Nursing 301: ATI Form A

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? "What could I have done to deserve this illness?" "I blame medical science for not curing me." "Where is my daughter at a time like this?" "Will I ever begin to feel in charge of my life again?"

"What could I have done to deserve this illness?" The client's terminal illness might prompt him to review his life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Wear sterile gloves when removing the old dressing. Warm the irrigation solution to 40.5 C (105 F) Cleanse the wound from the center outward Use a 20-mL syringe to irrigate the wound

Cleanse the wound from the center outward The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include is within the RN scope of practice? Insert an implanted port. Close a laceration with sutures. Place an endotracheal tube. Initiate an enteral feeding through a gastrostomy tube.

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? Neck vein distention Urine specific gravity Rapid heart rate Blood pressure 144/82 mm Hg

Rapid heart rate Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is planning care to improve self-feeding for a client who has vision loss, Which of the of the following interventions should the nurse include in the plan of care? Tell the client which food she should eat first. Provide small-handle utensils for the client Thicken liquids on the client's tray. Use a clock pattern to describe food on the client's plate.

Use a clock pattern to describe food on the client's plate. Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals.

A nurse is teaching an older adult client who is at risk for osteoporosis about to begin a program of regular physical activity. Which of the following types of activity should the nurse recommend? Walking briskly Riding a bicycle Performing isometric exercises Engaging in high-impact aerobics

Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse take? "They allow the court to overrule an adult client's refusal of medical treatment." "They indicate the form of treatment a client is willing to accept in the event of a serious illness." "They permit a client to withhold medical information from health care personnel." "They allow health care personnel in the emergency department to stabilize a client's condition."

"They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client.

Ask the client if he can bear weight Position the chair on the left side of the bed Have the client sit and dangle his feet at bedside Use the sand-and picot technique to move the client to the chair.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take? Suction the client's airway. Administer a bronchodilator. Increase the humidity in the client's room. Assist the client to an upright position.

Assist the client to an upright position. When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed to the semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs.

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as indication that the client's family member is coping effectively with the situation? "We are not worried. We still have hope that everything will be okay." "This is a difficult time, but we are helping each other through this." "After he comes home, we can plan our family reunion." "We don't need to talk about funeral arrangements at this time."

"This is a difficult time, but we are helping each other through this." An effective coping strategy is talking with others in the family and supporting each other. This statement displays effective coping skills because the family is using social supports to assist them throughout the grief process.

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse take? Drink a cup of hot cocoa before bedtime. Exercise 1 hr before going to bed. Use progressive relaxation techniques at bedtime. Reflect on the day's activities before going to bed.

Use progressive relaxation techniques at bedtime. Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication form a 2 mL vial. Which of the following actions should the nurse take? Ask another nurse to observe the medication wastage. Notify the pharmacy when wasting the medication. Lock the remaining medication in the controlled substances cabinet. Dispose of the vial with the remaining medication in a sharps container.

Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? Check the client for injuries. Move hazardous objects away from the client. Notify the provider. Ask the client to describe how she felt prior to the fall.

Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is providing care for four clients. Which of the following situations requires the nurse to complete an incident report? A nurse tied a client's restraint straps to the moveable part of the bed frame. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology. A nurse administers a medication to a client 30 min before the dose is due. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

A client who has an IV infusion pump receives an additional 250 mL of IV fluid. The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents.

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? Allow extra time for the client to respond to questions. Expect the client to have difficulty understanding the information. Avoid references to the client's past experiences. Keep the learning session private and one-on-one.

Allow extra time for the client to respond to questions Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? Auscultate lung sounds. Measure urine output Monitor blood pressure readings. Monitor serum electrolyte levels.

Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.

A nurse is admitting a client who has influenza. Which of the following types of transmission precautions should the nurse take? Droplet Airborne Contact Protective environment

Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.

A nurse is performing a Romberg's test during the physical examination of a client. Which of the following techniques should the nurse use? Touch the face with a cotton ball. Apply a vibrating tuning fork to the client's forehead. Have the client stand with her arms at her side and her feet together. Perform direct percussion over the area of the kidneys.

Have the client stand with her arms at her side and her feet together. Romberg's test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. Remove the NG tube if the client begins to gag or choke. Apply suction to the NG tube prior to insertion. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea.

A nurse in surgical notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Ensure sterilization of nondisposable items with ethylene oxide. Wrap monitoring cords with stockinette and tape them in place. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. Wear hypoallergenic latex gloves that contain powder.

Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? BUN 15 mg/dL Creatinine 0.8 mg/dL Sodium 143 mEq/L Potassium 5.4 mEq/L

Potassium 5.4 mEq/L The value is above the expected reference range and the nurse should report this finding. This client is at risk for dysrhythmias.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? Press gently on the tragus of the client's ear. Pack a small piece of cotton deep into the client's ear canal. Move the client's auricle down and back toward her head. Tilt the client's head backward for 5 min.

Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visual fields Visual acuity

Pupil clarity Cloudy pupils mean that the client has cataracts. This makes his vision cloudy and creates halos around lights, which can increase his risk for falls because he cannot see items in his path clearly Visual fields. The nurse should use a finger to test the client's peripheral vision by moving it out of range and then back into his visual field to determine when he sees the finger. If the client has a visual field impairment, he is at risk for falls because he might not see objects outside his central vision and trip over them or bump into them and fall. Visual acuity. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. If the client wears glasses, he should wear them during the assessments. If the client has a vision impairment, he is at risk for falls because he might not see objects in his path and trip over them or bump into them and fall..

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? Discuss the risk factors for colon cancer. Focus teaching on what the client will need to do in the future to manage his illness Provide the client with written information about the phases of loss and grief Reassure the client that this is an expected response to grief.

Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis.

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? Side-lying Supine Semi-Fowler's Trendelenburg

Semi-Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows for maximum expansion of the lungs.

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? Purulent exudate Warmth Skin blanching Bleeding

Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? "When do you usually bathe, in the morning or in the evening?" "Do you prefer a bath or a shower?" "At what temperature do you prefer your bath water?" "Are you able to help with your hygiene care?"

"Are you able to help with your hygiene care?" The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, the nurse's priority is to assess the client's ability to assist with her hygiene care.

A nurse is assessing a client's readiness to learn abut insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? "I can concentrate best in the morning." "It is difficult to read the instructions because my glasses are at home." "I'm wondering why I need to learn this.". "You will have to talk to my wife about this."

"I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I had a bowel movement, but I was able to save the urine." "I have a specimen in the bathroom from about 30 minutes ago." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." "I drink a lot, so I will fill up the bottle and complete the test quickly."

"I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I'm having mild pain." "The pain is like a dull ache in my stomach." "I notice that the pain gets worse after I eat." "The pain makes me feel nauseous."

"The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in her own words.

A nurse manager is preparing to review medication documentation with a group of newly lisenced nurses. Which of the following statements should the nurse manager plan to include in the teaching? "Use the complete name of the medication magnesium sulfate." "Delete the space between the numerical dose and the unit of measure." "Write the letter U when noting the dosage of insulin." "Use the abbreviation SC when indicating an injection."

"Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate

A nurse in a clinic is caring for a middle adult client who states, " The doctor says that, since I am at average risk fro colon cancer, I should have a routine screening. hat does that involve?" Which of the following responses should the nurse make? "I'll get a blood sample from you and send it for a screening test." "Beginning at age 60, you should have a colonoscopy." "You should have a fecal occult blood test every year." "The recommendation is to have a sigmoidoscopy every 10 years."

"You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." "I'll use a woolen blanket if I get chilly while I'm using my oxygen." '"I'll check the wires and cables on my TV to make sure they are in good working order." "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over."

'"I'll check the wires and cables on my TV to make sure they are in good working order." Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks.

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV state for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medication record? .3 mg 0.3 mg 0.30 mg 3/10 mg

0.3 mg The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A nurse is preparing a heparin infusion for a client who was hospitalized with deep vein thrombosis. The order reads 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

8 mL/hr

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse. A nurse asks a nurse from another unit to assist with her documentation. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside.

A nurse asks a nurse from another unit to assist with her documentation. Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of HIPAA guidelines.

A nurse caring for client who has herpes zoster and asks the about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? Biofeedback Aloe Feverfew Acupuncture

Acupuncture The nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse intake? Contact precautions Droplet precautions Airborne precautions Protective environment

Contact precautions Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? Bladder distention Decreased blood pressure Calf swelling Diminished bowel sounds

Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following if the nurse's priority action? Request that a respiratory therapist discuss the technique for incentive spirometry. Determine the reasons why the client is refusing to use the incentive spirometer. Document the client's refusal to participate in health restorative activities. Administer a pain medication to the client

Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The top of the cane is parallel to the client's waist. When walking, the client moves the cane 46 cm (18 in) forward. The client holds the cane on the stronger side of her body. The client moves her stronger limb forward with the cane.

The client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increase support and maintain alignment.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify which of the following actions requires further intervention? Erythema on pressure points Lower-extremity pulse strength of 2+ Fluid intake of 3,000 mL per day A bowel movement every other day

Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? Dissolve each medication in 5 mL of sterile water. Draw up medications together in the syringe. Push the syringe plunger gently when feeling resistance. Flush the tube with 15 mL of sterile water.

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? Tomato juice Banana slices Pancakes Fried Eggs

Fried eggs For a client who is prescribed a mechanical soft diet, the nurse should remove fried eggs from the meal tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are allowed on a mechanical soft diet and are an acceptable replacement for this item.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? Assign the client to a room with a negative air-flow system. Use alcohol-based hand sanitizer when leaving the client's room. Clean contaminated surfaces in the client's room with a phenol solution. Have family members wear a gown and gloves when visiting.

Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregivers must also wear gowns and gloves.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? Place the client in high-Fowler's position. Increase the client's intake of carbohydrates. Massage reddened areas with unscented lotion. Have the client use a trapeze bar when changing position.

Have the client use a trapeze bar when changing position. By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

A nurse is performing a peripheral vascular assessment for a client. When placing the stethoscope on the clients neck they hear a weird sound. This sound indicates which of the following? Narrowed arterial lumen Distended jugular veins Impaired ventricular contraction Asynchronous closure of the aortic and pulmonic valves

Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Limit each visitor to 2-hr increments. Wear a surgical mask when providing client care. Use antimicrobial sanitizer for hand hygiene.

Place the client in a room with negative-pressure airflow The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care The nurse should wear gloves when assisting with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever her hands might come in contact with a client's body fluids, such as saliva, and the mucous membranes in the mouth. Use antimicrobial sanitizer for hand hygiene The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. The nurse should also wash her hands with soap and water when her hands have visible soiling.

A nurse is planning to insert peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? Insert the catheter at a 45° angle. Place the client's arm in a dependent position. Shave excess hair from the insertion site. Initiate IV therapy in the veins of the hand.

Place the client's arm in a dependent position. The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? Apply the stockings so the creases are on the front side of the leg. Apply the stockings while the client's legs are in a dependent position. Remove the stockings at least once per shift. Remove the stockings while the client is sitting in a reclining chair.

Remove the stockings at least once per shift. The nurse should remove the stocking once per shift to check the client's circulation and skin integrity.

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. the nurse should identify that he is going through which of the following types of role-performances stress? Role ambiguity Sick role Role overload Role conflict

Role overload The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can perform.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheotomy. Which of the following actions should the nurse take? Use a resuscitation bag with 80% oxygen prior to the procedure. Select a suction catheter that is half the size of the lumen. Place the end of the suction catheter in water-soluble lubricant. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? Critical pathway Situation, background, assessment, and recommendation (SBAR) Transfer report Medication administration record (MAR)

Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool used to relate a client's status during a change-of-shift report.

A nurse if lifting a bedside cabinet to move it close to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse when lifting this object? Bend at the waist. Keep his feet close together. Use his back muscles for lifting. Stand close to the cabinet when lifting it.

Stand close to the cabinet when lifting it. This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Place the client in a side-lying position. Instill 15 mL of irrigation fluid into the catheter with each flush Subtract the amount of irritant used from the client's urine output Perform the irrigation using a 20 mL syringe

Subtract the amount of irritant used from the client's urine output The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is caring for a client who has an NG tube and receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Rinse the feeding bag with water between feedings. Tell the client to keep the head of the bed elevated at least 30°. Make sure the enteral formula is at room temperature. Wipe the top of the formula can with alcohol.

Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula backward into the esophagus.

A nurse is reviewing a client's medication prescription, which reads, digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? The medication The route The dose The frequency

The dose The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medications to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration. Transfer the medication to a medicine cup. Place the client in a semi-Fowler's position prior to medication administration. Verify the dosage by measuring the liquid before administering it.

The nurse should gently shake the liquid medication to ensure the medication is mixed. The nurse should gently shake the liquid medication to ensure the medication is mixed.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? Ask the client to consider a direct donation. Withhold the blood transfusion. Request a consultation with the ethics committee. Ask the client's family to intervene.

Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment.