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dullness

56. A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?

Respiratory rate

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

Albumin

58. A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

Hold the hands higher then the elbows.

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

A client who has preeclampsia with a BP or 138/90 mm/Hg

6. A nurse receives report about assigned clients at the start of shift. Which of the following clients should the nurse plan to see first?

Access the apical pulse for a full minute

60. A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following cations should the nurse take?

"If I could lose 50 pounds, I might stop having so many apneic episodes."

61. A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates and understanding up the teaching?

Determine if the client has hearing aids.

62. A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

tachycardia

63. A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Perfoming hand hygiene before, during, and after contact with the patient.

64. A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transition of the client's infection?

provide an adaptive feeding device for the client

66. A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

Determine the location of the pain.

67. A nurse is caring for a client who request prescription pain medication. Which of the following actions should the nurse perform first?

A client who sustained a head injury and is having periods of confusion.

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

How do you handle stress?

69. A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions asked by the newly licensed nurse requires intervention?

an intrauterine device (IUD)

7. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable?

"I will come back later and talk."

70. A nurse observes an adolescence client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

Clean under the nails with an orange stick

71. A nurse is providing nail care for a client. Which of the following actions should the nurse take?

"Information about a client can be disclosed to family members at any time."

72. A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPPA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

Ask the clients full home name and date of birth

73. Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Under the ankle

74. A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibia pulse? (Selectable areas are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

As the client to push her feet against the nurse's palms.

75. A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Contact the providers to question the dosage

76. When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Medical history

77. A nurse is assisting with admission of a client to inpatient unit. Which of the following sources of information should the nurse reply on for accurate information about the client?

Performing hand hygiene frequently and consistently.

78. A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is most effective way to prevent the spread of pathogens during client care?

earlobe

79. A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

2 1/2 cups

38. A nurse is instructing a group of adult clients about nutrition. The nurse should include which of the following as the recommended amount of vegetables serving per day?

Testing visual acuity

8. A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

use intermittent eye contact

1. A nurse is caring for a client using active listening skills. Which of the following actions should the nurse take?

blood

10. A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

peanut butter and jelly sandwich

11. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet?

-check the cannula position on regular basis -check the top of ears for skin breakdown -post "no smoking" signs in a prominent location in the home

12. A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply)

fifth intercostal, mid-clavicular (left)

13. A nurse is preforming a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot sports to select the artwork below. Select the only hot spot that corresponds to your answer.)

1 cup, 4 oz, 3 oz, 1 cup, 1 cup, 5oz, 3oz = 1170 mL

14. A nurse is calculating the total fluid intake for a client during a 4-hour period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number, using leading zeros if it applies, and do not use trailing zeros.)

"There were no injuries sustained."

15. A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to use the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentations should the nurse include in the client's medical record?

-providing hygiene care to a client who has HIV-positive -irrigating a client's abdominal wound -suctioning a client's new tracheostomy tube

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

"I will wear synthetic clothing and woolen socks when using my oxygen."

17. A nurse is providing a discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

conjunctiva

18. 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 the client?

"Before the examination, your provider will give you a sedative that will make you sleepy."

19. A nurse is providing instruction for 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following represents responses by the nurse is appropriate?

Wash with soap and water FIRST, then report to supervisor, and immediately seek medical treatment.

2. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Pinch the tube prior to attaching the medication syringe

39. A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

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

20. 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?

green pepper, orange, and strawberries

21. A nurse is developing an education program for a community group about dietary intake of vitamins and minerals in the diet. The nurses should include which of the following food as sources of vitamin C? (Select all that apply)

Furrowed tongue

22. A nurse in a community clinic is assessing in older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?

"What brought you to the hospital?"

23. A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

"Rub all the surfaces of your hands with an alcohol rub for 20 to 30 seconds."

24. A nurse is teaching a new group of assistive personnel about the importance of hand hygiene. Which of the following statements should the nurse include?

When asking if the client took his medications this morning.

25. A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?

Provide the client with a high diet in protein

26. A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Hold the container of solution 12" (30cm) above the anus

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

The client achieves optimal personal growth.

28. A nurse is reviewing goals of the nurse-client therapeutic relationship with a client who is seeking counseling. Which of the following information should the nurse include in this discussion?

Advocate

29. 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 decisions?

1 cup of milk

3. A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium? (Select all that apply)

Two nurses using the friction-reducing device.

30. A nurse is preparing to move a client who is only partially able to assist up to bed. Which of the following methods should the nurse plan to use?

Albumin

31. A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Place one finger across the acromion process and measure 3 fingers below the midpoint and center of the lateral aspect of the upper arm

32. A nurse is preparing to administer hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

The second left intercostal space

33. A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

"Documentation is a tool of the interprofessional health care team."

34. 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 newly licensed nurse indicates understanding of the purpose of documentation?

Close door and apply mask

35. A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (Select all that apply.)

Limit the client's fluid intake in the evenings.

36. A nurse us caring for an older adult who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Assigning task to an assistive personnel (AP)

37. 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?

turn the client on his side before starting oral care

4. A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

unknown

40. Unknown

Language barrier

41. A family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palates his abdomen, yet responds to questions only by nodding and smiling. Which of the following factor should the nurse identify as a likely explanation for the client's behavior?

pain

42. A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse is identifies with this client, which should the nurse interpret as a need to postpone the session?

Vitamin C

43. A nurse is instructing a group of clients about nutrition and eating high in iron. The nurse should include that which of the following aids in absorption of iron?

Use attentive listening with the client.

44. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Pinch up a fold of skin to check for turgor

45. A nurse in a clinic is caring for an older adult client who reports dry, flaky skim on her upper back. Which of the following is an intervention should the nurse complete?

Soybeans

46. A nurse is instructing a group of clients about mortician. The nurse should include that which of the following foods is a good source of high-quality protein?

Elevate the head of the bed 30-45 degrees

47. A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Lock the wheels of the bed and the wheelchair.

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

"I will wear gloves and gown when bathing a client who has open skin lesions."

49. A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

- emptying urine from an indwelling urine collection bag - providing oral care - changing ostomy care pouch - placing oral medication tables into a client's hand

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

Bruxism

50. A client tells a nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Assess the client.

51. A client receives a wrong medication. The nurse who made the mediation error should take which of the following actions first?

Confusion

52. The family of an older client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

Secure the restraint's using a quick-release tie.

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

Discard the tablet and obtain another dose of medication.

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

Move the client to a room closer to the nurses' station

55. A nurse is caring for an older 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?

Call the dietary department and ask for a Kosher tray

80. A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with non-fat milk. Which of the following actions should the nurse take?

Turn the client on his side before doing the oral care

81. A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)

"I cook my food with canola oil."

82. A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on low-cholesterol diet?

"When the client moves, he should move the cane forward first."

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

- decrease cough reflex, decrease bladder capacity, more difficulty seeing due to greater sensitivity to glare, dehydration of inter verbal discs

84. 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.)

Tie linen bags securely at the top

85. A nurse is on a medical unit is teaching a group of assistive personnel about handing client's bed linens safely. Which of the following instructions should the nurse include?

Assessment

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

Veracity

87. A nurse administering an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced to 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 principal did the nurse violate?

Instruct the client to tighten muscle groups for a short period, and then relax.

88. A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. Which of the following actions should the nurse take as directed by the plan of care?

Critically analyze client data to determine priorities

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

trust VS mistrust

9. A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a priority task of which of the following stages of psychosocial development?

A slice of cheese

90. A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the needs for further teaching?