practice exam 1

A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

"Client found lying on floor." The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation.

A nurse is performing a pre operative assessment on four clients. The nurse should the identify that which of the following clients is at risk for latex allergy

A client who has spina bífida They have frequent contact with latex product so they are more at risk

A nurse is caring for a client who has a sodium level of 125 mE/L. Which of the following findings should the nurse expect?

Abdominal cramping

A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

Administer pain medication 45 min before changing the client's dressing.

A nurse is preparing to administer an intermittent IV bolus of phenytoin to a client who is receiving, continuous IV infusion of dextrose, 5% in water. The nurse is unfamiliar with the administrating of phenytoin which of the following action should the nurse take to ensure that the medication and the IV solution are compatible.?

Consult the facilities pharmacist

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins Symptoms of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

The nurse is preparing to administer 15 units of regular insulin along with 25 units of NPH insulin, which of the following action should the nurse take when mixing the insulins?

Inject 25 units of air into the NPH vial of insulin

Hey Nurse, any providers office is reviewing laboratory reports for a client who is at risk for heart disease, which of the following results should the nurse report to the provider?

LDL 170mg/dl

A nurse is preparing the room for a client who is transferring from the emergency department and is on seizure precautions. Which of the following items should the nurse place in the clients room ?

Oral nasal suction

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload

A nurse is evaluating the developmental motor skills of a 4 month old infant which of the following should the nurse expect?

Sits up with support

A nurse is assessing an older client who has hemiparesis following a stroke. Which of the following findings should the nurse report to a nutritionist?

The client has a decrease in lean body mass

A nurse is providing teaching to a client who has severe weakness in there right lower extremity, and is learning how to walk using a cane, which of the following actions by the client indicates an understanding of the teaching?

The client moves the cane forward before taking a step

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?

Withhold the blood transfusion. Patients who are competent have the right to refuse

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

droplet

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

wear a gown when caring for the client

A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching?

•"I am limiting my sodium intake to 2 grams daily." •"I am eating fewer potato chips and more früit for snacks." •"I know to call my doctor if I gain 3 pounds or more in 2 days." The client should weigh in every day to monitor for fluid retention.

A nurse in a surgical suite notes documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place 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 assessing a client's readiness to learn about insulin self-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."

And Nurse is preparing to insert a new IV catheter for a client which of the following action should the nurse plan to take?

Choose a vein that is palpable

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep. The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

"It might help me to listen to music while I'm lying in bed." Listening to music is an effective nonpharmacological intervention for the management of mild pain.

A nurse manager is preparing to review medication documentation with a group of newly licensed 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."

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

107 mL/hr

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Provider is admitting client for the management of presumptive bacterial pneumonia.

Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has a temperature of 38.6° C (101.5° F) indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. Remain 1 m (3 feet) from the client.

A nurse is planning care to prevent plantar flexion for a client who is in a coma, which of the following intervention should the nurse include in the plan of care?

Brace of clients feet with ankle foot orthotics

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions.

A nurse is teaching a client how to perform active range of motion exercise of the lower extremities to improve mobility. Which of the following instruction should the nurse include in the teaching?

Complete each session 2 times per day

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.

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. Use antimicrobial sanitizer for hand hygiene.

A nurse is teaching a class about home safety. Which of the following instructions should the nurse include in the teaching?

Place toddlers in rear-facing car seats until they are 2 years old

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

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?

Subtract the amount of irrigant used from the client's urine output.

A nurse is planning to perform post Mortem care for a client which of the following action should the nurse plan to take?

Verify whether the client requires an autopsy

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

arrange food in a consistent pattern on the client's plate

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

"Would you like it if we discussed the transfer with your family member?"

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Allow the adolescent to make decisions regarding his daily routine.

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative teaching. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching

A nurse has just inserted a nasogastric (NG) tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus. An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

A nurse is completing an informed consent document for a 16 year old adolescent who is married and is scheduled for an emergency appendectomy. Which of the following actions should the nurse take?

Ask the client if they understand the providers plan for the appendectomy

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?

Assist the client to an upright position According to evidence-based practice the nurse should assist the client to an upright position. This assists with chest expansion and increases the effectiveness of the existing supplemental oxygen.

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 initiate?

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

A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

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?

Have family members wear a gown and gloves when visiting.

A nurse is teaching a client about health promotion, secondary prevention strategy, which of the following recommendations should the nurse include?

Hypertension screening

A nurse is completing dietary, teaching with a client who has heart failure and has a prescription of 2 g of sodium diet which of the following statements made by the client indicates an understanding of the teaching

I can have nonfat yogurt as dessert

A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?

I want you to tell me about measures available to keep me comfortable." This statement would indicate that the client has accepted that their diagnosis is terminal and is focusing on the goals of palliative care, which are comfort and manifestation control.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L

Complete the following sentence by using the list of options. The nurse should first address the client's _________ followed by the clients _______?

The nurse should first address the client's physical safety followed by the client's positioning

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

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 for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)

•Assist the client with a partial bed bath •Measure the client's BP after the nurse administers an antihypertensive medication •Use a communication board to ask what the client wants for lunch

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system."

The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching.

Eat probiotic foods, such as yogurt is correct. Probiotic foods, such as yogurt, contain live bacterial cultures, which can help to reduce diarrhea. Avoid alcohol while experiencing diarrhea is correct. Alcohol is a substance that stimulates gastrointestinal (Gl) motility. Eat raw vegetables is incorrect. Raw vegetables contain fiber. The nurse should instruct the client to eat vegetables that are well-cooked and do not have skins or seeds Avoid caffeine while experiencing diarrhea is correct. Caffeine is a substance that stimulates Gl motility. Follow a low fiber diet

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client identifies the location of a fire extinguisher. The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

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 planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should receive a pneumococcal vaccine when you are 65 years old." The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old.

A nurse and a providers clinic is teaching a female client how to collect a clean, catch urine specimen at home which of the following information should the nurse include in the teaching?

Clean your vaginal area from front to back

A nurse is reviewing the medical record for a client who is receiving continuous enteral feedings Which of the following findings should the nurse report to the provider?

Gastric aspirate ph of 7

Nurse is at a providers office is coming for young adult client which of the following information should the nurse provide regarding health promotion strategies?

Have a breast cancer screening after four years of age

A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

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-injury development.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

Otain the pronouncement of death from the provider Remove tubes and indwelling lines Wash the client's body Ask the client's family members if they would like to view the body Place a name tag on the body

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is planning comfort measures to decrease painful stimuli for a client who has back pain which of the following intervention should the nurse include in the plan of care?

Please pillows between the clients leg when lying laterally

A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

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 into the esophagus.

A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again.

Urinary output is correct. A client who has an indwelling urinary catheter should produce at least 30 to 50 mL/hr of urine. The client's output is less than the expected volume. The nurse should assess the catheter's placement and potential for blockage due to their reduced urine output. This finding should be reported to the provider. Reported pain level is correct. The client's pain has not been relieved with the administration of morphine. According to the client's report, their pain level is increasing. This finding should be reported to the provider. Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

A nurse is caring for a client in a medical-surgical unit. After reviewing the assessment findings, which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.

When generating solutions, the nurse should plan to administer analgesic prior to planned activities, assist the client to dangle their legs at the bedside prior to standing, and delegate the application of sequential compression devices to assistive personnel. Administering analgesia prior to activities can decrease pain and enable the client to perform their planned activities. Assisting the client to dangle their legs prior to standing can increase venous return and reduce orthostatic hypotension. The application of sequential compression devices can be delegated to assistive personnel after initial assessment by the nurse

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

bladder scan shows 525 mL of urine A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.

A charge nurse is teaching a newly hired nurse about the facility's computerized documentation system. Which of the following actions should the nurse take?

instruct the newly hired nurse to use direct quotes when recording client statements.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

maintain a consistent time to wake up each day The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

a nurse is working at a providers office that uses various forms of electronic communication devices. which of the following actions should the nurse take to protect client confidentiality

verify that recipient contact information is correct before faxing information