ATI Fundamentals

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this mediation at home, I will leave it for you to take." C. "I will come back in 30 mins to check that you took the medication so I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time."

"Call me when you are ready, and I will return with the medication." The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration.

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A. "Fats provide energy" B. "Carbohydrates repair body tissue" C. "Fats regulate fluid balance" D. "Carbohydrates prevent interstitial edema"

"Fats provide energy" Fat serves as a stored energy source for the body, providing 9 cal/g of energy.

A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? A. "Life has its ups and downs" B. "I believe that I control my own destiny" C. "God is punishing me for something" D. "I like to keep my rosary beads in bed with me"

"God is punishing me for something" Spiritual distress is an impaired ability to integrate meaning and purpose in life through various means, including belief systems and relationships. Manifestations of spiritual distress can include a feeling that a higher power is punishing the individual for some behavior.

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button, so I don't get an overdose." B. "If I push the button and still have pain after 2 mins, I'll push it again." C. "I'll ask my niece to push the button when I am sleeping." D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

"I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button." The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA pump to reduce the amount of opioid dosing the client needs.

A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? A. "I'm afraid this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family."

"I can't sleep well because whenever I move in my sleep, the pain wakes me up." The priority action the nurse should take when using Maslow's hierarchy of needs id to meet the client's physiological need for comfort. The nurse should re-evaluate the client's pain management plan immediately.

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. "My parents are retired, and they have come to help with our children." B. "I am going to ask my husband to go to counseling with me." C. "I keep having nightmares about my upcoming surgery." D. "My girlfriends bought me a nice wig."

"I keep having nightmares about my upcoming surgery." Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate a risk of experiencing psychological distress.

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? A. "I am comfortable with my decision to choose a lifelong partner." B. "I think I have done a good job with my children since they are all independent now." C. "As I look back over my life, I can see that I have achieved most of the goals I set for myself." D. "I love my work so much that it is difficult to think about retirement."

"I think I have done a good job with my children since they are all independent now." According to Erikson, the developmental task for middle adults is generativity vs. stagnation. Middle adults help shape future generations through community involvement, parenting, mentoring, and teaching. This statement about helping her children achieve independence indicates that the client has accomplished this developmental task.

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." C. "I'll need to take a pain pill 30 minutes before I change the dressing." D. "I'll wear sterile gloves when I apply the new dressing."

"I'll wash my hands before I remove the old dressing and again before putting on the new one." It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings.

A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "If I do this often, I won't experience muscle wasting." B. "If I do this often, I won't get pneumonia." C. "If I do this often, I won't get constipation." D. "If I do this often, I won't have a fast heartbeat."

"If I do this often, I won't get pneumonia." Turning, coughing, and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal.

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A. "A lot of clients who are cared for at home have the same problem" B. "Don't worry about it. He will get a bath, and that will take care of the odor." C. "It must be difficult to care for someone who is confined to bed." D. "When was the last time that he had a bath?"

"It must be difficult to care for someone who is confined to bed." This response addresses the feelings of the partner by reflecting her feelings, which facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands familycentered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge."

"Let's set up a meeting time with the doctor to discuss your options for home care." In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment.

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy and here I am dying!" Which of the following responses should the nurse provide? A. "Everyone dies sometimes; some die sooner than others." B. "Who do you think deserves to die more than you?" C. "It does seem unfair, doesn't it?" D. "Tell me more about how you feel about dying?"

"Tell me more about how you feel about dying?" This therapeutic response from the nurse seeks more information to form an accurate assessment of the client's feelings.

An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? A. "Don't worry; teenagers often have friends who give bad advice." B. "I think you should stop seeing those friends since they discourage you from following your treatment plan." C. "Tell me more about how your friends discourage you." D. "Where did you meet these friends?"

"Tell me more about how your friends discourage you." The nurse should ask an open-ended question that encourages the client to elaborate on these problems.

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down."

"There are times I should use soap and water rather than an alcohol-based rub to clean my hands." While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Centers Disease Control and Prevention recommend washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."

"Using a cuff that is too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff Is too small for the client.

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A. "We miss our daughter so much that we are going to move closer to her." B. "I think this year I can plan on managing the funding at church." C. "I really wish I could lose some of this weight." D. "I find I am spending more time at work now that my son is at college."

"We miss our daughter so much that we are going to move closer to her." According the Erikson, the stage of psychosocial development for middle adults is generativity vs. stagnation. Accepting the independence of adult children is part of the developmental task of middle age.

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"

"What do you think caused the onset of your pain?" The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than a few words.

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? A. "When did you start to believe in your faith?" B. "How often do you perform religious rituals?" C. "Which church do you regularly attend?" D. "What is your source of strength and hope?"

"What is your source of strength and hope?" This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It correctly focuses on a global view of spirituality as a complex concept that encompasses the client's life experiences and beliefs about strength, love, and hope.

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down, move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm." C. "With your palm facing down, move your wrist sideways toward your little finger." D. "Bring the back of your hand as far back toward the wrist as you can."

"With your palm facing down, move your wrist sideways toward your thumb." This motion describes adducting the wrist. The client should be able to move her wrist 30 to 50 degrees with this motion.

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "You look just fine to me" B. "Nobody expects you to look beautiful in the hospital" C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?"

"Would you like to talk about how you feel?" This is a therapeutic response that will encourage the client to talk about his concerns and feelings.

A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10lb)? A. 10 months B. 5 months C. 5 weeks D. 10 weeks

10 weeks Because 1 lb of body fat is equivalent to 3,500 calories, consuming 500 extra calories each day for 7 days would lead to a total of 3,500 calories and a 1 lb gain per week. At the rate of 1 lb per week, the client would gain 10 lb in 10 weeks.

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (round to nearest whole number)

1560

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (nearest tenth)

2

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (nearest whole number)

29gtt/min

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2mm B. 4mm C. 6mm D. 8mm

2mm The nurse should document a 2mm indentation after applying and removing pressure as 1+ pedal edema.

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Nearest whole number)

660 mL

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (nearest whole number)

770mL

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during 12-hour night shift? (round to the nearest whole number)

90

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed RBCs B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization

A client who has a prescription for a transfusion of packed RBCs Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who that can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN antianxiety medication

Accompany the client back to his room The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect him from injury due to wandering.

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear. B. Air conduction is greater than bone conduction in the left ear. C. Sound is lateralizing to the right ear. D. Sound is lateralizing to the left ear.

Air conduction is less than bone conduction in the left ear. This finding indicates conductive hearing loss of the left ear.

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep the room temperature warm D. Offer the client a cup of hot chocolate before bedtime

Allow the client to maintain the same bedtime routine as at home For many clients in an acute care facility, disrupting the usual sleep routine is the primary reason for a client's inability to sleep. Maintaining the home bedtime routine promotes sleep in ways that are effective for the client. Those whose usual bedtime routines include warm milk, massages, or pharmacological sleep aids might need and appreciate those interventions in inpatient settings.

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available. B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Ask the adolescent to sign the consent form

Ask the adolescent to sign the consent form Unemancipated minors (ex: those who do not live on their own, are not married, and are not in the military) can legally give informed consent for diagnostic procedures and treatment in some situations. These situations include treatment for STIs and substance use disorders.

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration

Ask the client to identify the specific food allergies The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals.

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first? A. Ask why the client is refusing the pain medication B. Administer a PRN antianxiety medication C. Help the client change positions D. Offer the client a heat or cold pack to place on painful areas

Ask why the client is refusing the pain medication Using the nursing process, the nurse should first assess the reason for the client's refusal of the opioid pain medication.

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Placing an unused portion of the medication in a sharps box B. Asking another nurse to observe the disposal of an unused portion of the medication C. Counting the inventory of the available narcotic after administering the medication D. Ensuring that another nurse signs the control inventory form after disposal of an unused portion of medication

Asking another nurse to observe the disposal of an unused portion of the medication The nurse should ask another nurse to witness the disposal of a controlled substance to maintain safe control of the narcotic.

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a medication error report B. Notify the prescribing provider C. Assess the client D. Notify the charge nurse

Assess the client The greatest risk to the client's safety is adverse effects from either receiving the wrong medication or not receiving the prescribed medication. The nurse should assess the client first for any possible adverse effects. This assessment also serves as a baseline for further monitoring for adverse effects.

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? A. Assessment B. Plan of Care C. Nursing interventions performed D. Evaluation of progress

Assessment When caring for a client, the nurse should apply the nursing process priority-setting framework. The nursing process is used to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make am appropriate decision.

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing a face mask when standing 0.5 m (1.6 ft) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility

Assigning another client with the same infection to share the room with the client The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available.

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? A. Assume an open position B. Sit upright and lean back into the chair C. Avoid direct eye contact until the client initiates it D. Sit next to the client

Assume an open position The nurse should sit with arms and legs uncrossed. Crossing them suggests a defensive posture.

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? A. Attempt to increase the client's self-motivation B. Keep detailed records of each client's progress C. Test client learning after each teaching session D. Avoid discussing topics that might increase client's anxiety

Attempt to increase the client's self-motivation Motivation to learn is a key part of improving a client's commitment to achieving a health goal, as well as increasing the amount and speed of learning.

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? A. Auscultation B. Light Palpation C. Percussion D. Deep palpation

Auscultation According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results.

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television for 30 minutes in bed to relax prior to falling asleep D. Advise the client to take several naps during the day

Avoid beverages that contain caffeine Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages.

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? A. Pulse rate 90/min B. Rectal Temp 38 C (100.4 F) C. Pulse oximetry 95% D. BP 145/90 mmHg

BP 145/90 mmHg This blood pressure is greater than the expected reference range and should be reported to the provider.

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (SATA) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice

Black beans Whole-grain bread -Dried peas and beans, including black beans, are high in fiber. -Whole grains consist of the entire kernel and are also high in fiber.

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage B. Give the medication in a safe dosage C. Give the dose the provider prescribed D. Call the provider to clarify the dosage

Call the provider to clarify the dosage After assessing the client for adverse effects of the medication, the nurse should notify the provider about her observations to determine the next step.

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

Check the client's pain level The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should determine the client's level of pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the client approximately 30 minutes prior to wound care will decrease pain and increase comfort.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum

Check the client's perineum The nurse should apply the nursing process priority-setting framework to plan care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? A. Trauma B. Severe infection C. Iron-deficiency anemia D. Chronic hypoxemia

Chronic hypoxemia Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen supply) such as COPD. It is a change in the angle between the nail and the nail base often with enlargement of the fingertips.

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward

Clean the drain site from the center outward The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound.

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Clients level of comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the client's recent illness D. Sociocultural history

Clients level of comfort and ability to participate in the interview The nurse should assess the client's level of comfort and establish a rapport during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (SATA) A. coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

Coat the tip of the tube with a water-soluble lubricant Ask the client to swallow water while the tube enters her throat Tell the client to tilt her head backward as insertion begins Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube slips into the client's airway, while using petroleum jelly could cause respiratory problems. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates the insertion of the NG tube.

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift. B. Cleanse the opening with soap and water after emptying. C. Maintain the tubing above the level of the surgical incision. D. Collapse the device to remove air after emptying.

Collapse the device to remove air after emptying. The nurse should collapse the device to remove air after emptying the contents periodically. This will create enough suction to pull fluid exudate into the collection area of the device.

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen when the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory

Collect the specimen when the client rises in the morning The nurse should plan to collect the sputum specimen when the client arises in the morning because the client will be able to cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. Give rescue breaths

Confirm unresponsiveness The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A. Confrontation test B. Symmetry of palpebral fissures C. Corneal light reflex D. Accommodation test

Corneal light reflex The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses.

A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following actions should the nurse perform first after discovering the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

Cover the incision with a moist sterile dressing The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound increases the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood Pressure C. Specific gravity D. Intake and Output

Daily weight According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status measurement.

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulses C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

Determine whether the client is able to breathe Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision. This client is demonstrating a universal choking gesture. If the client is unable to move air in or out, severe airway obstruction is present. The client would need emergency interventions to clear a partial obstruction, as indicated by stridor or minimal airway passage. As long as there is good air exchange and the client can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting B. Wear a mask while in the client's room C. Don gloves when entering the room and use hand sanitizer when exiting D. Take no special precautions unless engaging in direct contact with the client

Don gloves when entering the room and use hand sanitizer when exiting Clients who have MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require any staff member who will have contact with the client's environment to don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client; a mask and goggles are needed if the secretions from the infected area could spray into the worker's face. Delivering the tray will require contact with the client's environment; therefore, the dietary assistant must wear gloves.

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A. Popliteal B. Posterior Tibial C. Dorsalis Pedis D. Femoral

Dorsalis Pedis The nurse should identify that the dorsalis pedis pulse is located on the top of the foot, following the groove between the tendons of the great toe. It is best felt by moving the fingertip between the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is congenitally absent in some clients.

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

Edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration.

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles B. Educating clients about the recommended immunization schedule for adults C. Teaching clients who have type 1 diabetes mellitus about care of the feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually

Educating clients about the recommended immunization schedule for adults Primary prevention includes health education about disease prevention.

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30 or 40 degrees C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

Elevate the head of the bed to 30 or 40 degrees Elevating the head of the bed to at least 30 and preferably 45 degrees helps prevent the gravitational reflux of gastric contents, thereby decreasing the risk of aspiration.

A nurse is preparing to administer a feeding via gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the client's bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify that the client's gastric pH is above 4

Elevate the head of the client's bed Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the feeding.

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness. B. Encourage the client to express thoughts about death and dying. C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain.

Encourage the client to express thoughts about death and dying. The nurse should recognize the client's need to talk about impending death and encourage the client to discuss thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can encourage sharing when appropriate. If the nurse does not want to share personal beliefs, offering self and listening to the client's thoughts are appropriate.

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

Encourage the client to listen to soft music The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain.

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A. Establish client outcomes B. Collect information about past health problems C. Determine whether the client has met specific goals D. Identify the client's specific health problems

Establish client outcomes The planning phase of the nursing process includes developing go als and outcomes that help the nurse create the client's plan of care.

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

Evaluate pedal pulses For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? A. Explain that it is against policy to share access codes and refer the resident to his supervisor. B. Access the clients' online data and monitor the resident as he reads them. C. Access the online system and allow the resident to locate clients' data. D. Ask each client to give permission for the resident to access medical records.

Explain that it is against policy to share access codes and refer the resident to his supervisor. Staff members should never share access codes and passwords or allow people who do not have their own access code to use the system. Allowing unauthorized access is a breach of federal guidelines for data security and client confidentiality.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

Explain the procedure to the client The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention.

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 mins B. Fill the bag 2/3 full with ice C. Place the ice bag uncovered on the client's ankle D. Tell the client numbness is expected when the ice bag is in place

Fill the bag 2/3 full with ice The nurse should fill the bag 2/3 full with ice, which allows the bag to be molded around the clients ankle.

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A. Liver size B. Pedal edema C. Skin texture D. Gait

Gait Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing any unusual findings.

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (SATA) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

Gown Gloves The nurse should follow standard precautions when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should don a gown. Because the nurse's hands will come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE. The nurse should follow standard precautions when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should don a gown. Because the nurse's hands will come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE.

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups? A. Dairy B. Vegetables C. Fruits D. Grains

Grains This client only consumed 1 serving of grains on the day of the 24-hour dietary recall. USDA dietary guidelines recommend 3 or more ounce-equivalents of whole-grain products per day. Additionally, the choice of white bread is low in fiber, which can lead to constipation and an increased risk of developing hyperlipidemia. The USDA guidelines recommend that at least half of the grains consumed should be whole grain.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated B. The wound is closed at a later date C. A skin graft is placed over the wound bed D. Granulation tissue fills the wound during healing

Granulation tissue fills the wound during healing A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5-21 days. Open wounds increase the risk of wound infection.

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression. D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers.

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. The nurse should use this technique to assess skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; in dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the forearm.

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of nonadherence B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written and easy-to-understand materials D. Help the client identify ways that these changes will result in positive personal outcomes

Help the client identify ways that these changes will result in positive personal outcomes According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that's the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes.

A nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take first? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

Hold the medication bottle with the label against the palm of the hand when pouring The nurse should hold a multidose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible.

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. Hyper oxygenate the client before suctioning B. Insert the catheter during exhalation C. Apply suction during insertion of the catheter D. Apply suction for no more than 15 secs

Hyper oxygenate the client before suctioning The nurse should use a manual resuscitation bag to hyper oxygenate the client for several minutes prior to suctioning.

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A. Inspect both breasts simultaneously B. Squeeze the nipples C. Palpate the breast and tail of Spence D. Palpate the axillary lymph nodes

Inspect both breasts simultaneously According to evidence-based practice, the nurse should first inspect both breasts with the client's arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling.

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly B. Instruct the client to look at the floor while instilling the eye drop C. Remind the client to avoid using a facial tissue after instillation D. Instruct the client to apply pressure to the inside corner of the eye after instillation

Instruct the client to apply pressure to the inside corner of the eye after instillation The client should apply gentle pressure over the nasolacrimal duct to prevent the medication from flowing into the nasal passages where systemic absorption could result.

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt

Lentils Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds.

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher B. Instruct the client to raise his arms above his head C. Elevate the stretcher 2.5 cm (1in) above the height of the bed D. Log-roll the client

Lock the wheels on the bed and stretcher Locking the wheels prevents the client from falling on the floor by not allowing the cart or bed to move apart or away from the client.

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client B. Lowering the footplates of the wheelchair before the transfer C. Placing the wheelchair perpendicular to the bed D. Placing the wheelchair on the client's weaker side prior to the transfer

Locking the brakes on the bed and the wheelchair before moving the client Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair.

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A. Loss B. Trust C. Self-disclosure D. Risk-taking

Loss At the close of a relationship, even when planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? A. Heart B. Lungs C. Thyroid gland D. Skin

Lungs Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The nurse also uses auscultation and palpation when evaluating the lungs.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider of the client's decision.

Notify the provider of the client's decision. While acting as the client's advocate, the nurse should support her decision and notify the provider.

A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor B. Perform an abdominal pain C. Open the airway with a head-chin tilt D. Observe the client closely

Observe the client closely The nurse should observe the client closely at this point in time. As long as the client is able to cough strongly, the nurse does not need to intervene.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires interventions? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care

Obtaining cotton balls for tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the client's head backward when swallowing D. Turn on the television

Offer the client tart or sour foods first A client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which aids to chewing and swallowing.

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? A. Face away from the client to avoid distraction B. Pace speech to allow time for the interpreter to convey the words C. Make eye contact with the interpreter when explaining the procedure D. Stand in the background while the interpreter translates the message

Pace speech to allow time for the interpreter to convey the words The nurse should speak clearly and allow time for the interpreter to convey the message and for the client to receive it.

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. People who practice the Islamic faith pray over the deceased for a period of 5 days before burial. B. People who practice the Hindu faith bury the deceased with their head facing north. C. People who practice Judaism stay with the body of the deceased until burial. -In the Jewish faith, a family member often stays with the body until burial occurs. D. People who are practicing the Buddhist faith have the female family members prepare the body following death.

People who practice Judaism stay with the body of the deceased until burial. In the Jewish faith, a family member often stays with the body until burial occurs.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves D. Perform hand hygiene

Perform hand hygiene According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

Pinch the NG tube while removing the tube The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate the blood pressure at the dorsalis pedis artery B. Measure the blood pressure with the client sitting on the side of the bed C. Place the cuff 7.6 cm (3in) above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh

Place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the bladder of the cuff when the nurse is measuring a lowerextremity blood pressure.

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (SATA) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

Place the client in a supine position with the hips and knees flexed Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestations of shock The nurse should place the client in a supine position with the hips and knees flexed. This position can help to prevent further tearing of the incision and wound evisceration by lessening tension on the wound. The nurse should cover the protruding intestine with sterile dressing that is moistened with 0.9% sodium chloride to prevent further contamination of the wound and to keep the protruding intestine from drying out. The nurse should monitor the client for a physiological stimulus (ex: bleeding from the tearing or opening of the wound) or a psychological stimulus (ex: viewing the intestine protruding outside the body), which can increase the risk of shock. The nurse should monitor the client for increased heart rate and respiratory rate, changes in blood pressure or mentation and cool or clammy skin.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in lateral position with the head turned to the side before beginning the procedure. B. Use the thumb and index finger to keep the client's mouth open. C. Rinse the client's mouth with an alcohol-based mouthwash following the procedure. D. Cleanse the client's mucous membranes with lemon-glycerin sponges.

Place the client in lateral position with the head turned to the side before beginning the procedure. The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain

Place the client in the Trendelenburg position The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag

Place the stool specimen collection container in a biohazard bag The nurse should place the specimen collection container in a biohazard bag with the client label on the container and the bag for easy identification. This will also prevent contamination with microorganisms.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45-degree angle to the bed. D. Assume a narrow stance with the feet 15 cm (6 in) apart

Place the wheelchair at a 45-degree angle to the bed. Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount of rotation required.

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders

Plasma volume expanders Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency situations, such as after hemorrhage or burns.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6 in) B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm (36 inch) above the client's rectum

Position the client on his left side Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula

Provide more water with feedings The elevation in the client's specific gravity indicates dehydration. The nurse should provide more fluids either by adding free water to feedings or by instilling water between feedings. Another strategy is to request a formula that contains less protein.

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (SATA) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares

Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown Frequent oral hygiene comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately.

A nurse is inserting an NG tube into a client who begins to gag and cough. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

Pull the NG tube back slightly The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows.

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pin from the extinguisher D. Sweep the hose from side to side to dispense material

Remove the safety pin from the extinguisher Evidence-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is an action the nurse should instruct the client to perform first.

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line. B. Slow the infusion using a roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

Remove the sleeve of the gown from the arm without the IV line. According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client before stopping the system to remove the gown from the line, resulting in minimal interruption of the IV flow.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for the use of restraints within 24 hours B. Secure the restraint with the buckle side next to the client's skin C. ensure 4 fingers can be inserted under the secured restraint D. Remove the restraint every 3 hours

Renew the prescription for the use of restraints within 24 hours The nurse should plan to renew the prescription for the restraints within 24 hours; only after the provider has evaluated the client.

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted living facility C. Respite care D. Adult day care facility

Respite care Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance.

A nurse is preparing to administer a unit of packed RBC's to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? A. Return the blood to the laboratory B. Place the blood in the medication room C. Place the blood in the refrigerator D. Leave the blood at the client's bedside

Return the blood to the laboratory Because the nurse knows that the delay will be more than a few minutes, she should return the unit of packed RBCs immediately to the laboratory where the technician will maintain it at the appropriate temperature until the client is ready to receive it.

A nurse delegates the collection of a client's temperature to an AP. The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A. Right task B. Right circumstance C. Right person D. Right communication

Right communication The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objectives, limits, and expectations.

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis

Scoliosis The nurse should identify the finding of an S-shaped or C-shaped spinal column and uneven shoulder or hip heights as manifestations scoliosis.

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? A. Holding a community clinic to administer influenza immunizations B. Screening groups of older adults in nursing care facilities for early influenza manifestations C. Educating parents of young children about the dangers of influenza D. Finding rehabilitation programs for older adults who have complications related to influenza

Screening groups of older adults in nursing care facilities for early influenza manifestations Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent an illness from becoming severe.

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask someone to stay with the client B. Offer to call the client's minister C. Sit and hold the client's hand D. Leave the room and allow the client to cry privately

Sit and hold the client's hand This action uses the therapeutic communication techniques of silence, touch, and offering of self to the client.

A nurse is caring for a client who has bilateral cats on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside when feeding the client B. Order pureed foods C. Make sure feedings are provided at room temperature D. Offer the client a drink of fluid after every bite

Sit at the bedside when feeding the client The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? A. Kidney's B. Lungs C. Gastrointestinal Tract D. Skin

Skin The skin can excrete approximately 500 to 600 mL of insensible fluid loss. This type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin.

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A. Continue the teaching, but check afterward with the surgeon about informed consent B. Stop the teaching and check with the surgeon about informed consent C. Stop the teaching and ask the client to sign an informed consent form D. Continue the teaching and check the client's medical record afterward for a signed consent form

Stop the teaching and check with the surgeon about informed consent The client's statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon.

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy B. Lateral C. Supine D. Sims

Supine The nurse should tell the client to assume the supine position to promote relaxation of the abdominal muscles. Having the client bend the knees enhances relaxation of the stomach muscles.

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

Taut skin around the IV catheter site that is cool to the touch A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress (according to the type of infiltration).

A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? A. The RDA is a comprehensive term that includes various standards and scales. B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects. D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. The RDA represents daily requirements considered adequate for healthy people. RDAs are based on estimated amounts for each nutrient, including additional amounts for individuals such as women or infants.

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? A. The client holds the cane on the unaffected side. B. The client walks by stepping with the unaffected leg before the affected leg. C. The client holds the cane directly next to the foot. D. The client holds the cane with a straight elbow

The client holds the cane on the unaffected side. The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability.

A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? A. The client holds the hand with the palm up B. The client holds the hand with the palm down C. The client points the fingers toward the floor D. The client points the fingers toward the ceiling

The client holds the hand with the palm up The nurse should identify the client holding the hand with the palm up as a demonstration of supination of the hand

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? A. The client watches television in her bed during the day. B. The client drinks warm milk before bedtime. C. The client goes to bed at 2200 every night. D. The client gets up to use the bathroom once during the night.

The client watches television in her bed during the day. To promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? (SATA) A. The client's ID number B. The client's room number C. The client's name D. ABO compatibility E. Rh compatibility

The client's ID number The client's name ABO compatibility Rh compatibility Two nurses must verify this information, including the client's facility identification number, name, ABO compatibility, and RH compatibility, to prevent transfusion reactions due to human error.

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? A. One week prior to the client's discharge B. Upon the client's admission to the care facility C. Once the discharge date is identified D. When the client addresses the topic with the nurse

Upon the client's admission to the care facility The nurse should begin discharge planning at the time that the client is admitted to the facility.

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall

Use the index finger to insert the suppository To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible.

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

Vastus lateralis The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (SATA) A. Auscultate injected air B. Verify the initial X-Ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

Verify the initial X-Ray examination Measure the length of the exposed tube Determine the pH of aspirated fluid The nurse should confirm the NG tube placement by checking the X-ray results following the insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the client's nose to verify tube placement.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

Vitamin C and zinc The client's body needs both vitamin C and zinc to fight a wound infection. The client should receive a multivitamin and a mineral supplement of both these substances. In addition, vitamin E supplements also are needed to promote skin and wound healing.

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes

Washing dishes Washing dishes requires a low level of activity and is appropriate for this client.

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A. Whole Milk B. Chicken C. Oranges D. Dried peas

Whole Milk The fat-soluble vitamins (A,D,E, and K) require fatty substances or tissues to be dissolved and also require the presence of bile in the small intestine for absorption. Whole milk contains vitamins A and K and is often fortified with vitamin D.

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood D. Young adulthood

Young adulthood The developmental task of young adulthood is intimacy vs. isolation.