ati fundamentals
A nurse is caring for a client who has pneumonia. Vital Signs 0800:Heart rate 109/minRespirations 26/minBP 125/65 mm HgTemperature 39.2° C (102.6° F)Oxygen saturation 95% 1200:Heart rate 94/minRespirations 18/minBP 115/65 mm HgTemperature 37.8° C (100° F)Oxygen saturation 96% the nurse should identify that the client might be experiencing __(1)__ as evidenced by the client's __(2)__ 1. - urinary tract infection - seizures - extravasation 2. - urine appearance - IV catheter site - temperature
1. extravasation 2. IV catheter
A nurse in an emergency department is caring for a client. Physical Examination 1200:Influenza with nausea, vomiting, and diarrhea for 3 days.Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria.Plan: Admit for IV fluids. the nurse should first ___(1)__ followed by __(2)__ 1. a. review medications that might be causing confusion b. obtain a prescription from the provider for restraints c. assess where the restraint will be places on the client 2. d. padding body prominences under the restraint e. monitoring the client in restraints every 2 hr f. using other methods to keep the client safe
1. a 2. f.
A nurse is caring for a client who is receiving a unit of packed RBCs. Nurses' Notes 0800:Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815:Client reports itching and anxiety. Client's face is flushed and has hives. the client has manifestations of __(1)__ as evidenced by the client's __(2)__ 1. - allergic reaction - febrile reaction - fluid overload 2. - itching - temperature - oxygen saturation
1. allergic 2. itching
A nurse is caring for a client who has a new diagnosis of seizure disorder. Nurses' Notes 0800:Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. the nurse should first address the client's __(1)__ followed by the client's __(2)__ 1. a. blood pressure b. physical safety c. privacy 2. d. PRN medication e. positioning f. incontinence
1. b 2. e
A nurse is caring for a client. Exhibit 1: Medical History Client is receiving chemotherapy for treatment of breast cancer. Exhibit 2: Diagnostic Results Week 1:Hct 42% (37% to 47%)Hgb 15 g/dL (12 g/dL to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2:Hct 37% (37% to 47%)Hgb 12 g/dL (12 g/dL to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L) the client is at risk for __(1)__ as evidenced by the client's __(2)__ 1. - dysrhythmias - bleeding - infection 2. - platelet count - WBC count - Potassium level
1. bleeding 2. platelet count
A nurse is caring for a client who has a newly placed ileostomy. Exhibit 1 Nurses' Notes 0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. The nurse should first address the __(1)__ followed by the __(2)__ 1. - stoma color - hemoglobin level - ostomy leakage 2. - ostomy pouch seal - skin around the stoma - amount of stool in the pouch
1. stoma color 2. skin around the stoma
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
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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. place a name tag on the body 2. obtain the pronouncement of death from the provider 3. remove tubes and indwelling lines 4. wash the client's body 5. ask the client's family members if they would like to view the body
2, 3, 4, 5, 1
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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. inject 5 units of air into the bottle of regular insulin 2. withdraw the correct dose of NPH insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 4. withdraw the correct dose of regular insulin from the bottle
3, 1, 4, 2
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
8 mL/hr
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a. "Drink a cup of hot cocoa before bedtime." b. "Maintain a consistent time to wake up each day." c. "Exercise 1 hour before going to bed." d. "Watch a television program in bed before going to sleep."
b
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? a. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. b. The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field. c. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. d. The sterile field is positioned at the level of the newly licensed nurse's waist.
a
A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? a. back of the ankle b. below the knee c. inside the elbow d. above the elbow
a
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? a. Auscultate lung sounds. b. Measure urine output. c. Monitor blood pressure readings. d. Monitor electrolyte levels.
a
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? a. during the admission process b. as soon as the client's condition is stable c. during the initial team conference d. after consulting with the client's family
a
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? a. "We can talk about advance directives, and I can also give you some brochures about them." b. "You should set up a time to talk with your provider about that." c. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." d. "Why do you want to discuss this without your partner here to plan this with you?"
a
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? a. turn the client every 2 hr b. administer an antiemetic every 6 hr c. hold oral care d. increase the room's temperature
a
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 to the client? a. Use a bed exit alarm system. b. Raise four side rails while the client is in bed. c. Apply one soft wrist restraint. d. Dim the lights in the client's room.
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? a. "What could I have done to deserve this illness?" b. "I blame medical science for not curing me." c. "Where is my daughter at a time like this?" d. "Will I ever begin to feel in charge of my life again?"
a
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. c. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. d. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.
a
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.) a. Narrowed arterial lumen b. Distended jugular veins c. Impaired ventricular contraction d. Asynchronous closure of the aortic and pulmonic valves
a
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? a. Advocacy ensures clients' safety, health, and rights. b. Advocacy ensures that nurses are able to explain their own actions. c. Advocacy ensures that nurses follow through on their promises to clients. d. Advocacy ensures fairness in client care delivery and use of resources.
a
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? a. Ask another nurse to observe the medication wastage. b. Notify the pharmacy when wasting the medication. c. Lock the remaining medication in the controlled substances cabinet. d. Dispose of the vial with the remaining medication in a sharps container.
a
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. Administer the medication with the needle at a 45° angle. b. Administer the medication into the client's nondominant arm. c. Pull the client's skin laterally or downward prior to administration. d. Massage the injection site after administration.
a
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "When descending stairs, I will first shift my weight to my right leg." b. "I should place my crutches 12 inches in front and to the side of each foot." c. "As I sit down, I will hold one crutch in each hand." d. "I will make sure the shoulder rests are snug against my armpits."
a
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly b. Riding a bicycle c. Performing isometric exercises d. Engaging in high-impact aerobics
a
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? a. "Use the complete name of the medication magnesium sulfate." b. "Delete the space between the numerical dose and the unit of measure." c. "Write the letter U when noting the dosage of insulin." d. "Use the abbreviation SC when indicating an injection."
a
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? a. Pad the client's wrist before applying the restraints. b. Evaluate the client's circulation every 8 hr after application. c. Remove the restraints every 4 hr to evaluate the client's status. d. Secure the restraint ties to the bed's side rails.
a
a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take? a. examine personal values about the issue b. tell the parents that this is a necessary procedure c. inform the parents that the staff does not require their consent d. contact a spiritual support person to explain the importance of the procedure
a
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? a. check the client for injuries b. move hazardous objects away from the client c. notify the provider d. ask the client to describe how she felt prior to the fall
a
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. The nurse is assessing the client. Which of the following actions should the nurse take? (select all that apply) a. start a new IV in the client's left hand b. place a pressure dressing over the IV site c. apply heat to the client's left hand d. elevate the client's left arm e. stop the IV infusion
a, b, c
A nurse is caring for a client who has pancreatitis. Nurses' Notes 1000:Client states, "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fluids started and infusing in left peripheral IV site. Select the 3 tasks the nurse should delegate to an assistive personnel (AP). a. document the client's vital signs b. measure the client's intake and output c. transfer the client from wheelchair to bed d. insert an NG tube for the client e. collect data about the client's pain level
a, b, c
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. Rinse the feeding bag with water between feedings. b. Tell the client to keep the head of the bed elevated at least 30°. c. Make sure the enteral formula is at room temperature. d. Wipe the top of the formula can with alcohol.
b
Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply. a. wear an N95 mask when caring for the client b. place a container for soiled linens inside the client's room c. place the client in a negative airflow room d. remove mask after exiting the client's room e. wear a sterile, water-resistant gown if within 3 feet of the client
a, b, c, d
A nurse is admitting a client. Nurses' Notes 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. a. Place the client on droplet isolation precautions. b. Apply oxygen at 2 L/min via nasal cannula. c. Request a prescription for an antipyretic medication. d. Wear an N-95 mask when providing care to the client. e. Request a prescription for an antihypertensive medication. f. Remain 1 m (3 feet) from the client.
a, b, c, f
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) a. Place the client in a room with negative-pressure airflow. b. Wear gloves when assisting the client with oral care. c. Limit each visitor to 2-hr increments. d. Wear a surgical mask when providing client care. e. Use antimicrobial sanitizer for hand hygiene.
a, b, e
A nurse is caring for a client who has COPD. Nurses' Notes 1000:Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Select the 3 findings that require follow-up. a. breath sounds b. blood pressure c. oxygen saturation d. temperature e. heart rate
a, c, d
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 provide to the client and his family? (Select all that apply.) a. Check the cord routinely for frays or tearing. b. Keep the unit at least 1.2 m (4 feet) away from a gas stove. c. Consider purchasing a generator for power backup. d. Observe for signs of hypoxia. e. Select synthetic clothing and bedding.
a, c, d
A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Nurses' Notes 1200:Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Based on the client's clinical findings, which of the following actions should the nurse take? (Select all that apply.) a. Assist the client to a left side-lying position with the right knee flexed. b. Prepare the client for a chest x-ray. c. Administer a cleansing enema. d. Auscultate the client's bowel sounds. e. Perform a manual digital examination of the client's rectum. f. Administer oxycodone extended-release tablets. g. Prepare the client for NG tube placement.
a, c, d, e
A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. Nurses' Notes 1000:Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? (Select all that apply.) a. Request a prescription for an antibiotic medication. b. Apply oxygen at 2 L/min via nasal cannula. c. Initiate droplet precautions. d. Wear a mask within 1 m (3 feet) of the client. e. Place the client in a negative airflow room. f. Apply a mask on the client when they leave their room.
a, c, d, f
A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. A client who is 52 years old b. A client who smokes one pack of cigarettes each day c. A client who walks for 30 min every day d. A client who drinks one glass of wine three times per week
b
A nurse in a surgical suite 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? a. Ensure sterilization of nondisposable items with ethylene oxide. b. Wrap monitoring cords with stockinette and tape them in place. c. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. d. Wear hypoallergenic latex gloves that contain powder.
b
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? a. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. b. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. c. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. d. Palpate the client's abdomen before auscultating bowel sounds.
b
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? a. "They allow the court to overrule an adult client's refusal of medical treatment." b. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." c. "They permit a client to withhold medical information from health care personnel." d. "They allow health care personnel in the emergency department to stabilize a client's condition."
b
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? a. "I am not worried because I still have hope that he will be okay." b. "I am relying on support from our family during this time." c. "We can plan our family reunion once he recovers and comes home." d. "We don't see any reason to start discussing funeral arrangements right now."
b
A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. Describe the procedure to the client. b. Witness the client's signature on the consent form. c. Inform the client of alternatives to the procedure. d. Tell the client which team members will assist with the procedure.
b
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? a. "We would consult the person appointed by your health care proxy to make decisions." b. "We would give you oxygen through a tube in your nose." c. "You would be unable to change your previous wishes about your care." d. "We would insert a breathing tube while we evaluate your condition."
b
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? a. Make sure the client's room has at least six air exchanges per hour b. Make sure the client wears a mask when outside her room if there is construction in the area. c. Place the client in a private room with negative-pressure airflow. d. Wear an N95 respirator when giving the client direct care.
b
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? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment
b
A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. Gown b. N95 respirator c. Shoe covers d. Surgical cap
b
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? a. insert the catheter at a 45* angle b. place the client's arm in a dependent position c. shave excess hair from the insertion site d. initiate IV therapy in the veins of the hand
b
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? a. critical pathway b. situation, background, assessment, and recommendation (SBAR) c. transfer report d. medication administration record (MAR)
b
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? a. "I can place an extension cord across my living room to plug in my television." b. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." c. "I will place my alarm clock on my bedroom dresser across the room." d. "I will replace the old throw rug in my kitchen with a new one."
b
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. Use a resuscitation bag with 80% oxygen prior to the procedure. b. Select a suction catheter that is half the size of the lumen. c. Place the end of the suction catheter in water-soluble lubricant. d. Adjust the wall suction apparatus to a pressure of 170 mm Hg.
b
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? a. Remove the outer cannula cautiously for routine cleaning. b. Use tracheostomy covers when outdoors. c. Use sterile technique when performing tracheostomy care at home. d. Cleanse irritated skin with full-strength hydrogen peroxide
b
a nurse is caring for a client who has pharyngeal diphtheria. which of the following types of transmission precautions should the nurse initiate? a. contact b. droplet c. airborne d. protective
b
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 actions is the nurse's priority? a. request that a respiratory therapist discuss the technique for incentive spirometry with the client b. determine the reasons why the client is refusing to use the incentive spirometer c. document the client's refusal to participate in health restorative activities d. administer a pain medication to the client
b
a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. which of the following actions should the nurse include? a. regulate the flow rate by aligning the rate with the top of the ball inside the flow meter b. regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min c. make sure the reservoir bag of a partial rebreathing mask remains deflated d. use petroleum jelly to lubricate the client's nares, face, and lips
b
A nurse in a provider's clinic is caring for a client who has diarrhea. Vital Signs Temperature 36.2° C (97.2° F)Pulse rate 116/minRespiratory rate 24/minBP 102/68 mm HgOxygen saturation 95%Weight 52.2 kg (115 lb) The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. a. Increase intake of high-calcium foods. b. Eat probiotic foods, such as yogurt. c. Avoid alcohol while experiencing diarrhea. d. Eat raw vegetables. e. Eat three large meals a day. f. Avoid caffeine while experiencing diarrhea. g. Drink hot liquids several times a day. h. Drink carbonated beverages to replace lost fluids. i. Follow a low-fiber diet.
b, c, f, i
A nurse is caring for a client who had a spinal cord injury and has paraplegia. Nurses' Notes Day 1:Client is alert and oriented.Client is repositioned every 2 hr.Passive range-of-motion exercises to lower extremities performed once each day.Day 5:Client is alert and oriented.Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day.Feet warm. Pedal pulses 2+ bilaterally. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. a. Client is repositioned every 2 hr. b. Passive range-of-motion exercises to lower extremities performed once each day. c. Feet warm. Pedal pulses 2+ bilaterally. d. Plantar flexion contractures noted bilaterally. e. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.
b, d, e
a nurse is assessing an adult client's risk for falls. which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply) a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctivae d. visual fields e. visual acuity
b, d, e
A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? a. Medication name b. Route of administration c. Medication dose d. Frequency of administration
c
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? a. Activate the emergency fire alarm. b. Extinguish the fire. c. Evacuate the client. d. Confine the fire.
c
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 she received about pain management? a. "I think I should take my pain medication more often, since it is not controlling my pain." b. "Breathing faster will help me keep my mind off of the pain." c. "It might help me to listen to music while I'm lying in bed." d. "I don't want to walk today because I have some pain."
c
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. Client flow sheet b. Acuity ratings c. Current medications d. Incident reports
c
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? a. increase in hematocrit b. increase in respiratory rate c. decrease in heart rate d. decrease in capillary refill time
c
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? a. Verify the client's name on their identification bracelet with the medication administration record. b. Call the pharmacy to determine whether the client's medications are available. c. Compare the client's home medications with the provider's prescriptions. d. Place the client's home medication bottles in a secure location.
c
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? a. "I will return shortly after I document this in your record." b. "Most men live a long time with prostate cancer." c. "I am available to talk if you should change your mind." d. "I will make a referral to a cancer support group for you."
c
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? a. Neck vein distention b. Urine specific gravity 1.010 c. Rapid heart rate d. Blood pressure 144/82 mm Hg
c
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? a. the top of the cane is parallel to the client's waist b. when walking, the client moves the cane 46 cm (18 in) forward c. the client holds the cane on the stronger side of her body d. the client moves her stronger limb forward with the cane
c
A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? a. Touch the face with a cotton ball. b. Apply a vibrating tuning fork to the client's forehead. c. Have the client stand with their arms at their sides and their feet together. d. Perform direct percussion over the area of the kidneys.
c
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. a lesion with uniform pigmentation b. new appearance of petechiae c. a mole with an asymmetrical appearance d. the presence of a papule
c
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? a. Combine client care tasks when caring for multiple clients. b. Wait until the end of the shift to document client care. c. Use the planning step of the nursing process to prioritize client care delivery. d. Allow for interruptions in tasks to discuss client care issues with colleagues.
c
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. insert the needle at a 15* angle b. aspirate for blood return prior to administration c. administer the medication into the abdomen d. massage the site following the injection
c
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? a. Role ambiguity b. Sick role c. Role overload d. Role conflict
c
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? a. Place the client in a side-lying position. b. Instill 15 mL of irrigation fluid into the catheter with each flush. c. Subtract the amount of irrigant used from the client's urine output. d. Perform the irrigation using a 20-mL syringe.
c
a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. which of the following actions should the nurse take? a. assist the client into a prone position b. place a sleeve over the top of each leg with the opening at the knee c. make sure two fingers can fit under the sleeves d. set the ankle pressure at 65 mm Hg
c
a nurse is talking with an older adult client who is contemplating retirement. the client states, "i keep thinking about how much i enjoy my job. im not sure i want to retire." which of the following responses should the nurse make? a. " you would have so much more time to spend with your family" b. " you should consider getting a part-time job or doing volunteer work." c. "lets talk about how the change in your job status will affect you." d. "why wouldnt you want to retire and relax?"
c
A nurse in a provider's clinic is caring for a client who has heart failure. First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent 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? a. "I have been weighing myself every other morning." b. "I am trying to decrease my intake of foods with potassium." c. "I am limiting my sodium intake to 2 grams daily." d. "I am eating fewer potato chips and more fruit for snacks." e. "I lie down and rest after meals." f. "I know to call my doctor if I gain 3 pounds or more in 2 days."
c, d, f
A nurse is caring for a client who is postoperative following abdominal surgery. 1100:Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. a. neurological assessment b. incisional drainage c. urinary output d. reported pain level e. gastrointestinal assessment f. vital signs
c, d, f
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? a. Assign the client to a room with a negative airflow system. b. Use alcohol-based hand sanitizer when leaving the client's room. c. Clean contaminated surfaces in the client's room with a phenol solution. d. Have family members wear a gown and gloves when visiting.
d
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? a. The caregiver is the client's financial power of attorney. b. The client is in a wheelchair with the wheels locked. c. The client reports receiving a full bath twice each week. d. The caregiver insists on remaining in the room.
d
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? a. "Most people are happy when their children grow up and leave home." b. "You should be proud that your children are becoming independent." c. "Maybe you should consider why you are feeling useless." d. "People in middle adulthood often find satisfaction in nurturing and guiding young people."
d
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? a. protective environment b. airborne precautions c. droplet precautions d. contact precautions
d
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? a. "is your pain constant or intermittent?" b. "what would you rate your pain on a scale of 0 to 10?" c. "does the pain radiate?" d. "is your pain sharp or dull?"
d
A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.) a. crackles b. rhonchi c. friction rub d. normal breath sounds
d
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? a. Document the provider's statement in the medical record. b. Complete an incident report. c. Consult the facility's risk manager. d. Notify the nursing manager.
d
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? a. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. b. Remove the NG tube if the client begins to gag or choke. c. Apply suction to the NG tube prior to insertion. d. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
d
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? a. bend at the waist b. keep his feet close together c. use his back muscles for lifting d. stand close to the cabinet when lifting it
d
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? a. "You should have an eye examination every 2 years." b. "You should receive a tetanus booster every 5 years." c. "You should receive a shingles vaccine when you are 70 years old." d. "You should receive a pneumococcal vaccine when you are 65 years old."
d
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? a. Assign a staff member to feed the client. b. Provide small-handled utensils for the client. c. Thicken liquids on the client's tray. d. Arrange food in a consistent pattern on the client's plate.
d
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions
d
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? a. Dissolve each medication in 5 mL of sterile water. b. Draw up medications together in the syringe. c. Push the syringe plunger gently when feeling resistance. d. Flush the tube with 15 mL of sterile water.
d
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? a. alginate b. gauze c. transparent d. hydrocolloid
d
A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? a. 92 b. 102 c. 112 d. 122
d
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. BUN 15 mg/dL b. Creatinine 0.8 mg/dL c. Sodium 143 mEq/L d. Potassium 5.4 mEq/L
d
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. Insert an implanted port. b. Close a laceration with sutures. c. Place an endotracheal tube. d. Initiate an enteral feeding through a gastrostomy tube.
d
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a. Seal unused medications from the facility in a plastic bag. b. Evaluate the client's ability to self-administer medications. c. Report an identified discrepancy to The Joint Commission. d. Compare prescriptions with medications the client received while at the facility.
d
a nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. the nurse should inform the client that this condition is a contraindication for which of the following therapies? a. biofeedback b. aloe c. feverfew d. acupuncture
d
a nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. which of the following actions should the nurse take? a. discuss the risk factors for colon cancer b. focus teaching on what the client will need to do in the future to manage his illness c. provide the client with written information about the phases of loss and grief d. reassure the client that is an expected response to grief
d
