AtI pt 2 FDSPTQ

case study: a nurse is in the ER caring for a client with abdominal pain. based on clinical findings what actions does the nurse take? 1. assist the client to left-side laying position 2. Prepare the client for a chest xray 3. administer cleansing enema 4. auscultating bowel sounds 5. performing manual digital exam 6. Administer oxycodone 7. prepare client for NG tube placement

-assist the client to left-side laying position -cleansing enema - auscultating bowel sounds - performing manual digital exam

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure? A. 142/85 B.116/70 C. 130/76 D. 124/82

116/70 expected reference range is <120 systolic <80 diastolic

A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following is at an increased risk for hypertension? A. a client who is 52 years old B. A client who smokes one pack of cigarettes each day C. A client who walks for 30 mins every day D. A client who drinks one glass of wine three times per day

A client who smokes one pack of cigarettes each day

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

A. Air conduction is less than bone conduction in the left ear

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen concentrator. Which of the following instructions should the nurse provide to the client and 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 feet) away from a gas stove. C. Consider purchasing a generator for power backup. D. Observe for signs of hypoxia. E. Select synthetic clothing and bedding.

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

ABG Ph. - 7.5 PaCO2- 32 mm Hg HCO3 - 24 acid-imbalance is this? A. Respiratory Alkalosis B. Metabolic acidosis C. Respiratory Acidosis D. Metabolic Alkalosis

A. Respiratory Alkalosis

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

Ask the client to identify the specific food allergies the nurse should first assess the clients allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals

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? A. rock the client up to a standing position B. pivot on the foot that is the farthest from the chair C. Assess the client for orthostatic hypotension D. Apply a gait belt to the client

Assess the client for orthostatic hypotension

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

C. Assigning another client with the same infection to share the room with the client

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A. Apply a cold pack to the edematous area B. Check capillary refill before applying an ice pack to the affected area C. Half-fill an ice pack with crushed ice D. Apply an ice pack for 60 min intervals

Check capillary refill before applying an ice pack to the affected area

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

Chronic hypoxemia

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

Clean the drain site from the center outward

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

Don clean gloves to remove the old dressing

A charge nurse is discussing the responsibility of nurses caring for clients who have clostridium difficile infection. Which of the following information should the nurse include in the teaching? A. Assign the client to a room with a negative airflow system B. Use alcohol-based hand sanitizer when leaving the clients room C. Clean contaminated surfaces in the clients room with a phenol solution D. Have family members wear a gown and gloves when visiting

Have family members wear a gown and gloves when visiting

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

Help the client identify ways that these changes will result in positive personal outcomes

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

Pace speech to allow time for the interpreter to convey the words

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene

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

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? A. Use a resuscitation bag with 80% oxygen prior to the procedure B. Select a suction catheter that is half the side of the lumen C. place the end of the suction catheter in water soluble lubricant D. Adjust the wall suction apparatus to a pressure of 170 mm hg

Select a suction catheter that is half the side of the lumen

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

Stop the teaching and check with the surgeon about informed consent The clients statement indicates that she has not given informed consent therefore the nurse should interrupt the teaching and notify the surgeon

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

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

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record. A. The client refused to take medication today B. The client stated I will not take this pill C. The client seemed angry and hostile D. The client threw the medication on the floor

The client threw the medication on the floor

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

The dietitian will help you choose foods you are used to that also meet your health needs

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(telling the truth)? A. a client who is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively B. A client who has a prescription for a nasogastric tube refuses it and the nurse complies with the clients wishes C. A client who has a do not resuscitate order has a cardiac arrest, and the nurse does not perform CPR despite requests from the clients family D. A client who is about to undergo a painful procedure receives pain medication 30 mins before the procedure that the nurse previously promised to administer

a client who is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively

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

absent bowl sounds with distention

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? A. ambulating a client who is postoperative B. Inserting an indwelling urinary catheter for a client C. Demonstrating the use of an incentive spirometer to a client D. Confirming that a clients pain has decreased after receiving an analgesic

ambulating a client who is postoperative

A nurse rates a clients biceps reflex as 2+. Which of the following characteristics should the nurse document about the clients reflexes? A. Diminished B. Average C. Brisk D. hyperactive

average

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 B. Sodium 150 C. Potassium D. Magnesium 1.5

sodium 150

A nurse is teaching an older adult client 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

walking briskly

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? A. What could i have done to deserve this illness B. I blame medical science for not curing me C. Where is my daughter at a time like this D. will i ever begin to feel in charge of my life again

what could i have done to deserve this illness

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? A. The newly licensed nurse places the cap of a bottle of sterile saline on the sterile field B. The newly licensed nurse places sterile object 2.5 cm (1 inch) within the border of the field C. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring D. The sterile field is positioned at the level of the newly licensed nurse's waist

The newly licensed nurse places the cap of a bottle of sterile saline on the sterile field

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

Collect the specimen when the client rises in the morning

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed B. Tie the restraint with a quick release knot C. Allow a fingerbreadth between the restraint and the clients chest D. Place the restraint under the clients clothing

Tie the restraint with a quick release knot

A nurse is performing an admission assessment for a client. Which of the following response by the nurse reflects the communication techniques of clarifying? A. Now that we have talked about your medications, lets talk about your pain B. Are you having other symptoms C. It sounds like your pain is intermittent D. It seems as though you have really had a round time these past few weeks

it sounds like your pain is intermittent

A nurse is reviewing a clients 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? A. medication name B. Route of administration C. Medication dose D. frequency of administration

medication dose

A nurse on a medical-surgical unit is caring for a client which of the following actions should the nurse prioritize when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care

obtain client information the nursing process is based on the scientific process. The first step in the scientific process is collecting data. Therefore, the first step in the nursing process is assessing and obtaining information about the client

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. A. Inject 5 units of air into the bottle of regular insulin B. Withdraw the correct does of NPH insulin from the bottle. Inject 10 units of air into the bottle of NPH insulin D. Withdraw the correct does of regular insulin from the bottle

1. Inject 10 units of air into the bottle of NPH insulin 2. Inject 5 units of air into the bottle of regular insulin 3. Withdraw the correct does of regular insulin from the bottle 4. Withdraw the correct does of NPH insulin from the bottle Rationale: The nurse should first inject air into the vial of NPH (cloudy) without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular (clear) insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with the NPH insulin.

A nurse is caring for an adult client who has an ng tube in place under prescription for continuous and enteral feedings. Which of the following actions should the nurse perform to reduce clients risk of aspiration. A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30 or 45 C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

Elevate the head of the bed to 30 or 45

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the soiled linens on the chair while making the bed B. Hold linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold

Hold linens away from the body and clothing

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required? A. I should not leave all 4 side rails up unless there is a prescription for restraints B. An alert client will be safest if I raise the 2 upper side rails at the head of the bed C. If the client seems confused i'll raise all 4 side rails so that he doesnt hurt himself D. If a client is sedated, i should raise all 4 side rails to prevent a fall out of bed

If the client seems confused i'll raise all 4 side rails so that he doesnt hurt himself Raising all 4 side rails can put the client at greater risk for injury. For example the client might try to climb over the side rails which could result in a fall

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? A. Death is unacceptable under any circumstances B. Magical thinking helps avoid thoughts of death C. Death is viewed as an interruption of what might have been D. Death is a natural consequence of a deteriorating body

death is viewed as an interruption of what might have been young adults tend to see a whole life ahead of them, so death is often seen as interrupting that life. Young adults do not typically welcome death at this time.

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill of <2 sec

faint pedal pulses faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity