ATI - PN Fundamentals Online Practice 2020 A

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.) mL

1820 mL

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be sure to keep the crutch tips dry." B. "I will hold a crutch in each hand when sitting down." C. "I will place my weight on my underarms." D. "I will lead with my right leg when going up stairs."

A. "I will be sure to keep the crutch tips dry." The nurse should instruct the client to inspect the crutch tips frequently and keep them dry at all times to decrease the risk for slipping.

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? A. "Tell me what the afterlife means to you." B. "You should discuss the afterlife with your priest." C. "Keep praying. A miracle could happen." D. "Maybe your condition will lead you closer to God."

A. "Tell me what the afterlife means to you." This statement respects the client's spiritual needs by using open-ended therapeutic communication to assist the client to talk about their concerns.

A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching? A. "The living will directs my medical care when I am unable to make decisions." B. "I should have a nurse cosign my living will." C. "After signing the living will, I will not be able to make any changes." D. "I am required by Medicare to have a living will when I am admitted to the hospital."

A. "The living will directs my medical care when I am unable to make decisions." The living will provides specific directions for a client's medical treatment when the client is unable to make decisions due to their health status.

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? A. "The reduced muscle tone has relaxed the jaw muscles." B. "That happens when a person gets close to death." C. "I can apply a chin strap to help hold the mouth closed." D. "You shouldn't worry about that at this time."

A. "The reduced muscle tone has relaxed the jaw muscles." Prior to death, decreased muscle tone causes jaw muscles to relax, resulting in an open mouth.

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? A. A stage 3 pressure injury on the coccyx B. A contaminated wound that is closed after 72 hr C. A puncture wound that is sutured D. An abdominal surgical wound with intact staples

A. A stage 3 pressure injury on the coccyx The nurse should identify a pressure injury and other wounds with edges that are not approximated as healing by secondary intention.

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever? A. Administer acetaminophen. B. Apply ice packs to the client's axillae. C. Maintain the room temperature at 18.3° C (64.9° F). D. Assist the client to ambulate four times a day.

A. Administer acetaminophen. The nurse should administer acetaminophen or an NSAID such as ibuprofen to the client to reduce the body's temperature. Acetaminophen inhibits the synthesis of prostaglandins, resulting in a reduced fever.

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? A. Administer an analgesic 30 min before starting the procedure. B. Hold the syringe 5 cm (2 in) above the upper end of the wound. C. Place the irrigation solution in a basin of cool water. D.Perform the wound irrigation with a 10-mL syringe with an angiocatheter.

A. Administer an analgesic 30 min before starting the procedure. The nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation procedure.

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)? A. Apply thromboembolic stockings. B. Monitor the circulation in all four extremities. C. Record the condition of the client's skin. D. Reinforce teaching about performing range-of-motion exercises.

A. Apply thromboembolic stockings. The application of thromboembolic stockings is within the range of function of an AP and does not require further data collection by the nurse.

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? A. Check the pH of the gastric aspirate. B. Observe the color of the gastric aspirate after adding blue dye to the formula. C. Auscultate over the epigastrium. D. Measure the length of the inserted NG tube.

A. Check the pH of the gastric aspirate. The nurse should check the pH of the gastric contents to verify tube placement. A pH greater than 6 is an indication that the nurse has aspirated respiratory contents or that the tube is in the intestine, and that the nurse should withhold the feeding.

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? A. Clamp the infusion tubing. B. Remove the dressing. C. Withdraw the catheter from the vein. D. Ensure the catheter is intact.

A. Clamp the infusion tubing. Evidence-based practice indicates that the nurse should first clamp the infusion tubing after applying clean gloves. This action stops the flow of the IV fluid and prevents it from leaking out during the IV removal.

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.) A. Ensure that the client is wearing nonskid slippers. B. Move the bedside table away from the bedside. C. Place the client in a room near the nurses' station. D. Keep the bed's full side rails in the up position. E. Reinforce teaching about how to use the call bell.

A. Ensure that the client is wearing nonskid slippers. Nonskid slippers provide better traction and can help prevent slipping and falling. C. Place the client in a room near the nurses' station. Keeping the client close to the nurses' station allows for more frequent observation to help identify actions that increase the risk for falls. E. Reinforce teaching about how to use the call bell. Even if the client is confused, it is important to reinforce the use of the call bell for assistance to help prevent the client from attempting actions that could increase the risk for falls.

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? A. Precontemplation B. Preparation C. Maintenance D. Action

A. Precontemplation According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage, the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are precontemplation, contemplation, preparation, action and the maintenance stage.

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? A. Provide privacy for the client. B. Keep the lights at a dim level. C. Expose half of the body at a time. D. Encourage the client's friend to remain in the room.

A. Provide privacy for the client. The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment.

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? A. Young adults should receive a dental assessment every 6 months. B. Young adult males should have a testicular examination every 5 years. C. Young adult females should have a routine physical examination every 4 years. D. Young adults should receive a tuberculosis skin test every 3 years.

A. Young adults should receive a dental assessment every 6 months. The nurse should include the recommendation for young adults to receive a dental assessment twice per year.

A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching? A. "This can help prevent nausea." B. "This can help prevent pneumonia." C. "I should do this every 4 hours." D. "I should do this to keep my heart from beating too fast."

B. "This can help prevent pneumonia." The purpose of turning, coughing, and breathing deeply is to reduce the risk of respiratory complications such as atelectasis, which can lead to pneumonia. This helps to maximize lung expansion and assist with the removal of pulmonary secretions.

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? A. Restrict the client's visitors to the immediate family. B. Assign the client to a negative-pressure airflow room. C. Discard personal protective equipment outside the client's room. D. Have the client wear a HEPA mask during transportation throughout the facility.

B. Assign the client to a negative-pressure airflow room. The nurse should assign the client to a negative-pressure airflow room to ensure that the air from the client's room is not circulated throughout the facility.

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? A. Volunteer at the local food pantry. B. Attend an exercise program. C. Find an enjoyable hobby. D. Support environmental conservation.

B. Attend an exercise program. When using Maslow's hierarchy of needs, the nurse should determine that the priority activity is to fulfill the client's physiological needs for activity. Therefore, the nurse should recommend exercise and help the client select a suitable exercise program.

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? A. Autonomy B. Beneficence C. Justice D. Nonmaleficence

B. Beneficence The nurse is demonstrating beneficence by acting in the client's best interest to make it possible for the client to swallow the medication.

A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes? A. Body regulation of heat and cold increases with age. B. Circulation becomes less efficient with age. C. Increased metabolic rate occurs with age, increasing body temperature. D. Sweat gland activity is increased with age.

B. Circulation becomes less efficient with age. Older adults have an increased sensitivity to temperature extremes due to decreased cardiac output. Poor cardiac output leads to less efficient circulation of blood to the tissues.

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? A. Check for capillary refill proximally to the elastic bandages every 12 hr. B. Compare the client's pedal pulses bilaterally every 4 hr. C. Place the client's legs in a dependent position for 30 min before applying the elastic bandages. D. Remove the elastic bandages every other day to inspect the skin.

B. Compare the client's pedal pulses bilaterally every 4 hr. The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on their lower extremities.

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply.) A. Full bounding pulse B. Cool extremities C. Moist crackles in the lungs D. Orthostatic hypotension E. Flat neck veins

B. Cool extremities Cool extremities can indicate fluid volume deficit. D. Orthostatic hypotension Orthostatic hypotension indicates fluid volume deficit. E. Flat neck veins Flat neck veins indicate fluid volume deficit.

A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot? A. Posterior tibial B. Dorsalis pedis C. Popliteal D. Brachial

B. Dorsalis pedis The nurse should document palpating the dorsalis pedis pulse on the top of the foot.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? A. Empty the urine drainage bag every 12 hr. B. Drain urine from the tubing before ambulation. C. Use clean technique for urine specimen collection. D. Hang the urine drainage bag at the level of the bladder.

B. Drain urine from the tubing before ambulation. Draining urine from the tubing before ambulation will prevent backflow of urine into the bladder.

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? A. Place the client in a room with another client who has pharyngitis. B. Ensure that the client wears a surgical mask during transportation throughout the facility. C. Limit the client's visitors to visitations of 30 min. D. Provide the client a room with negative-pressure airflow of six air exchanges per hour.

B. Ensure that the client wears a surgical mask during transportation throughout the facility. Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room.

A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include? A. Alarm clock that shakes the bed B. Flashing smoke alarm C. Low-pitched buzzer doorbell D. Telephone with an amplified receiver

B. Flashing smoke alarm The greatest risk to the client's safety is injury from a fire. Therefore, the priority modification is to install flashing smoke alarms because this allows the client to see when the alarm is activated rather than having to hear it.

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? A. Keep the conversation moving by asking about the client's family. B. Let the client know that, as their nurse, they are available and willing to listen. C. Ask if the client understands what to expect in the advanced stages of the illness. D. Ask the client's visitors not to say anything about the advanced disease.

B. Let the client know that, as their nurse, they are available and willing to listen. Active listening conveys the nurse's respect and acceptance for the client's feelings and gives the client an opportunity to express their thoughts and needs.

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? A. Isopropyl alcohol B. Mild soap C. Chlorhexidine D. Triclosan

B. Mild soap The CDC recommends using soap and water for handwashing when caring for clients who have a C. difficile infection. C. difficile is a spore-forming bacterium that is difficult to kill with disinfectants.

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? A. Check that the restraint is tied to a fixed frame of the bed. B. Pad bony prominences on the wrist. C. Remove the restraint every 4 hr to allow movement. D. Tie the restraint with a knot that will tighten when pulled.

B. Pad bony prominences on the wrist. The nurse should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client's skin.

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? A. Stand facing the center of the bed at the client's side. B. Place feet apart with the foot nearest the head of the client's bed in front of the other foot. C. Keep knees and hips straight while bending at the waist toward the client. D. Encourage the client to keep their legs straight and remain still.

B. Place feet apart with the foot nearest the head of the client's bed in front of the other foot. Placing the feet apart provides a wide base of support, which improves balance. Additionally, a forward-backward stance enables the nurse to shift their weight as the client moves up in bed.

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? A. Discontinued medications B. Resolved health conditions C. Frequency of vital sign collection D. Completed nursing interventions

B. Resolved health conditions The nurse should report both unresolved and resolved health conditions to promote continuity of care.

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching? A. The client leans on the crutches for support while standing still. B. The client advances the unaffected leg first while climbing stairs. C. The client stands 5 cm (2 in) from the front of a chair before sitting. D. The client bears weight on their axilla while standing in the tripod position.

B. The client advances the unaffected leg first while climbing stairs. When ascending stairs, the client should first advance the unaffected leg.

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? A. Heart rate 62/min B. Urine output of 200 mL over 8 hr C. Pulse oximetry 95% on room air D. BP 112/76 mm Hg

B. Urine output of 200 mL over 8 hr A urinary output of less than 30 mL/hr can indicate low blood volume or kidney malfunction. The nurse should report an output that averages 25 mL/hr to the provider.

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? A. "Why are you angry about taking insulin?" B. "Don't worry. Diabetes runs in my family as well." C. "I see that you are angry. Let's sit down and talk." D. "You should take insulin, because it reduces the risk for complications."

C. "I see that you are angry. Let's sit down and talk." This is an example of the therapeutic communication technique of offering self. It provides an opportunity for the nurse to understand the reason for the client's anger and provides a means for further communication.

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? A. "We will make sure she eats three meals a day." B. "We will decrease her pain medication if she gets too drowsy." C. "We will keep her room cool to help her breathe better." D. "We will make sure to provide oral care twice a day."

C. "We will keep her room cool to help her breathe better." Clients who are dying will have thick secretions and decreased muscle tone, which can make breathing more difficult. Keeping the air in the room cool will ease the work of breathing.

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? A. "I don't understand why everyone is so worried about me." B. "I don't know if I'll ever find someone who wants to marry me." C. "When I look at myself in the mirror, I don't know if I can go on." D. "I feel like the doctor pressured me into having the mastectomy."

C. "When I look at myself in the mirror, I don't know if I can go on." This statement shows sadness and a decreased initiative. The greatest risk to this client is injury from suicidal ideation. Therefore, the priority action is for the nurse to immediately contact the client's provider regarding this statement.

A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? A. A client who is receiving opioid medications via a PCA pump B. A client who has moderate Alzheimer's disease C. An 18-year-old client who has acute appendicitis D. A 16-year-old client who has a fractured tibia

C. An 18-year-old client who has acute appendicitis A competent 18-year-old client who has acute appendicitis is able to provide informed consent for treatment.

A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body? A. Remove dentures. B. Apply a shroud around the body with a visible identification tag. C. Clean soiled areas of the body. D. Place the client's head in a dependent position.

C. Clean soiled areas of the body. A complete bath is not necessary because the body will be washed by the mortician. The nurse should cleanse any soiled areas prior to the family viewing the body, make sure dentures are in place if applicable, and comb the client's hair.

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take? A. Allow the client to continue taking the medications as they did at home. B. Take the medications from the client and discard them. C. Compare the medications the provider has prescribed with the client's medications from home. D. Place the medications in the medication cart and administer them as the client took them at home.

C. Compare the medications the provider has prescribed with the client's medications from home. During admission, the nurse should compare the medications that the provider has prescribed with the medications that the client is taking at home to decrease the risk of medication error. The nurse should include this information in the client's medical record as a resource for other health care personnel.

A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.) A. Replace the NG tube. B. Place the client in Sims' position. C. Decrease the rate of the feeding. D.Check the client's blood glucose.

C. Decrease the rate of the feeding. The nurse should expect to hear bowel sounds every 5 to 35 seconds. This audio clip indicates hypermotility because there are greater than 40 bowel sounds/min. Hypermotility leads to diarrhea and is an indication of intolerance to the enteral feeding. Therefore, the nurse should slow the rate of the feeding to promote the client's tolerance of the feeding.

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? A. Explain the negative consequences of the refusal. B. Discuss with the client's partner why the treatment is necessary. C. Document the client's refusal of the treatment. D. Try to convince the client that the treatment is needed.

C. Document the client's refusal of the treatment. The nurse is responsible for notifying the provider when a client refuses a treatment or procedure and documenting the client's decision.

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Close the fire doors on the unit. B. Use a fire extinguisher to put out the fire. C. Evacuate clients from the area. D. Pull the lever on the fire alarm box.

C. Evacuate clients from the area. The first action the nurse should take when using the RACE protocol is to "rescue" or evacuate the clients from the area to prevent harm. D. Pull the lever on the fire alarm box. For the next step, "alarm," the nurse should activate the facility fire alarm and call to report the fire to the facility emergency extension. A. Close the fire doors on the unit. For the third step, "confine," the nurse should close the unit fire doors to prevent the fire from spreading. B. Use a fire extinguisher to put out the fire. For the final step, "extinguish," the nurse should use a fire extinguisher to put out the fire by aiming the nozzle at the base of the fire and using a sweeping motion.

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. B. Use an adhesive oximetry probe for a client who has a latex allergy. C. Remove polish from the client's fingernail before applying the oximetry probe. D. Lubricate the tip of the oximetry probe.

C. Remove polish from the client's fingernail before applying the oximetry probe. The nurse should instruct the AP to remove the client's fingernail polish on at least one finger before placing the probe on that finger because the sensor needs to detect a pulsating vascular bed to produce a reading.

A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? A. Obscure the client's name with a marker prior to disposal. B. Place the paper in a trash can at the nurses' station. C. Shred the paper in a secure container. D. Secure the paper in the nurse's personal locker.

C. Shred the paper in a secure container. The nurse should shred any written information in a secure container after use to protect the client's privacy and adhere to HIPAA guidelines.

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? A. Place the client's medication record on the bedside table while ambulating the client. B. Give report about the client's status while standing at the nurses' station. C. Speak with the client about their condition after visitors have left. D. Place a message board in the client's room to post dietary information.

C. Speak with the client about their condition after visitors have left. The nurse should ensure a private environment before discussing the client's condition with them.

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? A. The client has smooth, brown, irregular lesions on the back of each hand. B. The client has glossy, white circles around the periphery of the corneas. C. The client reports urinary incontinence. D. The client reports a decreased sense of taste.

C. The client reports urinary incontinence. Aging is a risk factor for urinary incontinence as older adult males can experience hypertrophy of the prostate gland, and older adult females can experience stress incontinence with laughing, sneezing, or coughing. Urinary incontinence is an abnormal condition that can impact the quality of life for older adults. Urinary incontinence should be investigated; therefore, the nurse should report this finding to the provider. Interventions can be reinforced to the client to promote improved urinary function.

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? A. The client's body should be placed on the floor. B. The client's oldest child will bathe the body. C. The client's face should be turned toward Mecca. D. The client's body will be adorned with amulets.

C. The client's face should be turned toward Mecca. Following death, it can be a practice of the Islamic faith to turn the face of a deceased person toward Mecca.

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? A. "Keep your knees in a locked position when standing for prolonged periods." B. "Bend at the waist when lifting a heavy object." C. "Keep your feet close together when lifting a heavy object." D. "When lifting a heavy object, keep it close to your body."

D. "When lifting a heavy object, keep it close to your body." The nurse should instruct the client to keep the object as close to their body as possible to increase stability and decrease back strain when lifting a heavy object.

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? A. 1 cup of cantaloupe B. 1 large baked potato C. 4 oz of banana chips D. 1 cup of applesauce

D. 1 cup of applesauce The nurse should determine that applesauce is the best food choice because 1 cup of applesauce contains 184 mg of potassium per serving. Therefore, the client's food choice of applesauce demonstrates an understanding of the teaching.

A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse? A. A client who has a respiratory rate of 12/min B. A client who has a blood pressure of 110/74 mm Hg C. A client who has a temperature of 37.3° C (99.2° F) D. A client who has a pulse rate of 110/min

D. A client who has a pulse rate of 110/min This client's heart rate is above the expected reference range of 60 to 100/min. Therefore, the nurse should collect further data to determine the cause of the tachycardia.

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? A. Provide an artificial voice box. B. Avoid using facial gestures. C. Speak to the client in a louder voice. D. Ask the client close-ended questions.

D. Ask the client close-ended questions. Clients who have aphasia can have difficulty forming words. Therefore, the nurse should ask the client questions that can be answered with a "yes" or "no" because the client can respond to these close-ended questions by shaking or nodding their head.

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.

D. Assist a client to get out of bed after a breathing treatment. The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP's range of function.

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? A. Confidentiality B. Nonmaleficence C. Accountability D. Autonomy

D. Autonomy Autonomy is an ethical principle that refers to protecting a client's independence and right to make decisions about care.

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? A. Urine specific gravity 1.015 B. Hematocrit 42% C. Urine pH 6.5 D. BUN 8 mg/dL

D. BUN 8 mg/dL A BUN of 8 mg/dL is below the expected reference range of 10 to 20 mg/dL. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution.

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? A. Show the assistive personnel where to apply the medication. B. Ask the client when the previous nurse last applied the medication. C. Identify the client by comparing the medication administration record with the client's room number. D. Compare the label of the medication container with the medication administration record three times.

D. Compare the label of the medication container with the medication administration record three times. When preparing medication from a bottle or container, the nurse should compare the label of the medication container with the medication administration record three times to ensure it is the correct medication.

A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? A. Using hand sanitizer to cleanse their hands of spilled food from a client's meal tray B. Setting aside their gown for future use in the room of a client who has a wound infection C. Removing their gloves after exiting a client's room D. Donning a mask to measure the vital signs of a client who has pertussis

D. Donning a mask to measure the vital signs of a client who has pertussis Caring for clients who have pertussis requires droplet precautions. Therefore, the AP should wear a mask when within 1 m (3.3 feet) of the client.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? A. Support the client's head with a pillow that maintains cervical flexion. B. Position the client's shoulders off the pillow for internal rotation. C. Place the client's arms at their sides to keep their elbows extended. D. Internally rotate the client's hips by using a trochanter roll.

D. Internally rotate the client's hips by using a trochanter roll. The nurse should place trochanter rolls at the proximal end of each of the client's legs to maintain a neutral or internal rotation of the client's hips and to prevent external rotation of the hips, which can cause injury when the client is supine.

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? A. Nasal cannula B. Simple face mask C. Venturi mask D. Nonrebreather mask

D. Nonrebreather mask A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation.

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia? A. Bone pain B. Drowsiness C. Bowel hypomotility D. Positive Chvostek's sign

D. Positive Chvostek's sign To elicit Chvostek's sign, the nurse should tap the client's facial nerve near the ear. If the client's facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels.

A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Ask a family member who speaks the client's primary language to interpret. B. Plan a long teaching session initially to introduce the necessary material. C. Provide the least important information first. D. Provide handouts written in the client's primary language.

D. Provide handouts written in the client's primary language. The nurse should provide handouts that are easy to read in the client's primary language to promote learning.