ATI Fundamentals (EASY)

A client has 1 L dextrose 5% in 0.45% NaCl infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse?

ANS: 8

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber

ANS: A A Romberg test evaluates standing balance, first with the client's eyes open and then closed. The nurse should remain nearby because the client could fall during the test. Kinesthetic sensation tests the client's ability to identify the position in which the examiner is holding the client's middle finger or great toe. 2-point discrimination, the nurse touches various areas on a clients body with 1- and 2-pointed objects to see if the client can discriminate between 1 and 2 objects. Weber test is a hearing screening that uses a tuning fork.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

ANS: A A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. A febrile reaction occurs when the client's blood is sensitive to the WBCs and platelets in the donor's blood. Fevers, chills, headaches, and flushing are indications of a febrile reaction. Circulatory overload occurs when blood is administered too quickly for the client's circulatory system to handle. Dyspnea, coughing, headaches, and hypertension are indications of circulatory overload. Sepsis occurs when the blood is contaminated with bacteria. High fevers, vomiting, and diarrhea are indications of sepsis.

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

ANS: A A sodium level of 123 mEq/L is below the expected reference range of 136 to 145 mEq/L. Low sodium levels can cause confusion and lead to seizures, coma, and death. A blood glucose of 100 mg/dL is within the expected reference range of 70 to 110 mg/dL for fasting and less than 200 mg/dL for a casual blood draw. A potassium level of 3.5 mEq/L is within the expected reference range of 3.5 to 5 mEq/L. A hemoglobin level of 13 g/dL is within the expected reference range of 12 to 18 g/dL.

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist

ANS: A A speech-language pathologist can perform a thorough evaluation of the client for dysphagia and help the client learn to eat safely. For example, a speech-language pathologist can instruct the client in learning the supraglottic swallow: take a breath, hold the breath while swallowing, cough after swallowing, and swallow again to clear the mouth. A social worker can assist the client with finding and accessing community services (e.g. meal delivery and financial services) once the client is at home but cannot evaluate the skills the client needs to swallow and eat safely. A physical therapist can evaluate the strength and mobility of a client who has musculoskeletal problems but cannot evaluate the skills the client needs to swallow and eat safely. An occupational therapist can help clients who have physical limitations or disabilities gain the optimal level of independence in performing ADLs but cannot evaluate the skills the client needs to swallow and eat safely.

A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? A. Stat prescription B. PRN prescription C. Standing prescription D. Single prescription

ANS: A A stat medication prescription is carried out immediately or as soon as possible and for one time only.

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? A. Inspection B. Auscultation C. Percussion D. Palpation

ANS: A According to EBP, the nurse should inspect the abdomen first by observing the contour of the abdomen, the skin conditions and the position of the umbilicus. The nurse should auscultate the abdomen before percussion or palpation, both of which can stimulate peristalsis yielding inaccurate results.

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client

ANS: A According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits.

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

ANS: A 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 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 for PRBC B. A client who is being transported for a radiograph of the kidneys, ureters, adn 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

ANS: A Administration of bld is a procedure that carries risk; therefor, the client must sign a consent form prior to the procedure

A nurse is teaching a middle aged adult client about health promotion and disease prevention. The nurse should inform the client that wich of the following changes could occur? A. Decreased estrogen and testosterone production B. Increased tone of the large intestines C. Increased percentage of the body's muscle mass D. Decreased incidence of chronic illnesses

ANS: A Both estrogen and testosterone levels start to decrease in middle age. The tone of the large intestines decreases during middle age, placing clients at risk for constipation. There is also a decrease in the body's muscle mass as clients approach the later portion of middle age. and the likelihood of developing a chronic illness increases during middle age.

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 min in bed to relax prior to falling asleep D. Advise the client to take several naps during the day

ANS: A Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages. Sleep-promoting medication is a last resort. The nurse should not suggest this type of medication for the client before recommending other nonpharmacological interventions.

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A. Eggs B. Cereal C. Peanut butter D. Pasta

ANS: A Complete proteins contain all of the essential amino acids to support growth and homeostasis. Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese, soybeans, and soybean products. Incomplete proteins are missing one or more of the essential amino acids necessary to support growth and maintain homeostasis. Cereal is an example of an incomplete protein. However, it can be combined with skim milk to make a complete protein. Peanut butter is an example of an incomplete protein. However, it can be combined with whole-wheat bread to make a complete protein. Pasta is an example of an incomplete protein. However, it can be combined with cheese to make a complete protein.

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? A. Hold the sterile drape above the waist and away from the body B. Drop sterile objects toward the edges of the sterile field C. Hold packaged supplies 7.6 cm (3 in) above the sterile field D. Hold sterile objects over the field before setting them down on the field

ANS: A Hold the sterile drape above the waist and away from the body. Contamination occurs when the nurse holds any object that will be part of the sterile field below the waist or allows it to touch anything other than a sterile object. The nurse should drop sterile objects toward the center of the sterile field, as the 2.5 cm (1 in) border around the periphery of the field is not sterile. The nurse should hold packaged supplies 15 cm (6 in) above the sterile field before opening them and dropping them onto the sterile field. The nurse should add sterile objects at an angle from the side of the sterile field to avoid reaching over the sterile field and contaminating it.

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 (1 in) above the height of the bed. D. Log-roll the client.

ANS: A Lock the wheels on the bed and stretcher. The nurse should ask the client to cross his arms across his chest to avoid injuring the arms during the transfer. The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. Log-rolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery.

A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? A. Crackles in the lung fields B. Flat neck veins C. Postural hypotension D. Dark yellow urine

ANS: A Manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain. Flat neck veins when the client is supine are a manifestation of fluid-volume deficit, not fluid-volume excess. Postural hypotension and dark yellow urine are manifestations of fluid-volume deficit, not fluid-volume excess.

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information? A. Areas with no public access B. Outside the door of a client's room C. In the cafeteria during break D. In the hallway near the nurses' station

ANS: A Nurses should only discuss clients' information in private areas where no one else can overhear. For example, a unit medication room is a non-public area where nurses can privately discuss information that pertains to the client's care.

A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates that the teaching has been effective? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older" B. " Urinary incontinence is something I will have to live with as I grow older" C. "I can expect to have less ear wax as I get older" D. "My stomach will empty more quickly after meals as I grow older"

ANS: A Older adults experience decreased cardiac output, which causes an increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise. Although bladder capacity decreases in older adults, urinary incontinence is not expected and pt's should have it investigated and treated. Additionally, they have a increased buildup of cerumen in the ears which may increase problems with hearing loss. Decreased gastric emptying is expected.

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

ANS: A 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. The AP should place the wheelchair parallel to the bed.

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting

ANS: A Smoking cessation slows the progression of chronic obstructive pulmonary disease (COPD). It is not "too late" for this client to stop smoking, and the nurse should encourage the client to do so.

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium

ANS: A Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities. Calcium supports bone and tooth formation and facilitates nerve impulse transmission. Potassium affects storage of glycogen, nerve impulse transmission, cardiac conduction, and smooth muscle contraction. Magnesium affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles.

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.

ANS: A 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. The resident should not have access to client information until he participates in the facility's training, which includes information about data security and client confidentiality. Even then, he should only have access to information directly needed to provide care to his specific clients.

A nurse is teaching range-of-motion 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.

ANS: A The client holding the hand with the palm up is a demonstration of supination of the hand. Holding the hand with the palm down is pronation, pointing the fingers toward the floor is flexion, and pointing the fingers toward the ceiling is extension.

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

ANS: A 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. The water-soluble vitamins (B complex and C) readily dissolve in water and are absorbed into the bloodstream from the small intestine. Chicken contains many of the B complex vitamins, including B2, B3, B6, B12, and pantothenic acid. Oranges are a good source of vitamin C. Dried peas are a good source of many of the B complex vitamins, including B1, folate, and pantothenic acid.

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority? A. Measure the client's apical pulse B. Administer the allopurinol to the client C. Inform the nurse manager D. Complete an incident report

ANS: A The first action the nurse should take using the nursing process is to assess the client by measuring the client's apical pulse. Atenolol is a beta blocker and can decrease the client's heart rate.

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A. "A nurse will show me how to care for my wound." B. "A nurse will stay with me at home during the day." C. "I will call the nurse to change my bed linens." D. "I will call the nurse to help me bathe in the morning."

ANS: A The home health nurse will provide wound care as prescribed and educate the client about wound care and illness management.

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 medication at home, I will leave it for you to take." C. "I will come back in 30 minutes 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."

ANS: A 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 using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report. A. Assessment B. Background C. Situation D. Recommendation

ANS: A The nurse provides information about assessment findings in this portion of the report, including vital signs, pain assessment, and changes in assessment findings. Background includes: pertinent medical history, laboratory findings, allergies, and code status. Situation includes: information about problems the client is experiencing. Recommendation includes: treatment recommendations and asks the provider about additional options.

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

ANS: A 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. This approach reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Hence, the first action the nurse should take is to inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage is often due to a kink in the tubing or the client lying on it.

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. 2 mm B. 4 mm C. 6 mm D. 8 mm

ANS: A The nurse should document a 2 mm indentation after applying and removing pressure as 1+ pedal edema. The nurse should document a 4 mm indentation after applying and removing pressure as 2+ pedal edema. The nurse should document a 6 mm indentation after applying and removing pressure as 3+ pedal edema. The nurse should document an 8 mm indentation after applying and removing pressure as 4+ pedal edema.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure to the outer opening of the eye for 2 min C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close the eyes tightly after administration

ANS: A The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

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

ANS: A The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain. The nurse should instruct the client to practice tai chi to stimulate the immune system and to improve joint function and mobility. However, it is not effective for pain management. The nurse can use aromatherapy to promote the client's comfort and healing. However, jasmine is used to improve mood and is not effective for pain management. The nurse should offer the client ginger tea, if it is not contraindicated, to reduce nausea. However, it is not effective for pain management.

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. Increased blood pressure B. Decreased blood glucose level C. Decreased oxygen use D. Increased gastrointestinal motility

ANS: A The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood pressure and heart rate as a result of sympathetic stimulation. The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood glucose due to the release of glucocorticoids and gluconeogenesis. The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in oxygen use due to the increased metabolic rate and oxygen demands of the body. The nurse should expect a client who is experiencing stress and anxiety to manifest decreased gastrointestinal motility, which can result in constipation and flatus.

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium

ANS: A The nurse should identify that an albumin level within the expected reference range is an indication that the client has adequate protein uptake and synthesis. Albumin levels measure protein status. They are useful for identifying long-term protein depletion rather than short-term or acute changes in nutritional status. Calcium levels reflect the adequacy of bone and tooth formation, blood clotting, nerve impulse transmission, muscle contraction and relaxation, and various other essential processes. Sodium levels indicate fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities. Potassium levels reflect the status of many metabolic activities, including nerve impulse transmission, cardiac conduction, and skeletal and smooth muscle contraction.

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? A. Lactose B. Sucrose C. Maltose D. Fructose

ANS: A The nurse should identify that lactose is a form of sugar that is found in milk. Sucrose is table sugar and is also found in fruits and vegetables. Maltose is found in germinating cereals, such as barley. Fructose is found in honey and fruit.

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

ANS: A The nurse should identify the finding of an S-shaped or C-shaped spinal column and uneven shoulder or hip heights as manifestations scoliosis. The nurse should expect a client who has lordosis to exhibit manifestations of an exaggeration of the anterior convex curvature in the lumbar region of the spine. The nurse should expect a client who has torticollis to exhibit manifestations of the head inclining toward the affected side with a contraction of the sternocleidomastoid muscle. The nurse should expect a client who has kyphosis to exhibit manifestations of an increased convex curvature in the thoracic region of the spine.

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to place a towel between the heating pad and my skin." B. "I'll need to turn up the temperature if I can't feel the heat." C. "I'll sleep on top of the heating pad to increase the heat penetration." D. "Keeping the heat continuously on my back will help it heal."

ANS: A The nurse should instruct the client to place a towel between the heating pad and the skin to reduce the risk of burns.

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

ANS: A 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. The nurse should collect 4 to 10 mL of sputum before sending the specimen to the laboratory to provide an adequate amount of sputum for culture and sensitivity.

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves

ANS: A The nurse should use standard precautions by applying clean gloves when faced with the possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean gloves. The nurse should remove the tape by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges. The nurse should remove the old dressing a layer at a time to prevent the removal of drains and allow assessment of the drainage. The nurse should open the sterile supplies after removing the old dressings and washing the hands and before donning sterile gloves to apply the sterile dressing. These measures help prevent microorganisms from contaminating the sterile field.

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection? A. WBC 15,000 mm^3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063

ANS: A This finding is above the expected reference range and is an indication of infection.

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "Your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections."

ANS: A This response illustrates the therapeutic communication technique of clarifying and offering self. The nurse should allow the client to express feelings and fears and support the client in learning how to give the injections.

A nurse on the med-surg 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

ANS: A When caring for a client, the nurse should apply the nursing process priority setting framework. Each step of the process builds on the pervious step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implementa a nursing intervention, or notify a provider of a change in status, they must first collect adequate data.

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 too 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."

ANS: A While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the CDC recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids. Hand hygiene should be performed with warm water, which preserves the protective oil of the skin better than hot water. Friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least 15 to 20 seconds. Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands.

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed." D. "I will secure any wires in my home under rugs."

ANS: B "I will put a night-light in the hallway." The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home. The nurse should instruct the client to paint or mark only the edges of the steps with a light color to make them more prominent. Physiological changes associated with aging can affect an older adult client's ability to see the edges of the steps. The nurse should instruct the client to wear well-fitting slippers with non-skid soles as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to balance, increasing the risk of falls. The nurse should instruct the client that securing wires under a rug can create an electrical hazard and should be avoided. Physiological changes associated with aging can affect an older adult client's ability to see surroundings and to react quickly to hazards when walking.

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent? A. Illness is not influenced by culture. B. The meaning of disease can vary widely across cultures. C. Assigning clients to specific cultural categories facilitates communication. D. Predetermined criteria should generate client care activities.

ANS: B A client may define and react to disease based on his or her unique cultural perspective. The nurse should seek to understand a client's culture and life experiences in order to provide care that is effective, evidence-based, and culturally congruent. A client's culture affects the social determinants of health and contributes to how an individual defines illness. Culture and life experiences play an important role in a client's view about health, illness, and health care. The nurse cannot make the assumption that all clients within a specific culture have the same beliefs. The nurse should consider each client as an individual and respect individual life patterns, values, and definitions of illness in order to provide culturally congruent care. The nurse should consider that patterns of daily life and meaning are generated by the client, not predetermined criteria. To provide culturally congruent care, the nurse should adjust client care activities such as medication administration or bath time to the client's daily patterns.

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A. A client who has multiple sclerosis and uses a wheelchair B. A client who has end-stage cirrhosis C. A client who has hemiplegia due to a stroke D. A client who has cancer and receives weekly radiation therapy

ANS: B A client who has end-stage cirrhosis likely has a life expectancy of ≤6 months. Therefore, this client is eligible for hospice services. Although multiple sclerosis is a chronic debilitating disease, the client is not likely to be eligible for hospice services. A client who has hemiplegia due to a stroke might recover partially or fully. Therefore, this client is not likely to be eligible for hospice services. Clients currently undergoing treatment for cancer are not candidates.

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every 1 hr D. Provide ice chips as per provider prescription

ANS: B Check the client's vital signs. The greatest risk to this client is an injury from unstable vital signs (e.g. hypotension and respiratory depression) after receiving anesthesia and medication. Therefore, the first action the nurse should take is to check the client's vital signs and compare them with the readings during the PACU stay. The nurse should assess the client's pain and administer medication to relieve pain and promote comfort as needed. The nurse should instruct the client about using the incentive spirometer to prevent the development of atelectasis. The nurse should provide ice chips to the client as per provider prescription to promote comfort.

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 30mL sterile water B. Elevate the HOB to 30 or 45 degrees C. Suggest changing the feeding to lactose free formula D. Warm the enteral formula to room temperature before feeding

ANS: B Elevating the HOB helps prevent the gravitational reflux of gastric contents, thereby decreasing the risk of aspiration. Irrigation can help prevent or resolve clogging of the tube, lactose free formuls will reduce GI irritation or upset in clients who are sensitive to lactose, and warming the formula before feeding can help reduce abdominal cramping and discomfort.

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication? A. The motivation for communication is evident. B. Feedback is provided. C. A message is communicated to the group of clients. D. Multiple channels are used by the sender.

ANS: B Feedback in verbal and/or nonverbal forms is evidence of successful communication. Feedback can indicate to the nurse whether the meaning of the message was understood by the recipient. The element of "referent" motivates communication between people (e.g. a sound or perception). The message is only the content of what the sender is trying to convey in the communication process. It can contain both verbal and nonverbal expression. Messages should be clear and concise. However, even though a message might be clearly delivered, this does not mean the communication is effective. Using multiple channels (e.g. visual, auditory, and facial expressions) can improve the effectiveness of communication. However, this will not assist in determining if the communication is effective.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

ANS: B Fidelity means keeping a promise that was made. Autonomy involves ensuring the client has the right ot make personal decisions. Nonmaleficence involves doing no harm. Justice involves treating everyone fairly.

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

ANS: B 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. Clients should avoid exercising for 2 to 3 hours before bedtime. A cool room temperature is generally more conducive to sleep. Although the warm milk in hot cocoa or hot chocolate can promote sleep, the chocolate contains caffeine, which is a stimulant and can keep the client awake.

A nurse is 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

ANS: B 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 planning an inservice training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching? A. Ovo-vegetarian diets exclude eggs B. Kosher diets have restrictions regarding how the food must be prepared C. Macrobiotic diets are plant-based and exclude all animals and seafood D. Flexitarian diets exclude the consumption of dairy products

ANS: B Kosher diets are guided by a set of laws regarding the processing, preparation, and eating of food. Ovo-vegetarian diets are primarily vegetable based and exclude meat and dairy except for eggs, macrobiotic diets are primarily plant-based but do include fish and seafood, and flexitarian diets are plant-based with the occasional consumption of meat, fish, and dairy product.

A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take? A. Discourage the use of unregulated medications and supplements B. Verify the herbal supplements do not interact with medications the provider has prescribed C. Tell the client to limit the number of supplements to no more than 2 D. Describe the dangers of taking plant-derived medications and supplements

ANS: B Many herbal products interact with other prescription and nonprescription meds. Valerian, for example, interacts with antihistamines as well as barbiturates and other sleep-promoting medications. The nurse should report any potential interactions to the provider.

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

ANS: B Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the abdomen is distended.

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound

ANS: B Starting at the area of least contamination and working toward the area of greatest contamination prevents the spread of microorganisms within the wound.

A nurse on tha med-surg unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Evacuate the client from the room C. Sound the fire alarm D. Activate the fire extinguisher

ANS: B The acronym RACE can help nurses remember the order of actions to take in the event of a fire. RACE: rescue, activate, confine, and extinguish. The first priority is rescuing/removing the the patient.

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties? A. "I take a warm shower when getting ready for bed." B. "I often have a cup of coffee with my dessert before going to bed." C. "I usually read a chapter in a book before I go to bed." D. "I make sure I do my exercises in the morning."

ANS: B The client should avoid beverages that contain caffeine in the late afternoon and evening because caffeine stimulates the CNS and can result in sleep disturbances. Caffeine is also a diuretic and can cause nighttime awakenings for urination.

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations C. Prepare to administer oxygen D. Give the client a back rub to promote relaxation

ANS: B The nurse should apply the nursing process priority-setting framework when caring for this client 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 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; therefore, the nurse should first assess the client's respiratory status.

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

ANS: B The nurse should begin discharge planning at the time that the client is admitted to the facility.

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor

ANS: B The nurse should instruct the client to cleanse the skin around the stoma with warm water, as using soap can leave a residue on the skin and cause poor adherence of the pouch. The nurse should instruct the client to change the colostomy bag before a meal because drainage from the ostomy is less likely to occur. The nurse should instruct the client to change the pouch every 3 to 7 days to avoid skin breakdown around the stoma. The nurse should instruct the client not to place an aspirin in the ostomy pouch to decrease odor, as this can cause stoma bleeding.

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? A. Sit beside the client during the interview B. Make sure the device is functioning C. Make sure lighting in the room is soft D. Provide a lengthy interview process to allow adequate time to answer questions

ANS: B The nurse should make sure all of the client's assistive devices are working before the interview process. Room should be bright enough so the client can see the nurse's mouth during the interview and it should be brief so it does not tire the client.

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

ANS: B 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 collecting health history data from a client who is deaf and uses ASL to communicate. THe nurse will be working with and 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

ANS: B The nurse should speak clearly and allow time for the interpreter to convey the message and for the client to receive it. The nurse should face the client while speaking to offer the client the opportunity to observe facial expressions and gestures. To enhance the nurse-client relationship, the nurse should direct questions, instructions, and informato to the client, not the interpreter. The client's focus will be on the interpreter, but it is respectful to continue to address the client and not the interpreter. The nurse should sit at the same level as the client to give the client the opportunity to observe facial expressions/gestures.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. Spreading the labia with the dominant hand D. Using a cotton ball to wipe the right and left labia majora

ANS: B The nurse should wipe anteroposteriorly both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia

ANS: B The presence of cold extremities, first in the feet and then in the hands, is a physical change that occurs when a client's death is imminent. Urinary incontinence, hypotension and a slow weak pulse are physical changes that occur when a client's death is imminent.

A nurse is caring for a client who has injuries resulting from a MVC. 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"

ANS: B The priority action the nurse should taken when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort. The nurse should re-evaluate the client's pain management plan immediately.

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take? A. Place a padded tongue blade in the client's mouth B. Lower the client to the floor and place a pad under the client's head C. Seek the help of a coworker and lift the client back into bed D. Use an oropharyngeal airway to keep the upper airway passages open

ANS: B To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or another soft object under the client's head.

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contract

ANS: B Tuberculosis requires airborne precautions, which are protocols that prevent the spread of infections via very small droplets (e.g. measles and varicella). Protective environment precautions are for clients who are immunocompromised and are at high risk for infection (e.g. clients who had chemotherapy). Droplet precautions prevent the spread of infections via larger droplets (e.g. rubella, pertussis, and meningococcal pneumonia). Contact precautions prevent the spread of infections via direct or indirect contact with contaminated blood or other body fluids (e.g. Shigella, herpes simplex, and Escherichia coli).

A nurse is teaching a client who is post-op about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understand 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"

ANS: B Turning, coughing, and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal.

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? A. Complete an incident report B. Check the client for injuries C. Make sure the client has skid-free footwear D. Remind the client to ask for help when getting out of bed

ANS: B Using the nursing process, the nurse should first evaluate the client for any injuries or physiological changes. The nurse should also notify the provider to determine the need for any further examination or intervention.

A nurse is caring for a toddler at a well-child visit when the mother call, "Help, My baby is choking on food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability to cry or speak C. Presence of nausea D. Capillary refill time of 1.5 sec

ANS: B When the client has no sound passing through the vocal cords, a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea.

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 pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

ANS: C 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 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 in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation

ANS: C Collecting this data is included in the assessment portion of the nursing process. In addition, the nurse should explore the client's health history and perform a physical examination. Planning is the portion of the nursing process in which the nurse establishes goals and outcomes for the client and selects interventions that will help achieve those goals and outcomes. Planning also involves setting care priorities. Evaluation is the portion of the nursing process in which the nurse uses critical thinking skills to determine if goals and outcomes have been met. The nurse examines the results, compares the data, identifies errors, and considers the client's situation when performing the evaluation portion of the nursing process. Implementation is the portion of the nursing process in which the nurse provides client care based on assessment data and analysis and the plan of care developed in the previous step. The nurse also uses interpersonal and technical skills when implementing nursing interventions.

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

ANS: C EBP indicates removing the safety pin from the extinguisher is the first action; therefore, it is the action the nurse should instruct the client to perform first.

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? A. Ask the client if he wants to self-administer his insulin B. Have the client list the steps of the procedure C. Have the client demonstrates the procedure D. Ask the client if he understands the purpose of insulin

ANS: C Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning.

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec

ANS: C If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. Then, the nurse should document the irregularity in the client's medical record. The nurse should use a Doppler ultrasound stethoscope for a pulse that is nonpalpable or difficult to palpate. The nurse should assess pedal pulses to determine circulation in the client's lower extremities. The nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities.

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? A. Decreased respiratory rate B. Pinpoint pupils C. Increased blood pressure D. Bronchiolar construction

ANS: C Increased blood pressure. The nurse should expect a client who is experiencing the fight-or-flight response to manifest an increase in arterial blood pressure, heart rate, and cardiac output due to arousal of the central nervous system. The nurse should expect an increased respiratory rate, dilated pupils, and bronchiolar dilation in a client who is experiencing the fight-or-flight response.

A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include? A. "Include at least 3 g of sodium in your daily diet." B. "Limit wine consumption to 230 mL daily." C. "Include 2.5 cups of vegetables in your daily diet." D. "Limit water intake to 1.5 L each day."

ANS: C Nutritious diets contain a variety of foods to ensure the required daily allowance of nutrients is ingested. The nurse should instruct the women to include 2.5 cups of vegetables and 2 cups of fruit in their daily diets. Fruits and vegetables should be a variety of colors to provide an assortment of nutrients. Incorrect Answers:A. The nurse should instruct the women to consume sodium in moderation. The American Heart Association recommends consuming less than 2.5 g of sodium daily, and the adequate intake (AI) is 1.5 g. Excessive intake of sodium can lead to hypertension. Although certain alcoholic beverages, such as red wine, contain phytochemicals that can reduce the risk of cardiovascular disease and offer anti-inflammatory properties, excessive intake can lead to a deficiency in other nutrients. The recommended amount of alcohol for women is a drink per day, which is equivalent to 350 mL (12 oz) of beer, 148 mL (5 oz) of wine, or 44 mL (1.5 oz) of hard alcohol that is over 80 proof. Water is an important component of a nutritious diet because it is necessary for the digestion, absorption, and transport of nutrients. The nurse should instruct these women to drink between 2 and 3 L of water daily to maintain homeostasis, based on client comorbidities, the climate, and the client's activity level.

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area B. The AP tapes the catheter to the client's inner thigh C. The AP hangs the collection bag at the level of the bladder D. The AP ensures there are no kinks in the drainage tubing

ANS: C Place the drainage bag below the level of the bladder to ensure proper drainage by gravity.

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 15.2cm (6 in) B. Wear sterile gloves to insert the tubing C. Position the client of his left side D. Hold the solution bag 91 cm (36 in) above the client's rectum

ANS: C 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 desending colon. The tube should be inserted 7 to 10cm (3 to4 in), wear nonsterile gloves, hang the bag 30cm (12 in) above the rectum for a low enema and 45cm (18 in) for a high enema. If the nurse holds the solution to high, the solution might run in too fast causing discomfort and spasms that make retaining the enema more difficult.

A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A. Supine B. Lateral C. Fowler's D. Trendelenburg

ANS: C Sitting upright promotes full expansion of both lungs and facilitates ventilation and perfusion.

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."

ANS: C 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 inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands then throw the gloves away B. Prepare an incident report to document the event C. Carefully remove the gloves and proceed with hand hygiene D. Ask the provider to order a blood culture to determine the risk of infection

ANS: C Stand precautions require the use of gloves and hand hygiene in the care of all clients.

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. Palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia

ANS: C Tachycardia is a heart rate over 100/min in adults.

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.

ANS: C 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 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

ANS: C The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available. The nurse should not shake soiled linen because this action can transfer microorganisms. The nurse should wear a mask when working within 1 m (3.3 ft) of a client who is on droplet precautions to reduce the risk of transferring the particle droplets. The nurse should strictly limit the client's activity outside the room to reduce the risk of transferring microorganisms. Whenever the client has to leave the room, the nurse should place a mask on the client.

A nurse on a surgical unit is receiving a client who had abdominal surgery from the PACU. Which of the following assessments should the nurse make first? A. Pain level B. Hydration status C. Airway D. Urinary output

ANS: C The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them.

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

ANS: C 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 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.

ANS: C 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.

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

ANS: C 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 puls is congenitally absent is some clients. The popliteal pulse is located behind the knee, the posterior tibial pulse is located on the inner side of the ankle, and the femoral pulse is located in the inguinal area.

A nurse is caring for a client who had a stroke and is at risk for of fallings. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints

ANS: C The nurse should monitor the client frequently as a means of reducing the client's fall risk. Other measures can include keeping the client's bed in a low position, creating elimination schedules, and using a gait belt when the client is ambulating.

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'

ANS: C 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. The lithotomy position is useful for gynecological examinations. The lateral recumbent, or side-lying position, limits access to the abdomen. This position is useful when auscultating the heart to detect murmurs. The Sims' position limits access to the abdomen. This position is useful for rectal and vaginal examinations.

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. Insist that the AP attend an in-service training about standard precautions C. Talk with the AP about the technique used D. Observe the AP a second time and intervene if the technique remains the same

ANS: C The nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves.

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

ANS: C This client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site.

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? A. "The home health dietitian will visit and help you learn to cook all over again." B. "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control." C. "The dietitian will help you choose foods you are used to that also meet your health needs." D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian."

ANS: C This response shows respect for the client's food preferences and cultural needs by offering choices from among the client's usual foods.

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? A. Check the client's name and medical record number on the MAR against the room and bed number B. Call the client by name and check the name on her identification band against the MAR C. Compare the medical record number and name on the MAR with the client's identification band D. Ask the client's visitor to identify the client by name and to state the client's birth date

ANS: C. The Joint Commission requires the use of 2 client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band.

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible click B. Murmur C. Third heart sound D. Pericardial friction rub

ANS: D A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound that is beard best with the diaphragm of the stethoscope at the left sternal border. It is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following card surgery or trauma, and with some autoimmune problems like rheumatic fever. A client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up or leaning forward. Audible clicking sound occurs in clients who have undergone prosthetic valve replacement surgery. Heart murmur has a swishing or whistling sound caused by turbulent blood flow through valves. S3 is a low-pitched noise after S2, it is caused by rapid ventricular filling during diastole. Best head at the mitral area, with the client lying on the left side.

A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? A. Judgment B. Short-term memory C. Attention span D. Abstract reasoning

ANS: D Abstract reasoning evaluates higher-level thinking and the ability to understand and interpret abstract thoughts. To test judgment, the nurse could ask what decisions the client would make in response to a specific real-life challenge. To test short-term memory, the nurse could ask the client to recall something like a list of 3 words that was provided a few moments earlier. To test attention span, the nurse could ask the client to count backward from 100 in intervals of 7.

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 of sterile gloves D. Perform hand hygiene

ANS: D According to EBP, the nurse should first perform hand hygiene before touching the client or performing any skills. This is vital because contamination of the nurse's hands is a primary source of infections.

A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric ulcers C. Respiratory depression D. Liver Damage

ANS: D Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment. Constipation is an adverse effect of opioid analgesics. Gastric ulcers are an adverse effect of aspirin and other nonselective NSAIDs.

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a 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.

ANS: D 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 assessing a client who is post-op. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing

ANS: D Besides the client's self report of pain, facial expressions such as grimacing, clenching the jaw, and lip biting can be indication of pain.

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

ANS: D Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia such as with COPD. It is a change in the angle between the nail and the nail base, ofter with enlargement of the fingertips. Trauma and severe infection can cause Beau's lines (grooves that run horizontally across the nail plate).

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document

ANS: D Durable power of attorney document. A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so. Prior to specific procedures, clients must sign an informed consent form to confirm that the provider has explained the risks and benefits and pertinent information about the procedure. A living will contains advance directives that inform medical personnel about the care to provide in case the individual is unable to make decisions. A DNR directive is a prescription the provider writes on the client's request to instruct the staff to forego resuscitation efforts for the client.

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial

ANS: D During the denial stage of grief, a client is unable to accept the reality of the loss. A client who has a terminal disease has a limited amount of time, so building a house is unrealistic and denies reality. During the acceptance stage of grief, a client integrates the loss into his or her life (e.g. by making final arrangements). During the bargaining stage of grief, a client stalls awareness of the loss by trying to keep it from occurring. During the anger stage of grief, a client shows resistance or blames other people, a higher power, or the situation itself.

A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? A. Limit the client's fluid intake B. Assist the client into a supine position C. Administer oxygen at 2 L/min D. Encourage the client to cough

ANS: D Encourage the client to cough. Rhonchi are loud, low-pitched, rumbling sounds primarily detected over the trachea and bronchi. The nurse should encourage the client to cough because doing so often clears this adventitious sound. The nurse should attempt to clear the adventitious sound by asking the client to cough. The nurse should assist the client into an upright position to facilitate breathing. The nurse should administer oxygen to a client who is experiencing shortness of breath or is displaying an oxygen saturation level below the expected reference range of 95% to 100%.

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's

ANS: D Fowler's position. Although various definitions exist for Fowler's position, generally a low Fowler's position means 30° of elevation, semi Fowler's is 45° to 60°, and high Fowler's is 60° to 90° of elevation. Sim's the client lies on a side with the leg on that side slightly flexed and the opposite leg more acutely flexed. The lower arm is behind, with the opposite arm flexed at the shoulder and the elbow.

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 38C (100.4F) C. Pulse Ox 95% D. BP 145/90 mmHg

ANS: D Greater than 140/90

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? A. Blood loss B. NPO status after surgery C. Nasogastric tube suctioning D. Impaired peristalsis of the intestines

ANS: D Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to help the client ambulate to promote peristalsis.

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed

ANS: D Performing range-of-motion exercises will help the client maintain mobility until her pain is under control and she is able to ambulate without excessive discomfort.

A nurse is changing the dressings for a client who is 3 days post-op following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. THe nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous Exudate C. Serosanguineous exudate D. Purulent exudate

ANS: D Purulent exudate includes thick yellow, green, or brown drainage and usually indicates wound sloughing or infection. Sanguineous drainage indicates an accumulation or RBCs from the plasma and appears bright red. Serous drainage indicates plasma from the blood and appears watery and clear to light yellow. Serosanguineous indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood tinged, Watery drainage may also be evident.

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? A. Document the administration of the medication B. Count the amount of available medication on hand and sign for it C. Measure the client's respiratory rate D. Check the medication dose and the client's identification

ANS: D The "rights" of medication administration include verifying the right client and the right dose. The nurse should document the administration of the medication after dispensing it to the client, not before. Phenytoin is not a controlled substance, so narcotic counts do not apply. Phenytoin does not affect respiratory status, so it is not necessary for the nurse to measure the client's respiratory rate immediately prior to administering this medication.

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? A. Stand 3 feet from the client when assisting with lifting. B. Lock your knees when standing for long periods. C. Lift up to 22.6 kg (50 lb) without the use of assistive devices. D. When lifting an object, spread your feet apart to provide a wide base of support.

ANS: D The AP should spread the feet apart because a wide base of support increases stability.

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test

ANS: D The blanch test is an indicator of peripheral circulation and tissue perfusion. Romberg test is used to assess balance and gross motor function. Beau's lines are caused by systemic illness or injury. Resp excursion is palpated to determine thoracic expansion and depth of breathing.

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority is a fire occurs in the health care facility. A. Close the fire doors on the unit B. Use a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit

ANS: D The greatest risk during a fire is injury to clients; therefore, the priority action is to evacuate them from the unity. Utilize the RACE protocol.

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidone-iodine and continue the catheter insertion B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion C. Continue with the catheter insertion D. Obtain a new catheter and reattempt insertion

ANS: D The insertion of a urinary catheter is a sterile procedure. The only way to ensure sterility of the catheter the nurse plan is to insert is by obtaining a new sterile catheter and following surgical asepsis throughout the procedure.

A nurse is caring for a client who is postoperative following vascular surgery of the left femoral artery. The nurse should identify that the surgical sould should be cleansed in which of the following directions? A. From the middle of the thigh toward the wound B. From the left lower abdominal quadrant toward the wound C. From the left hip toward the wound D. from the wound toward the surrounding skin.

ANS: D The nurse should cleanse a surgical wound from the least contaminated location (the inside of the wound) toward the most contaminated (the surrounding skin).

A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions she the nurse take? A. Recap the needle on the syringe B. Schedule a nurse to administer future injections for the client C. Explain to the client that the syringe should be disposed of in the bathroom trash can. D. Place the syringe in a puncture proof disposal container

ANS: D The nurse should dispose of the syringe to prevent a needlestick then provide the client with educations

A provider is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine? A. Once during the client's lifetime B. Every 10 years C. Every 5 years D. Annually in the fall

ANS: D The nurse should recommend that older adult clients receive the influenza vaccine annually. Influenza outbreaks occur annually, and the influenza virus changes constantly. Consequently, an influenza vaccine from a previous year will not protect a client exposed to this year's influenza strain. Influenza in older adults can result in the development of primary viral influenza pneumonia, which causes several deaths a year. An influenza vaccine given in the fall, prior to the onset of flu season, will be most effective in preventing influenza in this target population.

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? A. "In time you'll know the right thing to do." B. "I am sorry. Would you like me to call someone for you?" C. "There are multiple treatment options for you to consider." D. "Can you explain the concerns you're having right now?"

ANS: D This response uses the therapeutic communication technique of asking a relevant question. By using an open-ended question to ask the client to explain any present concerns, the nurse is encouraging the client to respond and provide additional information.

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. 2-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test

ANS: D When using the Romberg test, the nurse instructs the client to stand with the feet together and arms at the sides, first with the eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test. Two-point discrimination is tested by touching the skin with 2 sharp, pointed objects. The purpose of the test is to determine when the client can differentiate between the points. The Glasgow coma scale is used to measure a client's level of consciousness. The Babinski reflex is tested by using an object to strike the sole of the foot. When the test is negative, all of the toes bend. The test is positive if the toes spread outward.

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

ANS: D While acting as the client's advocate, the nurse should support her decision and notify the provider. The client has the right to refuse a procedure after giving consent, it is not the responsibility of the nurse to call the OR to cancel the surgery because it is a decision between the surgeon and client. HIPAA precludes the nurse from telling the family.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500 mg/day of vitamin E C. Limit fluid intake to 20 mL/kg of body weight per day D. Provide a protein intake of 1.5 g/kg of body weight per day

ANS: D A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing. A caloric intake of 35 to 40 kcal/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing. Vitamin E is not essential for wound healing. The nurse should encourage a fluid intake of 30 to 35 mL/kg of body weight per day, as water is essential to the wound-healing process.

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child?

ANS: 2 5 mL = 1 tsp, 10 mL = 2 tsp