A...T...I 174Qw/no exp
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands that the preoperative teaching regarding pain control has been effective when the client states which of the following?
" It may help me to listen to music while I'm lying in bed."
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 reposnses made by the nurse is apporpriate?
"Have a seat and let me tell you what has happened"
A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her postoperative diet prescription reads: clear liq; advance as tolerated. Which is appropriate for the nurse to tell the client?
"I am going to listen to your abdomen."
A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
"I flushed what I urinated at 7 am and have saved the rest since"
A hospice nurse is providing end-of-life care to a client who has terminal lung cancer. The client states, "I am so tired and afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse?
"I will be able to give you more a medication to help your breathing"
A nurse is providing teaching to a client who is recieving chemotherapy. Which of the following client statements indicates an understanding of the teaching?
"I will disinfect my toothbrush weekly"
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further teaching?
"I will replace the old throw rug in the kitchen with a new one"
a nurse is performing a spiritual assessment on a client newly admitted to the unit. The nurse recognizes that the purpose of perfuming a spiritual assessment is to:
"Identify the clients religious...."
A nurse is caring for a client who asks about the purpose of advanced directives. Which of the following is an appropriate response by the nurse?
"It indicates the forms of treatment a client is willing to accept in the event of a serious illness"
A client demonstrates anger when the nurse does not response within 5 minutes of ringing for the nurse. Which of the following is an appropriate response by the nurse?
"It must be frustrating. I have a few minutes now."
A nurse is speaking with the parent of an infant who has a cardiac defect. After the parent expresses concern, which of the following is an appropriate response?
"Tell me about your baby while I bathe her"
A nurse is assessing a client admitted with a sudden onset of sever back pain of unknown origin. Which statement would be most effective for the nurse use to elicit further info from the client about his pain?
"Tell me how you are feeling right now."
A nurse on an oncology unit is caring for a client who has tears in his eyes and states "The doctor just told me that I don't have long to live." Which of the following is an appropriate response of the nurse?
"Tell me more about how you're feeling"
A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self care and appropriately adds which statement?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
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?
"The pain is like a dull ache in my stomach"
A nurse is caring for a client who cannot bear weight on the fractured ankle. Which of the following client statements indicates a need for further teaching regarding three point fait crutch walking?
"When I get out of a chair, I'll hand both crutches on the side near my weak leg"
A nurse is caring for a client who is postop following a partial colectomy. The client has a NG tube set to low cont. suction. The client tells the nurse his throat is sore and asks the nurse when the NG tube will be taken out. Which response is appropriate?
"When your gastrointestinal tract is working agin, in about 3-5 days, the tube can be removed."
An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth." which is an appropriate nursing response?
"you seem worried. are you concerned someone may see you without your teeth?"
a nurse is caring for four clients. which of the following actions should the nurse take to prevent the spread of infection?
(Cant see Answer)
a nurse is preparing to care for a client who has methicillin-resistant staphylococcus aureus, in addition to a gown and gloves, the nurse should also do which of the following
(Cant see answer)
A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?
0.9% sodium chloride
A nurse is performing an abdominal assessment of an adult client. Identify the correct sequence of steps used for this assessment.
1. Inspection 2. Auscultation 3. Percussion 4. Palpation
A nurse is caring for a client who has taken in 2,600 mL of fluids in 24 hr. Which of the following is an expected output for the client?
2,500 mL
A nurse is checking blood pressure at the community health screening. Which of the following clients is at risk for primary hypertension?
A client who has an elevated LDL
A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation of HIPPA guidelines?
A nursing student consults another classmate to assist with her documentation
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?
Are you able to help with your hygiene care?"
When admitting a client, the nurse records which information in the client's record first?
Assessment of the client
A nurse is planning care for a client who has had stroke resulting in aphasia and dysphagia. Which of the following task should the nurse assign to an AP? Select all that apply:
Assist the client with partial bed bath Measure the client's BP AFTER NURSE ADMINISTERS AN antihypertensive medication. Use communication board to ask what the client wants for lunch
A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long term goal of weight loss?
Attempt to develop the clients' self-motivation
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter should be irrigated?
Bladder scan reveals 525 mL of urine.
A nurse is giving an end-of shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide?
Breath sounds
A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which is priority?
Check the client's perineum
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client and his family?
Check the cord routinely for frays and tearing Consider purchasing a generator for power backup monitor for signs of hypoxia
a nurse has an order to remove sutures from a client. after retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
Clean sutures along with the incision site
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
Compare the clients home medications with the providers prescriptions
A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching?
Consume a light snack of carbohydrates at bedtime
a nurse is precepting a a newly licensed nurse who is preparing to help a client perform tracheostomy care. the nurse should intervene if the equipment the precept gathered included...
Cotton Balls
While measuring a client's vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?
Count the apical pulse rate for 1 full min. and describe the rhythm in the chart
A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan?
Demonstration of appropriate hand hygiene
A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self administration. Which of the following actions should the nurse take first?
Determine the patients learning style.
A client is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. Which of the following actions should the nurse take first?
Discontinue the infusion
A nurse's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surger, and the neighbor is aanxious about acquiring an infections from a blood transfusion. Which nursing response is appropriate?
Donating autologous blood before the surgery
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this patients care, when should the nurse initiate discharge planning?
During the admission process.
A fire starts in a patients room. what should the nurse do?
Evacuate the patient
An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?
Examine the elbow
A 3 year old child has had multiple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake. Which approach is likely to be successful:
Examine the mouth last
A nurse is preparing to insert a nasogastric tube for a client admitted with a bowel obstruction. Which of the following should the nurse do first?
Explain the procedure to the client
A nurse contacts the faculty interpreter to explain a therapeutic procedure for a client who does not speak english. Which of the following guidelines should the nurse follow when communicating with the interpreter?
Explain the purpose of the communication to the interpreter
A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is a nursing action?
Firmly tell the client not to grab.
A client is recovering from gall bladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?
Four to five
A client recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon?
Halo of erythema on the surrounding skin
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5 mg/ml. Which of the following is an appropriate nursing intervention?
Have a second nurse witness the disposal of remaining medication
A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse?
Have another nurse witness the disposal of the excess medication
an AP tells the nurse, "I am unable to find a large BP cuff for a client who is obese. Can I just use the regular cuff?" The nurse replies that using a regular cuff for an obese pt will result in a reading that is:
High
Which nursing action prevents injury to a client's eye during the administration of eye drops?
Holding the tip of the container above the conjunctival sac
A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching?
I will leverage my weight against my wife and shift as I move her"
A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he understands the use of this assistive?
I'll be sure to remove my hearing aid before taking a shower
A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route:
Increase infection rates
Which of the following is the responsibility of a nurse who is caring for a client receiving a PCA?
Instruct the family to avoid pressing the button for the patient
Following administration of levothyroxine 125 mcg at 0800, the nurse discovers the medication was given to a client for whom it was not prescribed. Which of the following is the correct way to document this error in the medical record of the client who received the medication?
Levothyroxine 125 mcg given at 0800 Provider notified
A nurse has inserted an indwelling urinary cath. for a male client. Where should the nurse tape the cath. to prevent pressure on the client's urethra at the penoscrotal junction?
Lower abdomen
A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision area?
Montgomery straps
A nurse is transcribing new prescriptions for a client. which of the following prescriptions is accurately transcribed by the nurse?
Morphine 4 mg IV bolus every 2 hours PRN for incisional pain
When a nurse makes an initial assessment of a client who is postoperative following a gastric resection, the client's NG tube is not draining. The nurses attempt to irrigate with 10ml of 0.9% sodium chloride is unsuccessful, she determines the tube is obstructed. Which action should the nurse take?
Notify the surgeon
A nurse is caring for a client who requires rectal temperature monitoring. Available at the client's bedside is a thermometer with a long, slender tip. Which of the following is the appropriate action for the nurse to take?
Obtain a thermometer with a short, blunt insertion end
A nurse is preparing to administer oral medication to a client who has dysphagia. Which of the following is an appropriate action by the nurse?
Offer each medication one at a time
A client develops a fecal impaction before digital removal of the mall, which type of enema should the nurse give to loosen the feces?
Oil retention
which of the following should the nurse do first when preparing to provide tracheostomy care?
PREFORM HAND HYGIENE
Cardiopulmonary resuscitation (CPR) has been initiated for a client in the emergency room. The nurse understands that a critical concept related to effective cardiac (chest) compressions is the need to:
PUSH HARD AND DEEP ON THE CHEST
A nurse is preparing to perform nasopharyngeal suctioning for the client who is unable to cough up excessive secretions. Which of the following actions is appropriate?
Perform suctioning while removing the trachea
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA
Place the client in a negative pressure room wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene
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
A nurse is preparing a change-of-shift report. Which of the following is an appropriate method to communicate continuity of care?
SBAR
A nurse is reviewing laboratory data for a client who has contusion to the chest wall following a motor vehicle crash. Which of the following values should the nurse report?
SaO2 86%
At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location?
Second intercostal space to the right of the sternum
A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions moximizes the effectiveness of incentive spirometry?
Semi-Folwers
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?
Serum albumin level below 3 g/dL indicates protein deficiency, putting the client at risk for pressure ulcer formation and poor wound healing
A nurse is developing a plan of care for an African-American child who is preschool-age and experiencing pain. Which of the following is the best way for the nurse to assess the child's pain?
Show the child the Oucher Pain Scale
A nurse is planning care for a patient who has dysphagia following a stroke. What therapy should the nurse seek help from:
Speech therapy
A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider?
Stoma appears purple in color
A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site?
The area around the injection site feels warm when touched.
A nurse is teaching a client about self administering NPH insulin.
The client inserts the need at a 30 degree angle.
A nurse is caring for several clients who are receiving oxygen therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity?
The client recieving 100% oxygen via partial rebreathing mask
A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client's temp. is 102.6 F, her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority?
The client's temperature
The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse should cause the nurse to intervene?
The newly licensed nurse places the cap of the sterile saline bottle on the sterile field
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
Thread the IV catheter so that the hub rests at the insertion site
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family?
Use tracheostomy cover when outdoors
The nurse is evaluating a client who has right leg weakness and is learning to use a rubber-tipped standard walker. Which of the following actions by the client indicates proper use of the walker?
Uses a lifting motion to move the walker
A nurse is performing an eye irrigation for a client who has been exposed to smoke and ash. Which of the following nursing actions should receive highest priority?
Wearing gloves during the procedure
A nurse is caring for a client and performing blood glucose monitoring. Which of the following is an appropriate nursing intervention?
Wipe away the first drip of blood from the clients finger
a nurse has just inserted an ng tube for a client. which of the following assessment findings indicates that the tube is properly positioned
XRAY
when initiating CPR, the nurse must confirm which of the following assessment findings prior to beginning chest compressions?
absence of pulse
A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of he client's abdomen, the nurse expects the bowl sounds to be:
absent
A nurse is in a public building when someone cries out, "Help! I think he's having a heart attack!" The nurse responds to the scene and finds an unconscious adult lying on the floor. The nurses action after making sure someone has called EMS should be to:
administer cardiac compressions
A nurse 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 the daily routine
A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding?
an adolescent who has visible accessory muscle movement when breathing
Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?
apply intermittent suction when withdrawing the catheter
A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to:
ask the client if she is choking
A nurse is caring for a client with cancer who lives at home with her spouse. The spouse tells the nurse that the client is in pain "all of the time." Which of the following actions is most appropriate for the nurse to take?
ask the client to rate her pain
A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, the nurse should..
ask the client why she has changed her mind
A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. Which of the following interventions is appropriate?
ask the family if there are any special rituals that they would like to follow at this time
A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take?
aspirate for residual
A nurse is caring for a pt who is at risk for hypokalemia. Which of the following foods should be included into the pt's diet ?
avocados
In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:
be at an increased susceptibility for infection
a nurse on a rehabilitation unit is transferring a client from a bed to a chair. to avoid back injury, which of the following techniques should the nurse use?
bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurses hands under the client's axillae
A nurse is transcribing new orders for insulin based on client's blood glucose readings. The nurse notes that the provider did not write the frequency for checking blood glucose levels on the order sheet. Which of the following is the appropriate action by the nurse?
call the health care provider to determine the frequency of blood glucose checks
a nurse is checking a client's blood pressure to assess for orthostatic hypotension. Which of the following actions should the nurse take?
check the blood pressure two minutes after placing the pt in a sitting position
a hospitalized client needs a chest x ray. the radiology department calls the nursing unit and says that they are sending a transporter for the client. when entering the client's room, the priority action is to:
check the client's identification bracelet
A postop client has an indwelling urinary cath in place to gravity drainage. The nurse notes that the client's urinary drainage bag has been empty for 2 hr. The first action the nurse should take is:
check to see if the tubing is kinked
When obtaining a specimen for a culture and sensitivity from an indwelling cath, the nurse should:
cleanse the entry port prior to withdrawing urine
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
cleanse the wound from the center outwards
The nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (Hemovac) in place. Which nursing action will ensure proper operation of the device?
collapsing the device whenever it is one half to two thirds full of air
A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 minutes. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which is an appropriate nursing action?
disconnect the machine, and measure the blood pressure manually every 15 min. (malfunctioning equipment is a safety risk, remove it)
When replacing a client's surgical dressing, the nurse should
don clean gloves to remove the old dressing
which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?
elimination of the exposure
A nurse is caring for a client diagnosed with a terminal illness. The client asks several religious beliefs related to death and dying. An appropriate nursing response is to:
encourage the client to express his thought about death and dying
A client is admitted for evaluation and control of hypertension. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurses first action is to
establish an airway
A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, thick is the most important nursing action initially?
evaluate pedal pulses (assessment of the reason for admission is first priority)
When communicating with a client who is hearing impaired the nurse should:
face the client and speak slowly
before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of..
friction
A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client's skin turgor, the nurse should:
grasp a fold of skin on the chest under the clavicle, release it, and not if it springs back
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. 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 performing a Romberg's test during the physical assessment of the client. Which of the following should the nurse use?
have the client stand with arms at side and feet together
A nurse is caring for a client for whom a nasogastric tube is ordered for stomach decompression. Which of the following actions is appropriate when inserting the NG tube?
have the client take sips of water to promote insertion of the NG tube into the esophagus
An older adult just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?
help the client write down the questions to ask the provider, so that the client doesn't forget
While changing the linen on a client's bed, the nurse should:
hold the linen away from his body and clothing
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?
implement a regular toileting schedule
A client's provider has ordered that a sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen:
in the morning, on arising
The mother of a toddler calls to the nurse, "Help! My baby is choking on his food." The nurse determines that the Heimlich maneuver is necessary based on
inability of the toddler to cry or speak
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions falls within the RN scope of practice?
initiate en enteral feeding through a PEG tube
a nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the:
involvement of the client in planning the change
a nurse tells a client that the provider has prescribed IV fluids. the client appears to be upset about the IV catheter insertion, but says nothing to the nurse. which of the following is an appropriate nursing response?
is there something about this procedure that concerns you?
A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:
is unable to swallow foods by mouth
an AP says to the nurse, "this client is incontinent of stool 3 or 4 times a day. i get angry, and i think the client is just doing it to get attention. i think we should put diapers on her." what is the appropriate response?
it is very upsetting to see an adult client regress
A nurse prepares to admit a client who is immediately postop. to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should:
lock wheels on the bed and stretcher
A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching?
maintain two points of support on the floor
A client who is postop following a laparotomy is reporting pain and a dry mouth. The client has morphine sulfate ordered to control the pain. Before administering the morphine sulfate ordered to control the pain. Before administering the morphine sulfate prescribed the nurse should first:
measure the client's vital signs
A nurse is assisting a client with range of motion exercise of the neck. Which of the following should the nurse suggest to promote neck rotation?
move her head from side to side
A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. Which of the following interventions should be initiated?
notify security for placement of necklace
A nurse is caring for a pt who is postoperative and has signs of hemorrhagic shock. When the nurse notices the surgeon he directs her to continue to take the pt's vital signs every 15 minutes and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next?
notify the nursing manager
To use the nursing process correctly, the nurse must first:
obtain information about the client
A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the clients blood pressure?
obtain the blood pressure under the same conditions each time
A nurse takes an older adult client who has dysphagia following a CVA to the dinning room for dinner. When assisting the client at mealtime, the nurse should:
offer the client tart or sour foods
When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. The sounds become for distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a..
pericardial friction rub
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?
place a warm compress over the IV site
to use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should..
place bed in high horizontal position
A nurse is preparing to insert a pherpheral IV catheter in an older adult, which of the following actions could the nurse
place the clients arm in a dependent position
A nurse is teaching a client with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client:
positition the irrigating solution bag 30 inches above the stoma
A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take?
pour warm water over the clients perineum
A nurse is completing an admission assessment of an older adult client. Which of the following findings is a potential indication of abuse?
presence of bruises on the arm in various stages of healing
A nurse is providing teaching to an older client about nutritional considerations associated with aging. What of the following should she choose to include in the teaching?
protein intake is often inadequate in older adults
A nurse is caring for a client who is 3 days postop following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as
purulent
A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse:
refrigerates the collected specimen
A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take?
remove each restraint one at a time every 2 hr
while starting an IV for a client, the nurse notices that her gloved hands get spotted with blood. the client has not been diagnosed with any infection transmitted via the bloodstream. which of the following should the nurse do as soon as the task is completed?
remove the gloves carefully and follow with hand hygiene
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client:
reports severe pain
A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse "All I have had since midnight is water and some juice." Which of the following nursing actions is appropriate?
reschedule this lab test for the next morning
A nurse is reviewing a protocol in preparation for suctioning a client who has a new tracheostomy. Which of the following is an appropriate action for the nurse to take?
select a suction catheter that is half the size of the lumen
a client is admitted to the hospital in the terminal stage of cancer. the nurse enters the client's room to administer medications and finds the client crying. the appropriate action is to...
sit and hold the client's hand
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 recognize as infiltration?
skin blanching
A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the results will indicate the amount of:
solutes in the urine
A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates to the charge nurse that the sterile field is contaminated?
sterile field is opened on a wet surface
A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dysphagia?
storing food in the mouth
A nurse is planning to delegate client care to an assistive personnel. Which of the following factors is most important for the nurse to consider before delegating care?
the facility's job description for the AP
A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. the client's surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that..
the signature on the preoperative consent form is the client's
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client?
use a bed exit alarm system
A nurse is caring for a client who has left-sided paralysis after a cerebrovascular accident. The client is unable to bear down his own weight. Which of the following actions is an appropriate method to move the client from his bed to wheelchair?
use a hydraulic life and have an AP help move the client
When ambulating a frail, older adult client, the nurse should:
use a transfer belt if the client is unsteady
The nurse is planning to teach a preschool child how to properly use a metered dose inhaler. Which of the following methods is appropriate for this client?
use role play and imitation while explaining
A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healthing and fight wound infection the nurse plans to arrange to increase the client's intake of:
vitamin C and zinc
Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shingella?
wash hands before and after client contact
The nurse is caring for an adult client who has fluid volume excess. When weighing this client, the nurse should:
weigh the client upon arising
At the surgical scrub sink, a surgical nurse demonstrates the proper surgical handwashing technique by scrubbing:
with her hands held higher than her elbows
A nurse is caring for a client who is refusing a scheduled 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 scheduled blood transfusion
