Funds Final

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following should the nurse prepare to infuse for this client?

0.45% sodium chloride

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decision?

Advocacy

A nurse is working in an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being the greatest risk for skin breakdown?

An older adult who has a hip fracture

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates an understanding of the discussion?

Consensus evolves in this stage

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? (select all that apply)

Coordinator Evaluator Energizer

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus

A nurse is caring for a client who is recovering from a cerebrovascular accident. Which of the following information should the nurse include when teaching family members about repositioning the client? (select all that apply)

Elevate the bed 2 waist height Stand with feet wide apart Face the direction of movement

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situation requires that the nurse wear gloves? (select all that apply)

Emptying urine from an indwelling catheter Providing Oral Care Changing an ostomy pouch

A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary to keep her from leaving the hospital. The nurse understands that restraining the client would be considered which type of civil action by the nurse?

False imprisonment

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

Gait belt

A nurse is removing personal protective equipment after giving Direct Care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

A nurse is planning home care for a nine-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning?

Industrial vs inferiority

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Inhale slowly and evenly through her nose

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time?

Interpersonal

A nurse intercepts a messenger at the nurse's station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" which of the following responses should the nurse provide?

It's my responsibility to remind

A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen?

Left forearm

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

Malpractice

A nurse is inserting an IV catheter for an older adult client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

Median vein in the forearm

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply)

More difficulty seeing due ... Decreased cough reflex Decreased bladder capacity Dehydration of Intervertebral

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity

A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move the client to a room closer

Providing postpartum care, Which action is a priority for the nurse?

Provide cultural sensitivity to care for the body

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective equipment? (select all that apply)

Providing hygiene care to a client

A nurse is working with an assistive Personnel while caring for a surgical client who is one day postoperative. Which tasks should the nurse take responsibility for completing?

Removing the abdominal dressing

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (select all that apply)

Repeat the order back Question any part of the order Transcribe the order into the clients

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

Reporting laboratory findings to a member of the client's family

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive mantoux test. ● Room 208 is private, a negative pressure airflow room ● Room 212 is a semi-private, positive pressure airflow room ● Room 214 is a negative pressure, semi-private room ● Roome 216 is a private, positive pressure airflow room To which of the following rooms should the nurse assign the client?

Room 208 is private, a negative pressure airflow room

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardize client confidentiality?

Sharing computer passwords

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following Health Care Professionals is responsible for obtaining informed consent from the client for the procedure?

Surgeon

A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include?

The nurse serves as a witness

An adolescent who is pregnant for the first time is at her initial prenatal visit. The women's health nurse practitioner informed her that she will be screening her for sexually transmitted infections. The patient replies "I know I don't have any STI because I don't have any symptoms." How should the NP nurse respond? (select all that apply)

Untreated STI can cause serious People between the ages of 15 Chlamydia screening is recommended

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Use soap and water to wash the catheter after each use

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

conjunctivae

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

footboard

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?

negligence

A nurse is preparing to administer an IM injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

respiratory rate

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

witness the client's signature

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment

A nurse is preparing to induce a 250 mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the flow rate to deliver how many drops per minute? (round answer. Use leading zero, no trailing zero)

1.25 gtt/min

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurse's station

A client who sustained a head injury

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first?

Determine if the client can bear weight

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the counter top. Which of the following actions should the nurse take?

Discard and give new tablet

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

Discharge planning begins @ admission

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

Droplet

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper socks for

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. the nurse should initiate a referral with which of the following members of the interprofessional healthcare team?

Occupational therapist

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and Restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (select all that apply)

the shoulders droop the facial muscles relax the post is within expected range

A nurse is administering an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

veracity

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly-licensed nurse indicates an understanding of the purpose of the documentation?

Documentation is a communication

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

Hold the container solution 30 cm above the anus

A nurse enters an older adult clients' room to insert a saline lock. The client asks the nurse "why do I need that? I am drinking plenty of fluids." (select all that apply) Which of the following responses should the nurse provide?-"It is quicker to administer medications intravenously in the hospital."-Clients over the age of 65 must have a saline lock according to facility policy."-"We administer all medications intravenously to clients in this unit."-"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

-"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." (Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.)

A nurse is caring for a client who has an NG Tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

4.0

A nurse is caring for a client who requires cold application with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following should the nurse take?

Apply the bag for 30 min at a time

A nurse is completing an admission history on a client and says "as a routine part of your medical history it's important to include the sexual aspects of your life. Would it be all right if we discussed this?" This is an example of the nurse using the PLISSIT model to:

Ask permission to discuss sexuality ...

A nurse is receiving a change of shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Assessment

A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity?

Assigning tasks to an assistive personnel

A nurse is caring for a client who experienced a lacerated spleen and has been on bed rest for several days. The nurse auscultates decreased breast sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted?

Bear down

A nurse is assessing a client's peripheral circulation. Which of the following locations should the nurse palpate to assess the posterior tibial pulse?

Behind the medial malleolus

A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint. Based on these findings, to which of the following providers should the nurse request a referral for the client?

Oral surgeon

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse?

Scheduling a diagnostic study for a client

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the wrist restraint use a quick-release knot

A nurse is caring for a client who has MRSA in an abdominal wound. The nurse enters the room to check the clients post. Which of the following actions should the nurse take?

Wear clean gloves

A nurse at an extended care facility is instructing a class of assistive personnel about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the assistive personnel about the client's use of a cane?

When the client moves he should move the cane forward first