Fundamentals test 2

A nurse is instructing a patient regarding collection of stool specimens for fecal occult blood testing. Which of the following should the nurse instruct the patient to avoid a few days before and during the testing period to help reduce the risk of false-positive results? A. Poultry B. Vitamin E C. Yogurt D.calcium supps

A. Poultry

Which action should the nurse take when a patient has achieved each expected outcome in the care plan? A. Terminate the care plan. B. Modify the care plan. C. Continue the care plan. D. Start a new care plan

A. Terminate the care plan.

A nurse should recognize that which of the following is correct regarding albumin level as a diagnostic marker for nutritional status? A) Albumin level is a poor short-term indicator of protein status B) Hydration status does not affect a patient's albumin level C) An albumin level of 3.2 g/dL is within the normal 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 at a providers office is reviewing the records of several clients. Which of the following client should the nurse recommend as the priority for treatment? A. A client who has a history of hypertension, and requires a yearly check up. B. Client who reports new chest pain. C. Client who reports increased joint stiffness due to arthritis. D. The client who has diabetes mellitus and needs dietary instruction.

B. Client who reports new chest pain.

Normal fresh urine has an ammonia odor. A. True B. False

B. False

There are no interventions effective for preventing urinary incontinence. A. True B. False

B. False

Where does heparin get injected? A. Scapula B. back of upper arm C. Abdomen D. Deltoid

C. Abdomen

Which of the following direct visualization tests uses a long flexible fiber optic lighted scope to visualize the rectum colon and distal small bowel? A. Esophagastroduodenoscopy B. Colonoscopy C. Sigmoidoscopy D. UGI Series

C. Colonoscopy

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion? A. Insertion. B. Implementation. C. Inference. D. Creativity. E. Inductive reasoning.

C. Inference. D. Creativity. E. Inductive reasoning.

Which of the following is the primary purpose for asking a patient to keep a 3- to 7-day food diary? A) To allow the patient to rely on health professionals to identify problem areas B) To determine any changes in the patient's appetite C) To evaluate any significant changes in body weight D) To assess the pattern of intake and compare with daily reference intakes

D) To assess the pattern on intake and compare with daily reference intakes

Nursing student is about to administer a flu vaccine in the patient's left deltoid where should a nursing student begin to measure to ensure accurate delivery of the medication A. Vastus lateralis. B. Greater trochanter. C. Xiphoid process. D. Acromion process

D. Acromion process.

Which enema would be used for a patient with intestinal parasites? A. Oil-retention enema B. Carminative enema C. Nutritive enema D. Anthelmintic enema

D. Anthelmintic enema

A nurse is caring for a client who has a nasogastric tube connected to section. Which of the following findings indicates that the tube has become occluded? A. Active bowel sounds. B. Passing flatus C. Increase and gastric secretions. D. Increased abdominal distention.

D. Increased abdominal distention.

True or false Asking a patient to plan an exercise program to lower blood pressure based on information provided to the patient in a AV presentation is an excellent message to evaluate a psychological outcome

False

True or false Food is more vital to life than water because it provides the medium necessary for all chemical reactions and it is not stored in the body

False

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

Stage 3 pressure injury to the coccyx observed with a full thickness skin loss and visible adipose tissue

True or false Blood vessels in the skin dilate to dissipate heat.

True

What do this mean? 1. Percocet 5 mg PO BID. 2. Lorazepam 2 mg IM at 0700 3. Digoxin 0.125 mg IV bolous STAT 4. Morphine 2 mg IV bonus every 1 hour as needed for chest pain 5. In the event of asystole give Epinephrine 1 mg IV every 3 to 5 minutes until cardiac rhythm returns

1. By mouth twice a day. 2. Intramuscular at 0700 am 3. Iv books immediately 4. Morphine q1hour PRN for chest pain 5. Give epinephrine q 3-5 minutes

A nurse is caring for a client who has a new prescription for prednisone 12.5mg by mouth daily. The medication is available in 5 mg tablets. How many tablets should the nurse administer for each dose?

2.5 tablets

A patient has finished a 16-oz container of orange juice. The intake and output sheet documents fluid in milliliters. Which of the following should the nurse document as intake?

480mL 1oz= 30mL 30 x 16= 480

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A bright pink incision site that is absent of exudate

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?

A client who is in continent and taking a prescribed diuretic

A nurse is caring for a client who has dime-sized stage 1 pressures injury located on the sacrum. Which of the following dressing types should the nurse use?

A transparent film

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? A. " critical thinking is the foundation for clinical decision making" B. " critical thinking, takes into consideration, Nursing, scientific, and technical logical knowledge in client situations." C. " critical thinking is the visible or observed I'll come while using evidence based practice." D. " Critical thinking, is necessary for the nurse to collect objective client data"

A. " critical thinking, is the foundation for clinical decision making"

Which follows part of ten rights of medication rights? A.admin medication by the Route provider says to. B. Follow how they take meds at home C. Gather medical background history D. Insist they take all meds

A. Admin medication by the route the prescriber says to.

A nurse is caring for a patient who has a suspected urinary tract infection (UTI). Which of the following urinalysis results should indicate to the nurse the presence of a UTI? A. Leukocyte esterase B. Trace amount of protein C. Specific gravity of 6.0 D. Ph of 6.0

A. Leukocyte esterase

In what order should I RN performed the steps of the nursing process? Analysis Assessment Planning Evaluation Implementation

Assessment, analysis, planning, implementation, evaluation

A nurse caring for a group of patients in an ambulatory care clinic is collecting urine for several prescribed diagnostic tests. For which of the following tests is a random sample voided into a clean cup appropriate A.urine culture B.routine urinalysis C. Urine creatinine clearance D.urine pregnancy test

B. Routine urinalysis

nurse is collecting a blood specimen for culture from a patient hospitalized for pneumonia. During this procedure, the nurse should A. Keep tourniquet in place from selection of vein B. Rub the clients arm at the selected site C. Elevate the arm above heart level for the vein puncture D.puncture the selected vein while the antiseptic solution is still visible

B. Rub the clients arm at the selected site

A nurse is caring for a patient who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the patient with feeding? A) Provide the patient with a straw B) Offer the patient thin fluids C) Elevate the head of the bed 45 to 90 degrees D) Place food in the weaker side of the mouth

C) Elevate the head of the bed 45 to 90 degrees

A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure? A. Cecostomy B. Loop colostomy C. Ileostomy. D. Descending colostomy.

C. Ileostomy.

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following action should you take? A. Stretch the sheath portion of the condom catheter along the length of a penis. B. Secure the sheath portion with adhesive tape. C. Leave a space between the penis and sheath portion tip. D. Reposition the foreskin after application

C. Leave a space between the penis and sheet portion tip.

In which phase of wound healing is a new tissue, go to Fielder in space, primarily through the action of fibroblasts? A. Hemostasis B. Inflammatory foods. C. Proliferation phase D. Maturation phase

C. Proliferation phase

A nurse caring for a patient who has diabetes mellitus is having difficulty obtaining a capillary fingerstick blood sample for point-of-care blood glucose testing. To help increase blood flow to the finger, the nurse should A. Elevate hand B. Pierce the skin in the middle of the finger pad C. Wrap the finger in a warm cloth D.firmly milk the puncture site.

C. Wrap the finger in a warm cloth.

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Clean the wound with 0.9 sodium chloride

To assess a stroke patient for complications secondary to inadequate swallowing, the nurse should do which of the following? A) With a penlight, inspect the patients uvula and soft palate B) Place the tip of the tongue depressor on the posterior tongue C) Place fingers on the patients throat at the level of the larynx and ask them to swallow D) Auscultate the patients lungs

D) Auscultate the patients lungs

A nurse is caring for a client who has a prescription for a fluticasone propionate inhaler with a spacer. The client asks the nurse why a spacer is needed with the inhaler. Which of the following responses should the nurse make? A. " by using a spacer, you can take the medication correctly without any spells" B. " you can and he'll five or more pops in one minute when using a spacer" C. " by using a spacer, you eliminate the need for mouth printing after administration." D. " more medication is delivered to the lungs when you use a spacer"

D. " more medication is delivered to the lungs when you use a spacer"

A nurse is providing education on the priority, setting framers to a group of newly licensed nurses. Which of the following statements should the nurse week regarding the safety and risk reduction priority, setting framework? A. " when using this framework, clients are prioritized using a color coded system" B. " this room work uses the least restrictive measures first as long as the client safety is maintained" C. " when using this framework, the nurse will encourage the client to have social relationships through group interaction." D. " this framework assigns the highest priority to the situation that possesses a threat to the clients physical well-being"

D. " this framework assigns the highest priority to the situation that possesses a threat to the clients, physical well-being"

You're writing a care plan for a newly admitted patient which of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient out for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5

D. The patient will identify the need to increase dietary intake of fiber by June 5.

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

Dehiscence

A nurse is prioritizing care for a client. Identify the priority of the client needs using Maslow's hierarchy of needs. Put them in order. A. Love and belonging. B. Safety C. Esteem. D. Self-actualization. E. Psychological

E. Physiological. B. Safety. A. Love and belonging. C. Esteem D. Self-actualization.

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

Empty and measure the drainage

True or false When a patient fails to cooperate with the care plan despite the nurses best efforts, it is time to reassign the patient to another caretaker

FALSE

True or false A collaborative intervention is an intervention initiated by a physician in response to a medical diagnosis, but carried out by nurse in response to a physician order

False

True or false A nursing assessment duplicates a medical assessment by focusing on the patient's responses to the health problem

False

True or false A patient ratings pain as a seven on a pain rating scale. This reading is considered to be objective data.

False

True or false Nursing diagnosis may be used to seek reimbursement for Nursing services

False

True or false Only pain medication's may be given to patients without a medication order from my license practitioner

False

True or false Red meat is an incomplete protein

False

True or false Urine specimen from a patient with an indwelling catheter should be obtained from the collection receptacle

False

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?

Hydrogel

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

I should report pain at my wound site

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

Increased blood glucose

A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?

Pressure injury documentation includes location, stage, measurements and condition of the wound bed and any drainage present

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity

The AP place the client in high Fowler position

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?

The dermis contains blood vessels that help nourish the epidermis

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching

The skin assisted in regulation of body temperature

A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

The skin of older adults is thinner and has less subcutaneous padding over bony prominences

A nurse is providing teaching for a client who has a prescription for alginate dressing for a wound. Which of the following statements by the client indicates an understanding of alginate dressing?

This type of freeing will need a secondary dressing for reinforcement

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

This type of healing begins in the wound bed with the generation of granulation tissue

A nurse is planning care for an older adult clients who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown

Tilt the client on their side at 30 degrees

True or false An outcome evaluation focuses on measurable changes in the health status of the patient or the end result of nursing care

True

True or false Most healthcare institutions establish a minimum dataset that specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster these data

True

True or false The nursing diagnosis risk for impaired skin integrity is an example of a correctly written diagnosis

True

True or false The purpose of evaluation is to allow the patient achievement of expected outcomes to direct future nurse-patient interactions.

True

True or false When collecting stool using the " timed specimen," the nurse should consider the first stool passed by the patient has a start of collection period.

True

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?

You should shift your weight off your buttocks at intervals throughout the day

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

Your staples will be removed in two weeks

A nurse is performing a nutritional assessment. When obtaining and interpreting anthropometric values, the nurse should recognize which of the following? A) Isolated measurements of height and weight are of greater significance than changes over time B) A weight increase of 4 lbs in a patient with renal failure indicates retention of 1,000 mL of fluid C) The patient should be weighed on the same scale at the same time each day D) The ratio of height-to-weight circumference is the most accurate way to identify obesity

c. The patient should be weighed on the same scale at the same time each day

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

A clients who has a Braden scale of 9

Which of the following are appropriate choices for a patient described a full liquid diet? A) Plain yogurt B) Custard C) Pureed vegetables D) Mashed potatoes E) Pureed meat F) Gelatin

A. Plain Yogurt B) Custard C) Ice Cream F) Gelatin

Diuretics cause increased urine production, resulting in the need for increased urination and possibly urge incontinence. A. True B. False

A. True

A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of the following? A) Chest xray B) Swallowing examination C) Nasogastric tube insertion D) Olfactory nerve evaluation

B) Swallowing examination Dysphagia: swallowing difficulties

Which of the following clients is exhibiting medication tolerance? A. A client who continues to take medication despite harmful effects B. A client who requires increased dose of a medication to achieve therapeutic benefits C. A client who exhibits signs of withdrawal D. Client who develops an intense craving for medication

B. A client who requires increased dose of a medication to achieve therapeutic benefits

Which of the following describes a medication's generic name? A. Chemical name for the medication B. Is is the same as the nonproprietary name C. Name under medication is marketed D. Formal name of a particular medication

B. It is the same as the nonproprietary name

A nurse is caring for a client who is recovering from gastric surgery, is NPO, and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A. Allow the client to suck on ice chips B. Provide frequent mouth care. C. Apply petroleum jelly to the clients naris D. Offer throat lozenges for the client to use

B. Provide frequent mouth care.

At 0700, a nurse obtains a capillary blood glucose result of 180 mg/dL from a patient who has diabetes mellitus. Which of the following is a correct action for the nurse to take? A. Encourage to get up and exercise B. Repeat the test using a different glucometer C. Give client a glass of OJ D. Admin insulin according to the patients sliding scale orders

D. Admin insulin according to the patients sliding scale orders

Which term describes a condition in which 24 hour urine output is less than 50 ML? A. Dysuria B. Glycosuria. C. Pyuria D. Anuria

D. Anuria

Which of the following prescriptions is complete? A. Aspirin PO 1 Tablet daily B. Ferrous sulfate 624 mg PO C. Hydrocodone/acetaminophen (Vicodin) 5/325 mg PRN D. Digoxin (Lanoxin) 1.25 mg PO daily

D. Digoxin (lanoxin) 1.25mg PO daily

A patient who has a full-thickness wound continues to experience considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? A. Wet-to-dry B. Antimicrobial C. Gauze D. Hydrogel

D. Hydrogel

A nurse is preparing an adult clean it for an enema. The nurse should assess the client into which of the following positions? A. Prone. B. Dorsal recumbent C. Right lateral with both knees at chest. D. Left lateral with the right leg flexed

D. Left lateral with right leg flexed.

A nurse is teaching a client about extended wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence? A. Use an oil based lotion on the parastomal area. B. Apply the skin barrier while the skin is slightly moist C. Leave the residue from the previous appliance on the skin. D. Press gently around the barrier for 30 seconds to 1 minute.

D. Press gently around the barrier for 30 seconds to 1 minute.

A nurse has received a change of shift report for a group of clients which of the following clients. Should the nurse plan to see first? A. Client is receiving a blood transfusion and reports urticaria B. Client who has back pain and is requesting muscle relaxant medication. C. A client who has an ankle sprain and request toileting assistance. D. Client who has chronic migraines and reports of a headache

A. A client who is receiving a blood transfusion and reports urticaria

A nurse is reviewing the medical record for clients. Which of the following client should the nurse identify as a priority for care? A. Client who receive digoxin and has a heart rate of 48/min B. Client who receive pain medication's and has a respiratory rate of 14/min C. Client who has a urinary tract infection in a temperature of 37.9°C (100.2°F) D. The client who has anemia and blood pressure of 118/78 mm Hg

A. Client who received digoxin and has a heart rate of 48/min

A nurse is reviewing methods, created to assist nurses in using evidence based practice. Which of the following NCSBN model that can assist the nurse with clinical taking in decision making? A. Clinical judgment. B. Critical thinking. C. Clinical reasoning. D. SMART goal.

A. Clinical judgement

A nurse is caring for a client who has COPD. For which of the following inhalation medications delivery methods should the nurse assess the client's ability to inhale deeply? A. Dry powder inhaler (DIP) B. Nasal spray. C. Metered dose inhaler (MDI) with attached spacer D. Use of a nebulizer via a mask.

A. Dry powder inhaler (DIP)

Which nursing action when was likely occur during the ongoing planning stage of the comprehensive care plan? A. The nurse collects new data and uses the problem to update the plant images of health problems. B. The nurse is teaching in counseling skills to help the patient carry out self-care behaviors at home. C. The nurse who performs the admission, Nursing history develops a patient care plan D. The nurse consults standardize care plans to identify nursing diagnoses, outcomes, and interventions.

A. The nurse collects new data and uses them to update the plan and resolve health problems

A nurse is preparing to administer the first of two large volume, cleansing enema is prescribed for a client in preparation for a diagnostic procedure. Which of the following action should the nurse take first? A. Warm the enema solution prior to installation. B. Prepare 1500 mL of enema fluid. C. Use tapwater as the enema fluid. D. Hang the enema container 24 inches above the anus.

A. Warm the enema solution prior to installation

A nurse is caring for a patient who has developed a stage I pressure ulcer in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the ulcer A. Zinc oxide B. Nystatin C. Papain-urea D. Polymyxin B

A. Zinc oxide

Which one of the following assessments will be performed on a patient to gather data about his previously diagnosed liver cancer? A. Initial comprehensive assessment. B. Focused assessment C. Emergency assessment D. Time lapsed-assessment

B. Focused assessment

A nurse is caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis? A. Transparent B. Hydrofiber C. Alginate D. Biologic

C. Alginate

A nurse is preparing to administer an oral medication to a client. Which of the following actions is the nurse's priority? A. Have another nurse check the dose B. Tech the client about possible side affects C. Confirm pts identity with two factors D. Confirm the pt can swallow

C. Confirm pts identity with two factors.

A nurse is administering aspirin 81 mg PO daily to a client who has a history of myocardial infarction. The medication is scheduled for 0800. Which of the following scenarios demonstrates proper use of one of the Ten Rights of Medication Administration? A. The nurse performs the first check of the correct Osage at the clients bedside B. The nurse identify as a client by stating the clients name as written on the medication administration record. C. The nurse documents to Aspirin was given at 0825 D. The nurse opens the 81 mg aspirin Unidos package prior to entering the clients room.

C. The nurse documents to aspirin was given at 0825

Which example illustrates a nurse variable influencing a patient outcomes? A. A patient in a nursing home, refuses to take his medication's. B. Low income families, unable to afford formula for their newborn infant C. An alcoholic patient is unwilling to participate in AA meetings. D. A rape victim does not receive counseling in the emergency department because it counselor is not available.

D. A rape victim does not receive counseling in emergency department because the counselor is not available.

A nurse is providing perineal care for a female client who has an in dwelling urinary Cather. Which of the following areas should the nurse cleanse last? A. Urethral meatus B. Labia minora C. Perineum D. Anus

D. Anus

What is the greatest risk of a feeding tube? A. Electrolyte imbalance B. Infection C. Fluid volume overload D. Aspiration

D. Aspiration

Which wound complication is caused by the overhydration related to urinary and fecal incontinence? A. Necrosis. B. Edema C. Desiccation D. Maceration

D. Maceration

A nurse is caring for a 6-month old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?

Dermatitis

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?

I should increase my protein intake

The nurse asks a client to write their current level of pain using a scale of 0 to 10 after administering pain medication's 30 minutes ago. Which of the following steps of the nursing process is the nurse performing? A. Evaluation B. Implementation. C. Analysis. D. Planning.

A. Evaluation.

The nurse is feeding a patient who is diagnosed with a stroke, which of the following indicates that the patient likely has problems with aspiration? A. Drooling between bites B. Lack of eating C. Coughing while drinking water D. Complaint of swallowing

C. Coughing while drinking water.

The nurse at an urgent care clinic is auscultating, the lungs of a client who reports a cough and shortness of breath which of the following steps of the nursing process is the nurse using? A. Evaluation. B. Implementation. C. Analysis. D. Assessment.

D. Assessment.

A nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month, but has no sign of infection or bow obstruction. The client tells the nurse that they avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? A. Consume foods that are low in fiber content B. Take an ounce of mineral oil twice a day. C. Add buttermilk, and cranberry juice to the diet. D. Increase water intake to 3 to 3.5 L per day

A. Consume foods that are low in fiber content.

Which type of wound is caused by blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact A. Contusion B. Abrasion C. Laceration D. Avulsion

A. Contusion

A nurse is preparing to administer a client's medication. The client states the medication makes them feel nauseated and refuses to take it. Which of the following actions should the nurse take? A. Document the reason for refusal along with the date and time in the client's medical record. B. Tell the client that if they don't take the medication that they will not get any better. C. Play some medication on the clients bedside so they can take it when they are no longer nauseated. D. Notify the pharmacist as a client refuses to take the medication.

A. Document the reason for refusal along with the date and time in the client's medical record.

A nurse is caring for a client who is receiving a medication that typically causes drowsiness. While assessing the client, the nurse notes that the medication has caused the client to become hyperactive. Which of the following terms describes the client's unexpected response to the medication? A. Idiosyncratic effect B. Allergic response C. toxic effect D. Synergistic effect

A. Idiosyncratic effect

A nurse is administering an enema medication was sodium polystyrene sulfonate to an adult client who is hyperkalemia. Which of the following links to the nurse insert the rectal tube? A. 2.5 cm to 3.75 cm (1 to 1.5 in) B. 5 cm to 7.5 cm (2 to 3 in) C. 7.5 cm to 10 cm (3 to 4 in) D. 10 cm to 12.5 cm (4 to 5 in)

C. 7.5 cm to 10 cm (3 to 4 in)

A nurse is preparing to administer medications for a client who has a nasogastric tube. Which of the following actions should the nurse take prior to administering the medications? A. Check to placement by inserting errand to the table auscultating at the gastric fundus B. Because the client adamant to assess the area of tympani and dullness C. Observe the amount of residue of volume left in the stomach. D. Determine the clients ability to cooperate with instructions

C. Observe the amount of residue of volume left in the stomach.

nurse assessing a pressure ulcer over a patient's right heel area observes a deep crater with no eschar or slough and no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is A. unstageable. B. a suspected deep tissue injury. C. stage IV. D. stage III.

D. Stage III

A nurse is observing an assistive personnel, make a client bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure? A. The AP records the tasks when it is complete. B. The AP where is sterile gloves when making the bed. C. The AP changes the clients pillowcase. D. The AP reuses the clients blanket and spread.

D. The AP reuses the clients blanket and spread

assistive personnel (AP) is collecting a 24-hour urine specimen from a patient. Which of the following statements by the AP indicates that the specimen collection will have to be restarted? A. I used a container from the lab B. The client voided into the toilet the next void can be collected C. I have the container in a plastic bucket with ice D. The client just told me they forgot to put the urine in the container.

D. The client just told me they forgot to put the urine in the container.

A nurse is planning to obtain a urinary specimen from a client closed urinary system. Identify the correct sequence of steps at the nurse should take. A. Attach a syringe to the collection, part of the indwelling catheter. B. Transfer the urine to a sterile specimen container. C. Withdraw 3 to 30 mL of urine D. Wipe the port with an alcohol swab or agency specified anti-septic. E. Transport the specimen to the laboratory.

D. Wipe the port with an alcohol swab or agency specified antiseptic. A. Attach a syringe to the collection, part of indwelling catheter. C. Withdraw 3 to 30 mL of urine B. Transfer the urine to a sterile specimen container. E. Transport the specimen to the laboratory

A nurse is performing a nasogastric intubation on a client and has reached the tube's predetermined length. Which of the following actions should the nurse take? A. Inspect the oropharynx with a penlight and a tongue blade B. Obtain an x-ray examination of the chest and abdomen C. Tape the tube secure;y in place with a tube holder device D. Aspirate gastric contents

A. Inspect the oropharynx with a penlight and a tongue blade

A nurse decide that a patient has a possible problem with high blood pressure during which step of data interpretation would this most likely be determined? A. Recognizing significant data. B. Recognizing patterns or clusters. C. Identifying strengths and problems. D. Reaching conclusions

A. Recognizing significant data.

A nurse is documenting data about a healing wound on a patient's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as A. serosanguineous. B. sanguineous. C. serous. D. purulent

A. Serosangguineous

A nurse is teaching the adult child of a client about instilling eye drops in the client's right eye. Which of the following statements by the client's adult child indicates an understanding of the teaching? A. " I will have a my mother look down while dropping the medication into her eye" B. " I will instruct my mother to tightly closed her eyes for 30 to 60 seconds after the medication has been given" C. " I should apply the medication using Ethan stream from the inner canthus to the outer canthus" D. " I will pull down her lower eyelid and drop the medication inside"

D. " I will pull down her lower eyelid and drop the medication inside"

A nurse is caring for a client who reports feeling inferior, and Steve said they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of Maslow's hierarchy of needs? A. Love and belonging. B. Self actualization. C. Safety D. Self-esteem.

D. Self-esteem.

A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary elimination? A. Kock's pouch. B. Ileal conduit. C. Cutananeous Ureterostomy D. Nephrostomy.

A. Kock's pouch

A nurse is caring for a patient who has multiple sclerosis and has a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? A. Tricyclic antidepressants B. Corticosteroids C. Beta blockers D. Anticholinergics

B. Corticosteroids

The nurse is caring for a patient who is cultured positive for C diff which action will the nurse take next A. Instruct assistive personnel to use soap and water. B. Plays the patient on droplet precautions. C. Wear a n95 mask. D. Teach the patient cough etiquette.

A. Instruct assistive personnel to use soap and water.

Which food is a recommended for an older adult who is constipated? A. Cheese B. Fruit C. Cabbage D. eggs

B. Fruit.

Which nursing diagnosis would most likely be considered a high priority? A. Disturbed personal identity B. Impaired gas exchange. C. Risk for powerlessness. D. Activity intolerance.

B. Impaired gas exchange

Which type of medication has no barriers to absorption A. Intramuscular B. Intravenous C. Subcutaneous D. Oral

B. Intravenous

A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer, based on his symptoms and series of test results. Which of the following is the etiology in this scenario? A. Lung cancer. B. Test results. C. Smoking cigarettes. D. The subjective and objective data.

C. Smoking cigarettes.

A nurse is caring for a client reports new onset of abdominal pain. The nurse should assign the clients condition to which of the following categories from prioritizing care? A. Chronic. B. Minimal. C. Urgent. D. Expectant.

C. Urgent.

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reasoning when it is complicated by which of the following factors? A. Complex clinical situation's. B. On going client and family concerns. C. Cost of healthcare. D. Decreased need for advance healthcare practitioner intervention. E. Availability of computerized medical records.

A. Complex clinical situation. B. On going client and family concerns

A nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent London changes. Which of the following should the nurse identify as a priority rationale for frequent linen changes? A. Moisture from excessive diaphoresis can cause skin breakdown. B. Moisture on the sheets can cause discomfort to the client. C. It provides an opportunity to frequently evaluate the skin on the clients backside. D. It provides an opportunity to turn the client from side to side to facilitate clearing potential food from the lungs.

A. Moisture from excessive diaphoresis can cause skin breakdown

The nurse is assessing a client using the ABCDE priority standing approach. Which of the following actions should the nurse take in completing the exposure components of a priority setting methods? A. Observe, the clients lower extremities are indications of deep vein, thrombosis B. Obtain a respiratory rate for one full minute C. Measure the clients temperature. D. Check the client for bruising. E. Obtain a blood pressure measurement.

A. Observe the clients lower extremities for indications of deep vein, thrombosis C. Measure declines temperature. D. Check the client for bruising.

A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the initial placement of the tube? A. Obtain an x-ray B. Auscultate injected air C. Take a pH measurement of gastric aspirate D. Identify the color of gastric contents

A. Obtain an x-ray

nurse is teaching a patient about home collection of a stool specimen for fecal occult blood testing. Which of the following instructions should the nurse provide? A. Obtain specimens from three stools B. Eat a diet low in fiber C. Avoid foods high in fat D. refrigerate the specie, card after obtaining the first sample.

A. Obtain specimens from three different stools.

The nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following action should the nurse take? A. Place the client in the dorsal recumbent position on a bed pan B. Administer the enema while the client sits on the toilet. C. Administer an anti-diarrheal medication three hours prior to the enema D. Install 200 mL of fluid over an hour at 15 minute intervals.

A. Place a client in the dorsal recumbent position on a bedpan.

A nurse is performing a complete that task for a client. Which of the following action should the nurse take? A. Raise the room temperature. B. Completely remove the linens. C. Add soap to the water in the basement before beginning the bath. D. Bathe one side of the body at a time.

A. Raise the room temperature.

The nurse is performing in admission assessment on a client. Using the safety and risk reduction, priority, setting framework, which of the following findings should the nurse identify as a priority? A. The client reports dizziness when standing. B. The client has not had a bowel movement in three days. C. The client has nonpitting edema in a lower extremities. D. The client has several scratch marks on their abdomen.

A. The client reports dizziness when standing.

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure? A. Bear down. B. Take deep breaths. C. Sip water. D. Tighten the perineum.

A. bear down

Which of the following dietary modifications should an adolescent engaging in sports implement? A) In crease fats to 30% to 40% of daily kilocalories B) Drink water before and after sports activity C) Keep protein intake at the same level D) Decrease carbohydrates to 30% to 40% of daily kilocalories

B) Drink water before and after sports activity

A nurse is preparing to provide oral care for a client who has NPO. The client tells the nurse, " I don't need oral care because I haven't eaten anything." Which of the following responses should the nurse make? A. " since you're not eating, we can wait to do it before bedtime" B. " oral care is still important even though you are not eating" C. " I'll give you a sip of water to switch around in your mouth and then you can spit it out." D. " we will wait until your family gets here to help"

B. " oral care is still important even though you are not eating"

The nurse is caring for a client who is experiencing unexpected manifestations of several body systems. Which of the following Purdy setting framer should the nurse use to prioritize client assessment? A. Acute versus chronic. B. ABCDE. C. Least restrictive/least invasive. D. Survival potential.

B. ABCDE

A nurse is a checking the client's nasogastric tube for placement. Which of the following procedures should the nurse implement? A. Instill 20 ml of air in to the tube and listen for a whooshing sound B. Aspirate stomach content and check the pH C. Aspirate stomach contents and check their color D. Auscultate lung sounds

B. Aspirate stomach contents and check the pH

Which of the following nursing diagnosis is written correctly? A. Child abuse related to maternal hostility. B. Breast cancer related to family history. C. Deficient knowledge of related to alteration in diet. D. Imbalanced nutrition related to insufficient funds in meal budget.

B. Breast cancer related to family history.

You're caring for a non-English-speaking male patient. When preparing to assist him with personal hygiene, you should: A. Use soap and water on all types of skin. B. Consider that culture in ethnicity influence hygiene practices. C. Sheu facial hair to make the patient more D. Know that all patients need to be bathed daily

B. Consider that culture and ethnicity influence hygiene practices.

A nurse is preparing to remove clients indwelling urinary catheter. Which of the following action should the nurse take? A. Pull the catheter out as quickly as possible. B. Deflate the balloon completely before removal. C. Cut the inflation port, to deflate the balloon. D. Tell the client to expect to feel a tugging sensation on removal.

B. Deflate the balloon before removal

A nurse is caring for a client who has been wheezing. The nurse asks an assistant personnel to grab a stethoscope and listen to the clients lung sounds to determine if they're wheezing has improved. This is an example of which of the following concepts? A. Delegation of the right circumstances. B. Delegation of the wrong task. C. Delegation to the right person. D. Delegation of the wrong time.

B. Delegation of the wrong task.

A nurse is teaching a client who has new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instruction should the nurse include? A. Apply hydrocortisone cream to the skin when changing the appliance B. Empty the pouch when it is less than half full. C. Wash the peristomal more skin frequently with deodorizing soap and water. D. Choose a time shortly after a meal for replacing the pouch

B. Empty the pouch when it is less than half full.

A nurse is preparing to administer several medications to a client who is receiving enteral feedings through a small bore nasogastric tube. Which of the following actions should the nurse take to ensure the medications are administered correctly? A. Add crushed medication to the internal tube, feeding and infuse via a electronic pump. B. Infused each medication by gravity and flush with water before and after installation. C. Administer medication through a 5 mL syringe. D. Lower the syringe to facilitate installation of medication.

B. Infused each medication by gravity and flush with water before and after installation.

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? A. Grasp the penis at its base B. Lift the penis perpendicular to the body C. Hold the penis parallel to the client's body D. Lift the penis to a 45° angle to the client's body

B. Lift the penis perpendicular to the body

A nurse is administering a return-flow enema to a client. After installing 100 mL of enema fluid, which of the following actions, should the nurse take? A. Instruct the client to retain the fluid B. Lower the container to allow the solution to flow back out. C. Helped the client to the toilet or bedside commode. D. Wait five minutes and install another hundred milliliters of fluid.

B. Lower the container to allow the solution to flow back out.

Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? A. Medication before administering it. B. Medication after administering it. C. Rationale for administering it. D. Prescriber rationale for prescribing it.

B. Medication after administering it

Which of the following nursing interventions is in indirect care intervention? A. A nurse explains availableBirth control measures to a young couple. B. The nurse meets with a collaborative care team to plan Nursing measures for a patient. C. The nurse prays with a patient prior to surgery. D. The nurse administers pain medication to a patient with end stage renal cancer.

B. Nurse meets with the collaborative care team to plan nursing measures for patient.

A nurse is admitting a client who has hypertension. Using the nursing process, which of the following action, should the nurse take first? A. Develop nursing diagnosis. B. Perform a physical assessment. C. Administer prescribe medication's. D. Develop goals and outcomes.

B. Perform a physical assessment.

A nurse is preparing to instill antibiotic ear drops into the ear of a 2-year-old child. Which of the following techniques should the nurse use when administering ear drops to this client? A. Have the client maintain a sidelining position for 30 minutes after administration of the eardrops. B. Pull the clients auricle down and back to open the back now when administering the eardrops C. Don sterile gloves, prior to a ministration of the eardrops. D. Insert the tip of the dropper into the ear canal when administering the eardrops.

B. Pull the clients auricle down and back to open the back now when administering the eardrops

Client who is postoperative is experiencing abdominal distention, and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? A. Cleansing. B. Return flow. C. Medicated. D. Oil retention

B. Return flow.

In which of the following medication supply systems are large quantities of medications kept on the nursing unit making them immediately available to the nurse? A. Individual supply B. Stock supply C. Unit dose system D. Bar-coded medication cart

B. Stock supply

Which example is a psychomotor outcome? A. Patient learns how to control his weight by the choose my plate food guide. B. The patient is able to test for glucose levels and inject insulin as needed C. A patient various his health enough to decide to quit smoking. D. The patient is able to ambulate the hallway following knee surgery

B. The patient is able to test for glucose levels and inject insulin as needed.

A nurse is providing preoperative teaching for a client who is scheduled it for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching? A. Expect the influent from the sigmoid colostomy to be loose and continuous. B. Use irrigation to help establish a regular bowel pattern. C. Change the stoma appliance every other day. D. Expect affluent from the newly created stoma within 24 hours after surgery.

B. Use irrigation to help establish a regular bowel pattern.

A nurse is documenting data about a deep necrotic wound on a patient's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse should document this type of necrotic tissue as A. fibrin. B. slough. C. gangrene. D. eschar.

B. slough.

Which of the following interventions should the nurse use at mealtimes for a patient who has visual deficits? A) Direct the order in which food items are consumed B) Have the patient tilt her head forward while eating C) Identify the food location as if the plate were a clock D) Avoid talking to the patient during mealtime

C) Identify the food location as if the plate were a clock

Which of the following strategies for enhancing the intake of healthful foods is appropriate for an adolescent? A) Encouraging the adolescent to consume snack foods with 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 choices

C) Making healthful food choices more convenient and available for the adolescent

A nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. Which of the following statements by the new license nurse indicates an understanding of the teaching? A. "I'll swab the clients mouth with lemon-glycerin swabs" B. " I'll swab the clients mouth with mouthwash" C. "I'll swab the clients mouth with chlorhexidine" D. "I'll swab the clients lips with a very small amount of mineral oil"

C. " I'll swab, the clients mouth with chlorhexidine."

The nurse is teaching a group of universities about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs an nasogastric tube intubation for gastric decompression? A. A 6 year old child, who ingested a toxin substance. B. A 60 year old client who has gastrointestinal hemorrhage C. A 40 year old client who is postoperative bowel obstruction. D. A 20-year-old client who has malabsorption syndrome

C. A 40 year old client who is postoperative bowel obstruction.

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? A. A client who has a persistent urinary tract infection B. A client who has urge incontinence C. A client who is in the ICU for a gastrointestinal bleed D. A client who has incontince due to cognitive decline

C. A client who is in the ICU for a gastrointestinal bleed

Which of the following represents the correct administration of the prescribed medication? A. Acetaminophen 650 mg PO prescribed; 5 tsp of 325 mg/10 mL liquid given B. Levothyroxine 100 mcg PO prescribed; three 0.025 mg tablets given C. Amoxicillin 1 g PO prescribed; two 500 mg tablets given D. Diphenhyframine 40 mg IM prescribed; 1.25 mL of 50 mg/mL for injection given

C. Amoxicillin 1 g PO prescribed; two 500 mg tablets given

Nurse is planning morning hygiene care for a postoperative client. Which of the following action should the nurse take? A. Inform the client one morning hygiene care is provided at the hospital. B. Schedule a clients morning hygiene care at the same time as their roommate C. Ask the client in what order they typically perform their morning routine. D. Plan to provide care of before the next scheduled dose of pain medication.

C. Ask the client in what order they typically perform their morning routine.

Charge nurse is planning to discuss factors that can influence the clinical decision making process in the client care with a newly licensed nurse. Which of the following factors to the charge nurse include? A. Appropriate delegation B. Cost of client care. C. Available resources D. Awareness of client status. E. Support from another staff.

C. Available resources D. Awareness of clients status. E. Support from another staff.

A nurse is caring for a patient with a stage IV sacral pressure ulcer for which the provider has prescribed mechanical debridement. Which of the following should the nurse plan for this patient? A. Placing a transparent dressing over the ulcer B. Applying larvae to the wound bed C. Changing dressings using the wet-to-dry method D. Using a topical enzyme solution in the wound's base

C. Changing dressings using the wet-to-dry method

Anders has received change of shift report on for clients. Which of the following client should the nurse plan to see first? A. A client who is scheduled for an abdominal ultrasound. B. Client who needs a urine specimen sent to the lab. C. Client who has audible wheezing during respiration. D. Client who request their routine pain medication.

C. Client who has audible wheezing during respiration.

A nurse is caring for a client who is confused and trying to remove the peripheral IV. Using the least restrictive/least invasive, priority, setting framework, which of the following action, should the nurse take first? A. Apply software restraints to the clients wrist B. Administer an antianxiety medicine to the client intramuscularly. C. Cover the IV site with an elastic bandage. D. Request a prescription for a central venous catheter.

C. Cover the IV site with an elastic bandage.

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? A. Be sure to keep skin moist. B. Do not use pillows to support extremities C. Flex the clients knees in the bee D. Provide a firm mattress for the client

C. Flex the clients knees while in bed

A nurse is caring for a female patient who needs to collect a midstream urine specimen. Which of the following actions should the nurse take A. Give the client a clean urine cup from the lab B. Instruct the client to wipe from back to front C. Have the client urinate a small amount of urine before starting the collection D. Tell the client to collect about 10Ml of urine

C. Have the client collect a small amount of urine before starting the collection.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following action should the nurse take? A. Measure the clients vital signs. B. Notify the primary care provider. C. Lower the enema fluid container. D. Stop the enema installation.

C. Lower the enema fluid container.

A nurse is reinforcing teaching with a client about replacing an ostomy pouch in system. The client reports that the occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? A. Left up on both sides of the skin barrier simultaneously. B. Release one corner of the very unpolite quickly over the stoma. C. Push the skin away from the barrier while removing it. D. Gently roll the barrier and over and across the stoma.

C. Push the skin away from the barrier while removing it.

A nurse is preparing to administer several PO medications to a client. The client states they can only take one pill at a time. Which of the following actions should the nurse take? A. Ask the pharmacy to change the formulation of each med B. Crush the pills and mix in applesauce C. Remain at bedside till all medications are taken D. Leave the pills at the bedside

C. Remain at bedside until the client has taken all medications

A nurse is informed during shift report that a client has a nasogastric tube connected to continuous suction. The nurse should identify that this client must have which of the following types of tubes? A. Dobhoff tube B. Songs taken-Blakemore Tube C. Salem sump tube D. Ewald tube

C. Salem sump tube

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and call for help. Which of the following actions should the nurse take

Cover the client wound with a sterile saline dressing

A nurse is caring for a patient who is admitted with multiple wounds sustained in a motor-vehicle crash. Understanding the patient's specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient's plan of care to prevent a prolongation of this phase? A. Leave nonbleeding wounds open to the air. B. Administer 325 mg aspirin PO as needed for pain. C. Initiate mechanical debridement. D. Apply oxygen at 2 L/min via nasal cannula.

D. Apply oxygen at 2 L /min via nasal cannula

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? A. The duration of the procedure. B. 10 to 15 minutes. C. Until the client feels the urge to defecate. D. At least 30 minutes.

D. At least 30 minutes.

A nurse is assessing a client using the ABCDE approach. The nurse has already assess the clients airways and breathing status. Which of the following assessment should the nurse perform next? A. Body temperature B. Abdominal contour. C. Skin integrity. D. Blood pressure.

D. Blood pressure.

Which outcome is an affective outcome? A. By 6/09.19, the patient will correctly demonstrate the procedure for washing her newborn baby B. By 6/09/19, the patient will less three benefits of eating a healthy diet. C. By 6/09/19, the patient will use a walker to ambulate the hallway. D. BY 6/09/19, the patient will verbalize valuing his health enough to stop smoking

D. By 6/09/19, the patient will verbalize valuing his health enough to stop smoking

A nurse is assessing a clients indwelling urinary catheter drainage at the end of the shift in notes. The output is considerably less than the fluid intake. Which of the following action should the nurse take first? A. Irrigate the catheter. B. Assessed for peripheral edema C. Palpate bladder distention. D. Check the catheter for kinks

D. Check the catheter for kinks

A nurse is assisting a client was personal hygiene care. Which of the following action should the nurse take to reduce the risk of infection? A. Massage reddened areas of the client skin. B. Wash eyes from the outer canthus to the inner canthus. C. Wash the client from the shoulder down to the fingertip with smooth short strokes. D. Clean the least soiled areas prior to cleaning the most soiled areas

D. Clean the least soiled areas prior to cleaning the most soiled areas.

A nurse is replacing the ostomy appliance for a client who is newly created colostomy is functioning. After removing the pouch, which of the following action, should the nurse take first? A. Measure the stoma. B. Cover the stoma with gauze C. Remove the backing of the skin barrier. D. Cleanse the stoma and peristomal skin.

D. Cleanse the stoma in peristomal skin.

The nurse is assisting with client triage at the scene of a mass casualty event. Which of the following client should the nurse recommend for a transport first? A. Client reports possible sprain wrist and is walking around. B. A client who has an open forearm fracture without visible drainage C. A client who has a respiratory rate of 6/min and no pupil response D. A client who has an abdominal wound that is actively bleeding.

D. Client who has abdominal wound that is actively bleeding.

When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures? A) Do not give the child peanut butter B) Have the child drink 28 to 32 oz of milk daily C) Give the child 8 to 12 oz of fruit juice daily D) Do not offer the child raw vegetables

D. Do not offer the child raw vegetables

A nurse is preparing to assist a client with a tub bath. Identify the sequence of steps the nurse should take. A. Instruct the client on using safety bars when getting in and out of the tub. B. Instruct the client to remain in the tub for no longer than 20 minutes. C. Place rubber mat on the tub floor. D. Gather all necessary supplies. E. Assist the client into the bathroom.

D. Gather all necessary supplies. C. Place rubber mat on the tub floor. E. Assist the client to the bathroom. A. Instruct the client on using safety bars when getting in and out of the tub. B. Instruct the client to remain in the tub for no longer than 20 minutes.

A nurse is developing a goal for a client to ambulate with assistance, at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process? A. Evaluation B. Implementation. C. Analysis. D. Planning.

D. Planning.

A nurse is caring for a patient who has a stage III pressure ulcer in the sacral area. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure ulcer? A. Irrigate the wound with an antiseptic B. Wipe the crusty area around the wound C. Collect drainage from site D. rotate a sterile swab in the area of drainage

D. Rotate a sterile swab in the area of drainage.