ATI Nursing Fundamentals Final
a nurse is preparing a heparin infusion for a pt who was admitted to the facility w/ 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
Echinacea
Derivative of the purple coneflower; prevents infection and has healing properties; used internally to support the immune system.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do?
Reduce activity level and notify the healthcare provider. Lochia should progress in stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare provider and reduce her activity to conserve energy (A).
a nurse is planning care for a client who has had a stroke, resulting in aphasia & dysphagia. which of the following tasks should the nurse assign to an assistive personnel (AP)? (select all that apply) a. assist the pt w/ a partial bed bath b. measure the pt's BP after the nurse administers an antihypertensive medication c. test the pt's swallowing ability by providing thickened liquids d. use a communication board to ask what the pt wants for lunch e. irrigate the pt's indwelling urinary catheter
a. b. d.
a nurse is discussing the use of herbal supplements for health promotion w/ a pt. which of the following pt statements indicates an understanding of herbal supplement use? a. "i can take echinacea to improve my immune system" b. "i can take feverfew to reduce my level of anxiety" c. "i can take ginger to improve my memory" d. "i can take ginkgo biloba to relieve nausea"
a. "i can take echinacea to improve my immune system"
a nurse manager is preparing a review medication documentation w/ a group of newly licensed nurses. which of the following statements should the nurse manager plan to include in the teaching? a. "use the complete name of the medication magnesium sulfate" b. "delete the space between the numerical dose & the unit of measure" c. "write the letter U when noting the dosage of insulin" d. "use the abbreviation SC when indication an injection"
a. "use the complete name of the medication magnesium sulfate"
a nurse is caring for a pt who has a terminal diagnosis & whose health is declining. the pt requests information about advance directives. which of the following responses should the nurse make? a. "we can talk about advance directives, & i can also give you some brochures about them" b. "you should set up a time to talk w/ your provider about that" c. "let's discuss how you are feeling today, & we'll save the planning for when you are feeling a little better" d. "why do you want to discuss this without your partner here to plan this w/ you?"
a. "we can talk about advance directives, & i can also give you some brochures"
a nurse is caring for a group of pts on a medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity? a. a pt who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, & the nurse responds affirmatively b. a pt who has a prescription for a nasogastric tube refuses it, & the nurse complied w/ the pt's wishes c. a pt who has a do-not-resuscitate (DNR) order has a cardiac arrest, & the nurse does not perform CPR despite requests from the pt's family d. a pt who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer
a. a pt who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, & the nurse responds affirmatively
a nurse is preparing to administer enoxaparin subcutaneously to a pt. which of the following actions should the nurse take? a. administer the medication w/ the needle at a 45° angle b. administer the medication into the pt's nondominant arm c. putt the pt's skin laterally or downward prior to administration d. massage the injection site after administration
a. administer the medication w/ the needle at a 45° angle
a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? a. advocacy ensures pt's safety, health, & rights b. advocacy ensures the nurses are able to explain their own actions c. advocacy ensures that nurses follow through on their promises to pts d. advocacy ensures fairness in pt care delivery & use of resources
a. advocacy ensures pt's safety, health, & rights
a nurse is preparing to delegate pt care tasks to an assistive personnel (AP). which of the following tasks should the nurse delegate? a. ambulating a pt who is postoperative b. inserting an indwelling urinary catheter for a pt c. demonstrating the use of an incentive spirometer to a pt d. confirming that a pt's pain has decreased after receiving an analgesic
a. ambulating a pt who is postoperative
a nurse is preparing to administer an injection of an opioid medication to a pt. the nurse draws out 1 mL of the medication from a 2 mL vial. which of the following actions should the nurse take? a. ask another nurse to observe the medication wastage b. notify the pharmacy when wasting the medication c. lock the remaining medication in the controlled substances cabinet d. dispose of the vial w/ the remaining medication in a sharps container
a. ask another nurse to observe the medication wastage
a nurse is providing discharge teaching for a pt who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the pt & his family? (select all that apply) a. check the cord routinely for frays or tearing b. keep the unit at least 1.2 m (4 ft) away from a gas stove c. consider purchasing a generator for power backup d. observe for signs of hypoxia e. select synthetic clothing & bedding
a. check the cord routinely for frays or tearing c. consider purchasing a generator for power backup d. observe signs of hypoxia
a nurse is responding to a call light & finds the pt lying on the bathroom floor. which of the following actions should the nurse take first? a. check the pt for injuries b. move hazardous objects away from the pt c. notify the provider d. ask the pt to describe how she felt prior to the fall
a. check the pt for injuries
a nurse is admitting a pt who has rubella. which of the following types of transmission-based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment
a. droplet
a nurse is admitting a pt who is having an exacerbation of heart failure. in planning this pt's care, when should the nurse initiate discharge planning? a. during the admission process b. as soon as the pt's condition is stable c. during the initial team conference d. after consulting w/ the pt's family
a. during the admission process
a nurse is assessing an adult pt who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene? a. erythema on pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3,000 mL per day d. one bowel movement every other day
a. erythema on pressure points
a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take? a. examine personal values about the issue b. tell the parents that this necessary procedure c. inform the parents that the staff does not require their consent d. contact a spiritual support person to explain the importance of the procedure
a. examine personal values about the issue
a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a pt. which of the following actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the pt in a semi-fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it
a. gently shake the container of medication prior to administration
a nurse is caring for a pt who is receiving pain medication through a pt-controlled analgesia (PCA) pump. which of the following actions should the nurse take? a. instruct the family to refrain from pushing the button for the pt while she is asleep b. inform the pt that because she is on PCA, vital signs will be taken every 8 hrs c. teach the pt to avoid pushing the button until pain is above a 7 on a scale of 0 to 10 d. increase the basal rate & shorten the lock-out interval time if the pt's pain level is too high
a. instruct the family to refrain from pushing the button for the pt while she is asleep
a nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. which of the following actions should the nurse take? a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails
a. pad the client's wrist before applying the restraints
a nurse is caring for a pt who has tuberculosis. which of the following actions should the nurse take? (select all that apply) a. place the pt in a room w/ negative-pressure airflow b. wear gloves when assisting the pt w/ oral care c. limit each visitor to 2-hr increments d. wear a surgical mask when providing pt care e. use antimicrobial sanitizer for hand hygiene
a. place the pt in a room w/ negative-pressure airflow b. wear gloves when assisting the pt w/ oral care e. use antimicrobial sanitizer for hand hygiene
a nurse is administering an otic medication to an older adult client. which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. press gently on the tragus of the client's ear b. pack a small piece of cotton deep into the client's ear canal c. move the client's auricle down & back toward her head d. tilt the client's head backward for 5 min.
a. press gently on the tragus of the client's ear
a nurse is caring for a pt who has a terminal illness & is approaching death. the pt is short of breath & has noisy respiration's from secretion in their airway. which of the following actions should the nurse take? a. turn the pt every 2 hr b. administer an antiemetic every 6 hr c. hold oral care d. increase the room's temperature
a. turn the pt every 2 hr
a nurse is caring for a pt who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the pt? a. use a bed exit alarm system b. raise four side rails while the pt is in bed c. apply one soft wrist restraint d. dim the lights in the pt's room
a. use a bed exit alarm system
a nurse is teaching an older adult pt who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend? a. walking briskly b. riding a bicycle c. performing isometric exercises d. engaging in high impact aerobics
a. walking briskly
narrowed arterial lumen
arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries
a nurse is assessing a pt's readiness to learn about insulin self-administration. which of the following statements should the nurse identify as an indication that the pt is ready to learn? a. "i can concentrate best in the morning" b. "it is difficult to read instruction bc my glasses are at home" c. "im wondering why i need to learn this" d. "you will have to talk to my wife about this"
as "i can concentrate best in the morning"
a nurse is caring for a pt who has a terminal illness & is at the end of life. the nurse should recognize that which of the following statements by the pt's partner indicates effective coping? a. "i am not worried bc i still have hope that he will be okay" b. "i am relying on support from our family during this time" c. "we can plan our family reunion once he recovers & comes home" d. "we don't see any reason to start discussing funeral arrangements right now"
b. "i am relying on support from our family during this time"
a nurse is providing discharge instructions to a pt who will be using a walker. which of the following pt statements indicates an understanding of the teaching? a. "i can place an extension cord across my living room to plug in my TV" b. "i will hire someone to trim the tree that hangs low over the stairs of my front porch" c. "i will place my alarm clock on my bedroom dresser across the room" d. i will replace the old throw rug in my kitchen w/ a new one"
b. "i will hire someone to trim the tree that hangs low over the stairs of my front porch"
a nurse is caring for a pt who reports difficulty falling asleep. which of the following recommendations should the nurse make? a. "drink a cup of hot cocoa before bedtime" b. "maintain a consistent time to wake up each day" c. "exercise 1 hour before going to bed" d. "watch a television program in bed before going to sleep"
b. "maintain a consistent time to wake up each day"
a nurse i caring for a pt who reports pain. when documenting the quality of the pt's pain on an initial pain assessment, the nurse should record which of the following pt statements? a. "i'm having mild pain" b. "the pain is like a dull ache in my stomach" c. "i notice that the pain gets worse after i eat" d. "the pain makes me feel nauseous"
b. "the pain is like a dull ache in my stomach"
a nurse is caring for a pt who asks about the purpose of advance directives. which of the following statements should the nurse make? a. "they allow the court to overrule an adult pt's refusal of medical treatment" b. "they indicate the form of treatment a pt is willing to accept in the event of a serious illness" c. "they permit a pt to withhold medical information from health care personnel" d. "they allow health care personnel in the emergency department to stabilize a pt's condition"
b. "they indicate the form of treatment a pt is willing to accept in the event of a serious illness"
a nurse is educating a pt who has a terminal i'll ed's about declining resuscitation in a living will. the pt asks, "what would happen if i arrived at the emergency department & i had difficulty breathing?" which of the following responses should the nurse make? a. "we would consult the person appointed by your health care proxy to make decisions." b. "we would give you oxygen through a tube in your nose." c. "you would be unable to change your previous wishes about your care." d. "we would insert a breathing tube while we evaluate your condition."
b. "we would give you oxygen through a tube in your nose."
a nurse is planning care for a pt who has tuberculosis. the nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap
b. N95 respirator
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. a nurse who is caring for a pt reviews the pt's medical chart w/ a nursing student who is working w/ the nurse b. a nurse asks a nurse from another unit to assist w/ documentation for a pt c. a nurse who is caring for a pt returns a call to the person appointed in the health care proxy to discuss the pt's care d. a nurse discusses a pt's status w/ the physical therapist who is caring for the pt
b. a nurse asks a nurse from another unit to assist w/ documentation for a pt
a community health nurse is checking blood pressures for a group of pt's at a community health screening. which of the following pt's is at an increased risk for hypertension? a. a pt who is 52 years old b. a pt who smokes one pack of cigarettes each day c. a pt who walks for 30 min every day d. a pt who drinks one glass of wine three times per week
b. a pt who smokes one pack of cigarettes each day
a nurse has just inserted an NG tube for a pt. which of the following should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowel sounds are present on auscultation d. the pt reports relief of nausea
b. an x-ray shows the end of the tube above the pylorus
a nurse is caring for a pt who has a respiratory infection. which of the following techniques should the nurse use when performing nasotracheal suctioning for the pt? a. insert the suction catheter while the pt is swallowing b. apply intermittent suction when withdrawing the catheter c. place the catheter in a location that is clean & dry for later use d. hold the suction catheter w/ her clean, nondominant hand
b. apply intermittent suction when withdrawing the catheter
a nurse is caring for a pt who is postoperative & refuses to use an incentive spirometer following major abdominal surgery. which of the following actions is the nurse's priority? a. request that a respiratory therapist discuss the technique for incentive spirometry w/ the pt b. determine the reasons why the pt is refusing to use the incentive spirometer c. document the pt's refusal to participate in health restorative activities d. administer a pain medication to the pt
b. determine the reasons why the pt is refusing to use the incentive spirometer
a nurse is caring for a pt who has a pharyngeal diphtheria. which of the following types of transmission precautions should the nurse initiate? a. contact b. droplet c. airborne d. protective
b. droplet
a nurse is assessing four adult pts. which of the following physical assessment techniques should the nurse use? a. use the face, legs, activity, cry, & consolability (FLACC) pain rating scale for a pt who is experiencing pain b. ensure the bladder of the blood pressure cuff surrounds 80% of the pt's arm c. obtain an apical heart rate by auscultating at the third intercostal space left of the sternum d. palpate the pt's abdomen before auscultating bowel sounds
b. ensure the bladder of the blood pressure cuff surrounds 80% of the pt's arm
a nurse is initiating a protective environment for a pt who has had an allogenic stem cell transplant. which of the following precautions should the nurse plan for this pt? a. make sure the pt's room has at least six air exchanges per hour b. make sure the pt wears a mask when outside her room if there is construction in the area c. place the pt in a private room w/ negative-pressure airflow d. wear an N95 respirator when giving the pt direct care
b. make sure the pt wears a mask when outside her room if there is construction in the area
a nurse is caring for a group of pt's. which of the following actions should the nurse take to prevent the spread of infection? a. carry a pt's soiled linens out of the room in a mesh linen bag b. place a pt who has tuberculosis in a room w/ negative-pressure airflow c. provide disposable plates & utensils for a pt who is HIV-positive d. dispose of a pt's blood-saturated dressing in a trash bag
b. place a pt who has tuberculosis in a room w/ negative-pressure airflow
a nurse is planning to insert a peripheral IV catheter for an older adult pt. which of the following actions should the nurse plan to take? a. insert the catheter at a 45° angle b. place the pt's arm in a dependent position c. shave the excess hair from the insertion site d. initiate IV therapy in the veins of the hand
b. place the pt's arm in a dependent position
a nurse is assessing an older adult pt's risk for falls. which of the following assessments should the nurse use to identify the pt's safety needs? (select all that apply) a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctiva d. visual fields e. visual acuity
b. pupil clarity d. visual fields e. visual acuity
a nurse is reviewing evidence-based practice principles about administration of oxygen therapy w/ a newly licensed nurse. which of the following actions should the nurse include? a. regulate the flow rate by aligning the rate w/ the top of the ball inside the flow meter b. regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min c. make sure the reservoir bag of a partial rebreathing mask remains deflated d. use petroleum jelly to lubricate the pt's nares, face, & lips
b. regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
a nurse is reviewing protocol in preparation for suctioning secretions from a pt who has a new tracheostomy. which of the following actions should the nurse plan to take? a. use a resuscitation bag w/ 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction in water-soluble lubricant d. adjust the wall suction apparatus to a pressure of 170 mm Hg
b. select a suction catheter that is half the size of the lumen
a nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care? a. critical pathway b. situation, background, assessment, & recommendation (SBAR) c. transfer report d. medication administration record (MAR)
b. situation, background, assessment, & recommendation (SBAR)
a nurse is caring for a pt who has an NG tube & is receiving intermittent feedings through an open system. which of the following actions should the nurse take first? a. rinse the feeding bag w/ water between feedings b. tell the pt to keep the head of the bed elevated at least 30° c. make sure the enteral formula is at room temperature d. wipe the top of the formula can w/ alcohol
b. tell the pt to keep the head of the bed elevated at least 30°
a nurse is performing a home safety assessment for a pt who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol? a. the pt uses a wool blanket on their bed b. the pt uses nonacetone nail polish remover c. the pt stores an extra oxygen tank on its side under their bed d. the pt has a weekly inspection checklist for oxygen supplement
b. the pt uses nonacetone nail polish remover
a nurse is teaching a pt & his family how to care for the pt's tracheostomy at home. which of the following instructions should the nurse include in the teaching? a. remove the outer cannula cautiously for routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritate skin w/ full-strength hydrogen peroxide
b. use tracheostomy covers when outdoors
a nurse is caring for a pt who is refusing a blood transfusion for religious reasons. the pt's partner wants the pt to have the blood transfusion. which of the following actions should the nurse take? a. ask the pt to consider a direct donation b. withhold the blood transfusion c. request a consultation w/ the ethics committee d. ask the pt's family to intervene
b. withhold the blood transfusion
a nurse in a surgical suite notes documentation on a pt's medical record that he has a latex allergy. in preparation for the pt's procedure, which of the following precautions should the nurse take? a. ensure sterilization of no disposable items w/ ethylene oxide b. wrap monitoring cords w/ the stockinette & tape them in place c. cleanse latex ports on IV tubing w/ chlorhexidine before injecting medication d. wear hypoallergenic latex gloves that contain powder
b. wrap monitoring cords w/ the stockinette & tape them in place
a nurse is caring for a pt who has an aggressive form of prostate cancer. the provider briefly discusses treatment options & leaves the pt's room. when the nurse asks if the pt would like to discuss any concerns, the pt declines. which of the following statements should the nurse make? a. "i will return shortly after i document this in your record" b. "most men live a long time w/ prostate cancer" c. "i am available to talk if you should change your mind" d. "i will make a referral to a cancer support group for you"
c. "i am available to talk if you should change your mind"
a pt who is postoperative is verbalizing pain as a 2 on a scale of 0 to 10. which of the following statements should the nurse identify as an indication that the pt understands the preoperative teaching she received about pain management? a. "i think i should take my pain medication more often, since it is not controlling my pain" b. "breathing faster will help keep my mind off of the pain" c. "it might help me to listen to music while i'm lying in bed" d. "i don't want to walk today because i have some pain"
c. "it might help me to listen to music while i'm lying in bed"
a nurse is talking w/ an older adult pt who is contemplating retirement. the pt 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? a. "you would have so much more time to spend w/ your family" b. "you should consider getting a part-time job or doing volunteer work" c. "let's talk about how the change in your job status will affect you" d. "why wouldn't you want to retire & relax?"
c. "let's talk about how the change in your job status will affect you"
a nurse enters a pt's room & finds her on the floor. the pt's roommate reports that the pt was trying to get out of bed & fell over the side rail onto the floor. which of the following statements should the nurse document about this incident? a. "incident report completed" b. "pt climbed over the side rails" c. "pt found lying on floor" d. "pt was trying to get out of bed"
c. "pt found lying on floor"
a nurse in a clinic is caring for a middle adult pt who states, "the doctor says that, since i am at an average risk for colon cancer, i should have a routine screening. what does that involve?" which of the following responses should the nurse make? a. "i'll get a blood sample from you & send it for a screening test" b. "beginning at age 60, you should have a colonoscopy" c. "you should have a fecal occult blood test every year" d. "the recommendation is to have a sigmoidoscopy every 10 years"
c. "you should have a fecal occult blood test every year"
a nurse is calculating a pt's fluid intake over the past 8 hr. which of the following items should the nurse plan to document on the pt's intake & output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea
c. 8 oz of ice chips a. 2 cups of soup = 480 mL of fluid b. 1 qt of water = 960 to 1,000 mL of fluid c. ice = 1/2 liquid amt 8oz ice chips = 4oz fluid d. 6 oz of tea = 180 mL of fluid
a nurse is performing a skin assessment for a pt who expresses concern about skin cancer. which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. a lesion w/ uniform pigmentation b. new appearance of petechiae c. a mole w/ an asymmetrical appearance d. the presence of a papule
c. a mole w/ an asymmetrical appearance
a nurse is providing discharge teaching for a pt about self-administering heparin. which of the following instructions should the nurse include in the teaching? a. insert the needle at a 15° angle b. aspirate for blood return prior to administration c. administer the medication into the abdomen d. massage the site following the injection
c. administer the medication into the abdomen
a nurse is preparing to transfer a pt 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? a. rock the pt up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the pt for orthostatic hypotension d. apply a gait belt to the pt
c. assess the pt for orthostatic hypotension
a nurse is assessing a client who has required bed rest for the past month. which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. bladder distention b. decreased blood pressure c. calf swelling d. diminished bowel sounds
c. calf swelling
a nurse is caring for a pt who has a prescription for wound irrigation. which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5° C (105° F) c. cleanse the wound from the center outward d. use a 20-mL syringe to irrigate the wound
c. cleanse the wound from the center outward
a nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation? a. verify the client's name on their identification bracelet w/ the MAR b. call the pharmacy to determine whether the client's medications are available c. compare the client's home medications w/ the provider's prescriptions d. place the client's home medication bottles in a secure location
c. compare the client's home medications w/ the provider's prescriptions
a nurse in an acute care facility is preparing a discharge summary for a pt who is transferring to a long-term care facility. which of the following documentation should the nurse include? a. pt flow sheet b. acuity ratings c. current medications d. incident reports
c. current medications
a nurse is administering 1 L of 0.9% sodium chloride to a pt who is postoperative & has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful? a. increase in hematocrit b. increase in respiratory rate c. decrease in heart rate d. decrease in capillary refill time
c. decrease in heart rate
a nurse is performing a Romberg test during the physical assessment of a pt. which of the following techniques should the nurse use? a. touch the face w/ a cotton ball b. apply a vibrating tuning fork to the pt's forehead c. have the pt stand w/ their arms at their sides & their feet together d. perform direct percussion over the area of the kidneys
c. have the pt stand w/ their arms at their sides & their feet together
a nurse is caring for a pt who has a prescription for 5 units of regular insulin & 10 units of NPH insulin to mix together & administer subcutaneously. determine the correct order of steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle
c. inject 10 units of air into the bottle of NPH insulin a. inject 5 units of air into the bottle of regular insulin d. withdraw the correct dose of regular insulin from the bottle b. withdraw the correct dose of NPH insulin from the bottle
a nurse is caring for a pt who is postoperative following a knee arthroplasty & requires the use of thigh-length sequential compression sleeves. which of the following actions should the nurse take? a. assist the pt into a prone position b. place a sleeve over the top of each leg w/ the opening at the knee c. make sure two fingers can fit under the sleeves d. set the ankle pressure at 65 mm Hg
c. make sure two fingers can fit under the sleeves
a nurse is reviewing a pt's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify w/ the provider? a. medication name b. route of administration c. medication dose d. frequency of administration
c. medication dose
a nurse is completing an admission assessment for a pt who reports vomiting & diarrhea for the past 3 days. which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mm Hg
c. rapid heart rate
a nurse is talking w/ the partner of a pt who has dementia. the pt's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. the nurse should identify that the partner is experiencing which of the following types of role-performance stress? a. role ambiguity b. sick role c. role overload d. role conflict
c. role overload
a nurse is caring for a lot 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? a. purulent exudate b. warmth c. skin blanching d. bleeding
c. skin blanching edema & coolness indicate this
a nurse is using an open irrigation technique to irrigate a pt's indwelling urinary catheter. which of the following actions should the nurse take? a. place the pt in a side-lying position b. instill 15 mL of irrigation fluid into the catheter w/ each flush c. subtract the amt of irrigant used from the pt's urine output d. perform the irrigation using a 20-mL syringe
c. subtract the amt of irrigant used from the pt's urine output
a nurse is evaluating a pt's use of a cane. which of the following actions should the nurse identify as an indication of correct use? a. the top of the cane is parallel to the pt's waist b. when walking, the pt moves the cane 46 cm (18 in) forward c. the pt holds the cane on the stronger side of her body d. the pt move her stronger limb forward w/ the cane
c. the pt holds the cane on the stronger side of her body
a home health nurse is performing a follow-up visit for a client who has a gastronomy tube through which they receive intermittent feedings & medications. the pt has recently developed diarrhea. which of the following findings should the nurse identify as a possible cause of the diarrhea? a. the pt is receiving formula at room temp b. the feedings infuse at a slow, continuous drip over 8 hr each night c. the pt's caregiver washes out the feeding bag w/ warm water once every 24 hr d. the pt's caregiver flushes the tube w/ water before & after administering medications
c. the pt's caregiver washes out the feeding bag w/ warm water once every 24 hr
a nurse is planning strategies to manage time effectively for pt care. which of the following strategies should the nurse implement? a. combine pt care tasks when caring for multiple pts b. wait until the end of shift to document pt care c. use the planning step of the nursing process to prioritize pt care delivery d. allow for interruptions in tasks to discuss pt care issues w/ colleagues
c. use the planning step of nursing process to prioritize pt care delivery
a nurse is caring for a pt who has recently started using a behind-the-ear hearing aid. which of the following statements should the nurse identify as an indication that the pt understands the use of this assistive device? a. "this type of hearing aid does not allow for fine tuning of volume" b. "i shouldn't have trouble keeping the hearing aid in place during exercise" c. "i expect to hear a whistling sound when i first insert the hearing aid" d. "i will be sure to remove my hearing aid before taking a shower"
d. "i will be sure to remove my hearing aid before taking a shower"
a nurse is assessing a pt who reports increased pain following physical therapy. which of the following questions should the nurse ask when assessing the quality of the pt's pain? a. "is your pain constant or intermittent?" b. "what would you rate your pain on a scale of 0 to 10?" c. "does the pain radiate?" d. "is your pain sharp or dull?"
d. "is your pain sharp or dull?"
a middle adult pt tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? a. "most people are happy when their children grow up & leave home" b. "you should be proud that your children are becoming independent" c. "maybe you should consider why you are feeling useless" d. "people in middle adulthood often find satisfaction in nurturing & guiding young people"
d. "people in middle adulthood often find satisfaction in nurturing & guiding young people"
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) a. 186 mL/hr b. 150 mL/hr c. 280 mL/hr d. 107 mL/hr
d. 107 mL/hr
a nurse is caring for a pt who has a sodium level of 125 mEq/L. which of the following findings should the nurse expect? a. numbness of the extremities b. bradycardia c. positive Chvostek's sign d. abdominal cramping
d. abdominal cramping
a nurse is caring for a pt who has herpes zoster & asks the nurse about the use of complementary & alternative therapeutics for pain control. the nurse should inform the pt that this condition is a contraindication for which of the following therapies? a. biofeedback b. aloe c. feverfew d. acupuncture
d. acupuncture
a nurse is caring for a pt who is postoperative. when the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much." which of the following interventions is the nurse's priority action? a. encourage the pt to relax & take deep breaths during the dressing change b. educate the pt about the importance of the dressing change to prevent infection c. assist the pt to a comfortable position for the dressing change d. administer pain medication 45 min before changing the pt's dressing
d. administer pain medication 45 min before changing the pt's dressing
a nurse is caring for a pt who has decreased mobility. which of the following actions should the nurse take to decrease the pt's risk of developing plantar flexion contracture? a. place a pillow under the pt's knees b. position a trochanter roll under each of the pt's hips c. advise the ot to wear rubber-soled slippers d. apply an ankle-foot orthotic device to the pt's feet
d. apply an ankle-foot orthotic device to the pt's feet
a nurse is planning care for a pt who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the pt w/ feeding? a. assign a staff member to feed the pt b. provide small-handled utensils for the pt c. thicken liquids on the pt's tray d. arrange food in a consistent pattern on the pt's plate
d. arrange food in a consistent pattern on the pt's plate
a nurse receives report about a pt who has 0.9% sodium chloride infusing IV at 123 mL/hr. when the nurse performs the initial assessment, he notes that the pt has received only 80 mL over the last 2 hr. which of the following actions should the nurse take first? a. reposition the pt b. document the pt's IV intake in the medical record c. request a new IV fluid prescription d. check the IV tubing for obstruction
d. check the IV tubing for obstruction
a nurse on a medical unit is preparing to discharge a pt to home. which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medications from the facility in a plastic bag b. evaluate the pt's ability to self-administer medications c. report an identified discrepancy to The Joint Commission d. compare prescriptions w/ medications the pt received while at the facility
d. compare prescriptions w/ medications the pt received while at the facility
a nurse is admitting a pt who has an abdominal wound w/ a large amt of purulent drainage. which of the following types of transmission precautions should the nurse initiate? a. protective environment b. airborne precautions c. droplet precautions d. contact precautions
d. contact precautions
a nurse is assessing a pt who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins
d. distended neck veins
a nurse is preparing to administer multiple medications to a pt who has an enteral feeding tube. which of the following actions should the nurse plan to take? a. dissolve each medication in 5 mL of sterile water b. draw up medications together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube w/ 15 mL of sterile water
d. flush the tube w/ 15 mL of sterile water
a nurse is caring for a pt who requires an NG tube for a stomach depression. which of the following actions should the nurse take when inserting the NG tube? a. position the pt w/ the head of the bed elevated to 30° prior to insertion of the NG tube b. remove the NG tube if the pt begins to gag or choke c. apply suction to the NG tube prior to insertion d. have the pt take sips of water to promote insertion of the NG tube into the esophagus
d. have the pt take sips of water to promote insertion of the NG tube into the esophagus
a nurse is caring for a pt who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown? a. place the pt in high-fowler's position b. increase the pt's intake of carbohydrates c. massage reddened areas w/ i scented lotion d. have the pt use a trapeze bar when changing position
d. have the pt use a trapeze bar when changing position
a nurse is preparing to apply a dressing for a pt who has stage 2 pressure injury. which of the following types of dressing should the nurse use? a. alginate b. gauze c. transparent d. hydrocolloid
d. hydrocolloid
a nurse is reviewing practice guidelines w/ a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice? a. insert an implanted port b. close a laceration w/ sutures c. place an endotracheal tube d. initiate an enteral feeding through a gastronomy tube
d. initiate an enteral feeding through a gastronomy tube
a nurse is caring for a pt who is postoperative & is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the pt's vital signs every 15 min & report back in 1 hr. which of the following actions should the nurse take next? a. document the provider's statement in the medical record b. complete an incident report c. consult the facility's risk manager d. notify the nursing manager
d. notify the nursing manager
a nurse is reviewing a pt's fluid & electrolyte status. which of the following findings should the nurse report to the provider? a. BUN 15 mg/dL b. creatinine 0.8 mg/dL c. sodium 143 mEq/L d. potassium 5.4 mEq/L
d. potassium 5.4 mEq/L a. normal range (10-20 mg/dL) b. normal range for women 41-60 yrs old (0.5-1.1 mg/dL) for men 41-60 yrs old (0.6-1.3 mg/dL) c. normal range (136-145 mEq/L) d. normal range (3.5-5 mEq/L)
a nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions
d. practice sessions
a nurse is caring for a pt who is expressing anger about his diagnosis of colorectal cancer. which of the following actions should the nurse take? a. discuss the risk factors for colon cancer b. focus teaching on what the pt will need to do in the future to manage his illness c. provide the pt w/ written information about the phases of loss & grief d. reassure the pt that this is an expected response to grief
d. reassure the pt that this is an expected response to grief
a nurse is lifting a bedside cabinet to move it closer to a pt who is sitting in a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? a. bend at the waist b. keep his feet close together c. use his back muscles for lifting d. stand close to the cabinet when lifting it
d. stand close to the cabinet when lifting it
a home health nurse is completing an admission assessment of an older adult pt who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse? a. the caregiver is the pt's financial power of attorney b. the pt is in a wheelchair w/ the wheels locked c. the pt reports receiving a full bath twice each week d. the caregiver insists on remaining in the room
d. the caregiver insists on remaining in the room
a nurse is caring for a pt who has diarrhea due to shigella. which of the following precautions should the nurse implement for this pt? a. have the pt wear a mask when receiving visitors b. limit the pt's time w/ visitors to no more than 30 min per day c. assign the pt to a room w/ negative-pressure airflow exchange d. wear a gown when caring for the pt
d. wear a gown when caring for the pt
distended jugular veins
does not produce a sound congestive heart failure
what herbal supplement can be taken to relive nausea, vomiting, & aid in digestion?
ginger
what herbal supplement can be take to improve memory & reduce stress?
ginkgo bilboa
Asynchronous closure of aortic and pulmonic valves
known as "splitting" of S2, the nurse should hear two "dub" sounds during auscultation. best heard over the aortic area of the heart
impaired ventricular contraction
produces extra heart sounds, either S3 or S4. best heard over the aortic area of the heart
What is feverfew used for?
taken to promote wound healing & decrease inflammation associated w/ arthritis
Principle of Veracity
truthful statements are preferable to lies in the absence of special circumstances that overcome the negative weight
what herbal supplements can be taken to reduce anxiety?
valerian & chamomile
