank pain , and the nurse notes reddish - brown urine in the client's urinary catheter bag . The nurse recognizes these manifestations as which of the following types of transfusion reactions

Hemolytic

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media . Which of the following actions should the nurse plan to take ?

Hold the dropper 1 cm ( 0.5 in ) above the ear canal during administration

As a nurse is preparing to administer liquid medication from a bottle to a client . Which of the following actions should the nurse take ?

Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is caring for a client who has gastric ulcer . The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur ?

Hyperglycemial

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty . Which of the following interventions should the nurse plan to take to prevent a complication of immobility ?

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation ( TENS ) for pain management . The client asks the nurse how a TENS unit helps to relieve pain . Which of the following responses should the nurse make ?

It modulates the transmission of the pain impulse . "

A nurse is talking with the parent of a preschool - aged child who tells the nurse , " My child has suddenly become disinterested certain foods . " Which of the following statements should the nurse make ?

Keep a diary of the foods your child eats each day . "

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination . Which of the following rationales should the nurse identify for using this technique ?

Keeping microorganisms from entering the wound

A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600 / mm ^ 3 . The nurse should identify result as which of the following conditions ?

Leukopenia

A nurse is employing a thorough , systematic method while obtaining objective data about a client . Through which of the following methods should the nurse collect this information ?

Physical examination

A nurse is leading an education session about disposing of biohazardous materials . Which of the following instructions should the nurse include in the teaching

Place soiled linen in a single linen bag .

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

Place the stool specimen collection container in a biohazard bag

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair . Which of the following techniques should the nurse use ?

Place the wheelchair at a 45 - degree angle to the bed

A nurse is preparing to insert an NG tube for a client who requires enteral feedings . Which of the following instructions should the nurse give the client before beginning the procedure ?

Raise your index finger if you need to pause during the insertion . "

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client . Which of the following actions should the nurse plan to take ?

Record the amount of medication wasted on the controlled substance inventory record

A nurse is caring for a client who has chronic kidney disease . The kidneys regulate body fluids as well as assisting with which of the following functions ?

Regulation of acid - base balance

prescribes soft wrist restraints . Which of the following actions should the nurse take while the client is in restraints ? A nurse is caring for an older adult client who is violent and attempting to disconnect her lines The provider

Remove the restraints one at a time .

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

Remove the sleeve of the gown from the arm without the IV line

A nurse in the emergency department is caring for a client who has abdominal trauma . Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock ?

Tachycardia

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

Taut skin around the IV catheter site that is cool to the touch

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 usage of this equipment ?

The client has slightly flexed elbows when ambulating with the crutches

A nurse is caring for a semiconscious client who had a small - bore NG tube placed yesterday for the administration of enteral feeding . Which of the following methods should the nurse use to verify correct tube placement ? ( Select all that apply . )

Verify the initial X - ray examination Measure the length of the exposed tube Determine the pH of aspirated fluid

A nurse is preparing to irrigate a client's wound . Which of the following actions should the nurse take ?

Warm the irrigating solution to 37 ° C ( 98.6 ° F )

A nurse is performing a straight urinary catheterization for a female client who has urinary retention . Which of the following actions indicates the nurse is maintaining sterile technique ?

Wiping the labia minora in an anteroposterior direction

punctures the client's finger for the procedure but does not obtain an adequate amount of blood . Which of the A nurse is obtaining a capillary blood sample to determine a client's blood glucose level . The nurse prepares and following actions should the nurse take next ?

Wrap the client's finger in a warm washcloth

A nurse is evaluating the development of a group of clients . According to Erikson , the developmental ta intimacy vs. isolation occurs during which of the following stages of development ?

Young adulthood

A nurse is caring for a middle - aged adult client . The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group ?

" I think I have done a good job with my children since they are all independent now

A nurse is performing a focused assessment of a client's peripheral vascular system . In which of the following locations should the nurse palpate the posterior tibial pulse ?

Below the medial malleolus

A nurse is using a portable ultrasound bladder scanner to measure a client's post - void residual volume . Which of the following actions should the nurse take ?

Apply light pressure to the scanner head once it is in position

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

Hyperoxygenate the client before suctioning

A nurse is preparing to administer eye drops for a client who has glaucoma . When instilling the medication , which of the following actions should the nurse take ?

Apply pressure to the puncta after instilling the medication

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

Insert the tip of the tubing 8 cm ( 3.1 in )

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 clients commitment to a long - term goal of weight loss ?

Attempt to increase the clients ' self - motivation

A nurse on a telemetry unit is caring for a client who had a myocardial infarction . The client states , " All this equipment is making me nervous . " Which of the following responses should the nurse offer ?

All of this equipment can be frightening . "

A nurse rates a client's biceps reflex as 2+ . Which of the following characteristics should the nurse document abou the client's reflexes ?

Average

A nurse is caring for a client who has a temperature of 38.7 ° C ( 101.7 ° F ) . Which of the following actions should the nurse take

B. Keep the client's bed linens dry

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach . Which of the following pH values should the nurse expect ?

B.2

A nurse is preparing to insert an indwelling urinary catheter . Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus ?

Bear down . "

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

C. Pinch the NG tube while removing the tube

A nurse is reviewing the use of side rails with an assistive personnel ( AP ) . Which of the following statements by the AP indicates that further teaching is required ?

If the client seems confused , I'll raise all 4 side rails so that he doesn't hurt himself . "

nurse is caring for a client who has xerostomia with a lack of saliva . Which of the following nutrients will be affected by the lack of salivary amylase ?

C. Starch

A nurse is caring for a client who had a mastectomy and has a self - suction drainage evacuator in place . Which of the following actions should the nurse take to ensure proper operation of the device ?

Collapse the device to remove air after emptying

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

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

A nurse is caring for a client who is producing large amounts of urine . The nurse should document this finding as which of the following ?

Diuresis

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may 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 share with the client ?

Donate autologous blood before the surgery . "

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

Drop the eye medication into the lower conjunctival sac

A nurse is assessing a client . Which of the following findings should the nurse identify as an indication of protein calorie malnourishment ? ( Select all that apply

Dry , brittle hair Edema Poor wound healing

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter . The nurse should identify that which of the following findings is an indication of infiltration ?

Edema at the infusion site

nurse is performing a physical assessment of a client . The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity ?

Faint pedal pulses

A nurse is caring for a client who has a terminal illness . The family wants to care for the client at home . Which of the following statements indicates that the nurse understands family - centered care ?

Let's set up a meeting time with the doctor to discuss your options for home care . "

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment . Which of the following interventions should the nurse include ?

Limit drinking liquids with food

A nurse on a mental health unit is requires care . Which of the following concepts should the nurse and client discuss in the termination phase of the preparing to terminate the nurse - client relationship with a client who no longer relationship

Loss

A nurse is preparing to insert an indwelling urinary catheter for a male client . Which of the following locations should the nurse secure the urinary catheter tubing ?

Lower abdomen

of the following actions should the nurse take first ? A nurse is caring for a client who begins having a tonic - clonic seizure while sitting in a chair at the bedside . Which

Lower the client to the floor

A nurse caring for a client who starts to experience a seizure while sitting in a chair . Which of the following actions should nurse take ?

Lower the client to the floor and place a pad under the client's head

A nurse is performing a physical examination of a client . The nurse should use percussion to evaluate which of the following parts of the client's body ?

Lungs

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision . Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation ?

Montgomery straps

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings . Which pieces of information are critical to communicate to the next nurse who will be caring for this client ? ( Select all that apply . )

New prescriptions Arterial blood gas results Tracheal secretion characteristics

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long - term care facility . Using this scale , which of the following parameters should the nurse evaluate ?

Nutrition

A nurse is caring for a client who has a dysrhythmia . Which of the following techniques should the nurse to use to assess for a pulse deficit

Obtain the apical and radial

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 ?

Obtaining cotton balls for tracheostomy care

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

Offer the client tart or sour foods first

A nurse is planning care for a clienc who is confused and requires a prescription for wrist restraints . Which the following interventions should the nurse include in the plan of care ?

Renew the prescription for the use of restrains within 24 hr

A nurse is planning to perform passive range - of - motion exercises for a client . Which of the following actions should the nurse take ?

Repeat each joint motion 5 times during each session

A home health nurse is visiting an older adult client with severe dementia . The client's son , who serves as her primary caregiver , reports being " exhausted " from working part - time and caring for his mother at home . Which of the following options should the nurse suggest to the caregiver ?

Respite care

A nurse is assessing a client's incision and observes the drainage to be blood - tinged . Which of the following terms should the nurse use to document this finding ?

Sanguineous

As part of a neurological examination , a nurse instructs a client to keep his eyes closed , places an object in his hand , and asks him to identify the object . Which of the following abilities is the nurse evaluating with this technique ?

Stereognosis

A nurse is preparing to administer a unit of packed RBCs to a client . Which of the following pieces of information must the nurse verify with another nurse prior to the administration ? ( Select all that apply . ) .

The client's ID number The client's name ABO compatibility Rh compatibility

A nurse is providing nutrition counseling to a middle - aged adult client who has a sedentary job . Which of the following factors should the nurse consider ?

The client's basal metabolic rate could decrease .

A nurse is caring for an adult client who is grieving following the death of a loved one . Which of the following factors increases the client's risk of developing complicated grief

The death was sudden .

A nurse is assessing a client's thyroid gland . Which of the following instructions should the nurse give before inspecting and palpating this gland ?

Tilt your head back and swallow . "

A nurse is administering an IM injection to a 5 - month - old infant . Which of the following injection sites should the nurse use ?

Vastus lateralis

A nurse is preparing to administer an intramuscular injection to a young adult client . Which of the following injection sites is the safest for this client ?

Ventrogluteal

nurse is providing teaching about crutches to a client who has the following instructions should the nurse include ?

the rubber crutch tips securely in place . "

A nurse is teaching a client who has urinary incontinence about bladder retraining . Which of the following instructions should the nurse include ?

" Try to block the urge to urinate until the next scheduled time . "

A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees children at an acute care facility . Which of the following activities should the nurse include as an example of concrete operational thinking ?

Collecting and trading game cards

A nurse on a medical - surgical unit is admitting a client Which the following pieces of information should the nurse document in clients recor first?

Assessment

A nurse is admitting a client who has a hearing aid . Which of the following actions should the nurse take before beginning the interview process ?

B. Make sure the device is functioning

A nurse is teaching a client with lower extremity weakness how to use a 4 - point crutch gait . Which of the following instructions should the nurse include in the teaching ?

Bear weight on both of your legs . "

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash . The nurse should suspect an injury to which of the following parts of the brain

Brainstem

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

Clamp the tubing below the collection port

A nurse is caring for a client who is having difficulty breathing . The nurse should assist the client into which of the following positions ?

Fowler's

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care - associated infections ( HAIs ) . Which of the following routes of infection should the manager identify as an atrogenic HAI ?

Infection acquired from a diagnostic procedure

A client who has glaucoma of the right eye self - administers timolol eye drops by looking at the ceiling , instilling a drop onto the center of the conjunctival sac , and applying gentle pressure to the lower lid with a facial tissue . After observing this process , which of the following actions should the nurse take ?

Instruct the client to apply pressure to the inside corner of the eye after instillation .

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery . In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU ?

Intraoperative

A nurse in the emergency department is assessing a client who has deep , rapid respirations . Arterial blood gas analysis includes the following values : pH 7.25 , PaCO2 40 , and HCO3- 18. Which of the following acid - base imbalances should the nurse identify and report to the provider ?

Metabolic acidosis

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room . The client states she no longer wants to have the surgery . Which of the following actions should the nurse take ?

Notify the provider of the client's decision .

A nurse on a medical - surgical unit is caring for a client . Which of the following actions should the nurse prioritize when using the nursing process ?

Obtain client information

A nurse is caring for a client who has a fecal impaction . Before the digital removal of the mass , which of the following types of enemas should the nurse plan to administer to soften the feces ?

Oil retention

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse . Which of the following statements by the newly licensed nurse indicates an understanding of the teaching ?

People who practice Judaism stay with the body of the deceased until burial .

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens 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 ?

Pericardial friction rub

A nurse is obtaining the blood pressure in a client's lower extremity . Which of the following actions should the nurse take ?

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

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 ?

Provide more water with feedings

A nurse is planning care for a client who has a single lumen nasogastric NG ) tube for gastric decompression of the following actions should the nurse include the plan of care

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

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

Pull suction catheter back 1 cm ( 0.5 in ) if the client starts coughing

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

Purulent exudate

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 stethoscope to auscultate the aortic valve ?

Second intercostal space to the right of the sternum

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

Side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who has bilateral casts on her hands Which of the following actions should the nurse take when assisting the client with feeding ?

Sit at the bedside while feeding the client

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

Sit on the toilet 30 min after eating a meal . "

A community health nurse is conducting a class about body mechanics for county office workers . Which of the following instructions should the nurse include ? ( Select all that apply . )

Sit with your back supported Keep your knees at hip level Use an ergonomically designed computer keyboard

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to The nurse later observes the AP emptying the bag without wearing an gloves . Which of the following actions should the nurse take ?

Talk with the ap about the technique used

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 ?

The client holds the cane on the unaffected side .

A nurse is assisting a client who has right - sided weakness while ambulating using a cane . Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking

The client keeps 2 points of support on the ground

A nurse is assessing a client's respiratory system . Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields ?

Vesicular

A nurse is teaching a client how to perform range - of - motion exercises of the wrist . To perform adduction , which of the following instructions should the nurse include ?

With your palm facing down , move your wrist sideways toward your thumb

A nurse is preparing to administer an afternoon dose of ampicillin to a client . The client appears upset and refuses to take the medication before throwing the pill on the floor . Which of the following entries should the nurse into the client's medical record ?

client threw the medication on the floor .

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

keep having nightmares about my upcoming surgery

A nurse is caring for a client who is unconscious . Which of the following actions should the nurse take when providing oral care for the client ?

client Test for the presence gag reflex

A nurse is caring for a client who is dehydrated . The nurse should expect that insensible fluid loss of approximately 500 to 600 each day through which of the following organs ?

Skin