ATI Medsurg A and B

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position (veins will dilate due to gravity)

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?.

"I am available to talk if you should change your mind." When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client

A nurse in a provider's clinic is caring for a client who has heart failure. Nurses' Notes First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from 20 mg to 40 mg daily. Client to return in 2 weeks for follow-up. Second Clinic Visit: Client arrives for follow-up visit 2 weeks later. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus rhythm. Pulses to lower extremities weak. +1 dependent edema present. Respirations even. Chest clear. Reports less coughing. Bowel sounds all present. Abdomen slightly distended. Reports last bowel movement previous evening. States voiding without difficulty, clear yellow urine. States urination has increased with increased dose of furosemide.

"I am limiting my sodium intake to 2 grams daily." "I am eating fewer potato chips and more fruit for snacks." "I know to call my doctor if I gain 3 pounds or more in 2 days.'

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time." This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the trees that hangs low over the stairs of my front porch." Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

"Let's talk about how the change in your job status will affect you." This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"The indicate the from of treatment a client is willing to accept in the event of a serious illness." Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness

A client who is postoperative is verbalizing pain as a 2 on a pain scale of o to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

'It might help me to listen to music while I'm lying in bed." Listening to music is an effective nonpharmacological intervention for the management of mild pain

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach" - The client is describing the quality of the pain, which is how the pain feels in the client's own words

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them." With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose." Explanation: Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"When descending stairs, I will first shift my weight to my right leg." To descend stairs, the client should first shift his body weight to his right, unaffected leg.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year."

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should receive a pneumococcal vaccine when you are 65 years old."

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Obtain the pronouncement of death from the provider. 2. Remove tubes and indwelling lines. 3. Wash the client's body. 4. Ask the client's family members if they would like to view the body. 5. Place a name tag on the body. The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

107 mL/hr

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

3) Inject 10 units of air into the bottle of NPH insulin1) Inject 5 units of air into the bottle of regular insulin4) Withdraw the correct dose of regular insulin from the bottle2) Withdraw the correct dose of NPH insulin from the bottle The nurse should first inject air into the vial of PH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the PH insulin vial and withdraw the correct amount of PH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with PH insulin.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips *The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. Four oz of liquid water equals 120 mL of fluid.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A community health nurse is checking blood pressures for a group of clients at a community health screening Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day A client who smokes one pack of cigarettes each day is at an increased risk for hypertension.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance Explanation: An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

A nurse is caring for a client who has a newly placed ileostomy. The nurse should first address the followed by the

Stoma color is correct. Skin around the stoma is correct.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

Acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen. Explanation: The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures clients' safety, health, and rights. Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse is caring for a client who is receiving a unit of packed RBCs. Nurses' Notes 0800: Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815: Client reports itching and anxiety. Client's face is flushed and has hives. Complete the following sentence by using the list of options. The client has manifestations of BLANK AEB BLANK

Allergic reaction AEB Clients itching

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

Apply an ankle foot orthotic device to the clients feet Rationale: The nurse should use a device to maintain dorsiflexion, such as an ankle- foot orthotic device or a footboard placed perpendicular to the mattress

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension The first action the nurse should take using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. The nurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)

Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed. Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply

Assist the client to a left side-lying position with the right knee flexed. Administer a cleansing enema. Auscultate the client's bowel sounds. Perform a manual digital examination of the client's rectum

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung sounds The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

Diagnostic Results Week 1: Hct 42% (37% to 47%) Hgb 15 g/dL (12 g/dL to 16 g/dL) WBC count 8,000/mm3 (5,000 to 10,000/mm3) Platelet count 350,000/mm3 (150,000 to 400,000/mm3) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2: Hct 37% (37% to 47%) Hgb 12 g/dL (12 g/dL to 16 g/dL) WBC count 6,000/mm3 (5,000 to 10,000/mm3) Platelet count 100,000/mm3 (150,000 to 400,000/mm3) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) The client is at risk for by the client's as evidenced

Bleeding AEB platelet count

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse is caring for a client who has COPD. Select the 3 findings that require follow-up.

Breath sounds is correct. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse.

A nurse in the emergency department (ED) is caring for a client. Click to highlight the findings that indicate the client is malnourished.

Cachectic, with flaccid muscle tone. Skin dry and scaly with bruises on extremities. Pulse rate 118/min Abdomen distended BMI 17

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries Explanations: The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.)

Check the cord routinely for frays or tearing. Consider purchasing a generator for power backup Observe for signs of hypoxia

A nurse in a medical-surgical unit is caring for six clients. The first client the nurse should assess is followed by 0900: Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL) Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL) Client 3: Oxygen saturation 88% (95% to 100%) Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL) Client 6: Glycosylated hemoglobin 8% (less than 7%)

Client 3 then client 4

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received during hospitalization. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

Current Medications Rationale: The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is caring for a client who has pancreatitis. Nurses' Notes 1000: Client states, "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fluids started and infusing in left peripheral IV site. Select the 3 tasks the nurse should delegate to an assistive personnel (AP).

Document the client's vital signs. Measure the client's intake and output. Transfer the client from wheelchair to

A nurse in a provider's clinic is caring for a client who has diarrhea. 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 Ib). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Increase intake of high-calcium foods. Eat probiotic foods, such as yogurt. Avoid alcohol while experiencing diarrhea. Eat raw vegetables. Eat three large meals a day. Avoid caffeine while experiencing diarrhea. Drink hot liquids several times a day. Drink carbonated beverages to replace lost fluids. Follow a low-fiber diet. Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching.

Eat probiotic foods, such as yogurt. Avoid alcohol while experiencing diarrhea. Avoid caffeine while experiencing diarrhea. Follow a low-fiber diet.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. .The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.

A nurse is caring for a client who has pneumonia. Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified. The client is showing signs of :

Extravasation is correct. The client's report of severe pain and the appearance of the IV catheter site are indications of extravasation. Vancomycin is a medication that carries the risk of extravasation. IV catheter site is correct. The appearance of the site is an indication of extravasation. Vancomycin is a medication that carries a risk of extravasation.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PA) pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area? An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves. The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

Medication dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement such as mg, to clarify the amount the nurse should administer.

A nurse is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? 1030: Blood pressure 110/68 mm Hg Heart rate 110/min Respiratory rate 24/min Temperature 38.6° C (101.5° F) Oxygen saturation 91% on room air

Place the client on droplet isolation precautions Apply oxygen at 2 L/min via nasal cannula. Request a prescription for an antipyretic medication. - Remain 1 m (3 feet) from the client.

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

N95 respirator - The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)

Narrowed arterial lumen

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Day 1: Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Day 5: Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.

Passive range-of-motion exercises to lower extremities performed once each day. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, Skin intact.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

Practice sessions Practice sessions require psychomotor skills when learning.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)

Pupil clarity Visual fields Visual acuity Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal canal at a flow rate of no more then 6L/ min Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula, Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The patient is dx with pneumonia The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

Request a prescription for an antibiotic medication. Wear mask within 3 feet of the client Initiate droplet precaution Apply a mask on the client when they leave their room.

A nurse in an emergency department is caring for a client. Nurses' Notes 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation. The nurse should first BLANK followed by BLANK

Review medications that might be causing confusion is correct. Using the nursing process, the first step the nurse should take is to assess for a cause of the client's confusion Using other methods to keep the client safe is correct. After assessing for the cause of the client's confusion, the nurse should attempt alternatives to the use of restraints, such as covering the client's IV lines or asking a family member to stay with the client. The use of restraints should be avoided if possible

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it. This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. The nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply.

Stop the IV infusion. Elevate the client's left arm. Apply heat to the client's left hand.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output. The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

'A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. Day 1: Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active × 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of O to 10. Client repositioned every 2 hr while in bed. Day 4: Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of O to 10. Client repositioned every 2 hr while in bed.

Temperature WBC count Prealbumin level Pain level Odor of wound

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increase support and maintain alignment.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client identifies the location of a fire extinguisher The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hr. Explanation: The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field

A nurse is caring for a client who is postoperative following abdominal surgery. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of O to 10. No additional urine output since 1200. Repositioned client for comfort. Vital Signs 1100: Temperature 36.2° C (97.2° F) Heart rate 76/min Respirations 18/min BP 122/68 mm Hg Oxygen saturation 95% on room air 1200: Temperature 36.8° C (98.2° F) Heart rate 116/min Respirations 20/min BP 112/68 mm Hg Oxygen saturation 93% on room air Click to highlight the assessment findings below that the nurse should report to the provider.

Urinary output Reported pain level Vital signs

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system. Explanation: The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling. A bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery. Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse is admitting a client to a health care facility. Nurses' Notes 1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.

Wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room. Place the client in a negative airflow room. Remove mask after exiting the client's room.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

'A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

Witness the client's signature on the consent form. The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

administer the medication with the needle at a 45 degree angle The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

arrange food in a consistent pattern on the client's plate Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

compare the client's home medications with the provider's prescriptions The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

contact precautions Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

decrease heart rate Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission process Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

evacuate the client According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

examine personal values about the issue Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

have the client stand with their arms at their sides and their feet together A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

maintain a consistent time to wake up each day The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.)

normal breath sounds

A nurse is caring for a client who has a new diagnosis of seizure disorder. 0900: On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. The nurse should first address the client's

physical safety followed by the client's PRN medication

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days Which of the following findings should the nurse expect?

rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

tap just bellow the kneecap The nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

the caregiver insists on remaining in the room A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

use tracheostomy covers when outdoors Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

what could i have done to deserve this illness?： The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.