ATI RN Assessment Level 1 B
A nurse is teaching a client who has left-sided weakness and a history of falls to use a quad cane. In what order should the nurse provide the following instructions? A. Place the cane on right side of the body B. Move your left leg forward until it is even with the cane C. Advance the can 6 to 12 inches forward D. Keep weight in both legs as you mire the cane forward
1. Place the cane on right side of the body 2. Keep weight in both legs as you mire the cane forward 3. Advance the can 6 to 12 inches forward 4. Move your left leg forward until it is even with the cane
A nurse is care for a client who has a history of depressive disorder. The client states, "It feels pointless to get up in the morning." Which of the following responses should the nurse make? A. "Everyone goes through times where they feel really low." B. "It sounds as if life seems meaningless to you now." C. "How long does it normally take for you to feel better?" D. "Did you take your medication this morning?"
B. "It sounds as if life seems meaningless to you now."
A nurse is caring for a client who uses a fetanyl trans-dermal patch to treat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurse expect to administer? A. Sumatriptan B. Alprazolam C. Oxycodone D. Midazolam
C. Oxycodone
A nurse is documenting information in a clients medical record. Which of the following entries should the nurse make? A. "Client's provider prescribed the wrong medication." B. "Client has had a good day without any problems." C. "Client has concerns about care provided by previous nurse." D. "Client reports no pain while ambulating in the hallway."
D. "Client reports no pain while ambulating in the hallway."
A nurse is teaching an in-service about applying the National Patient Safety Goals when taking a verbal consent for a client. Which of the following instructions should the nurse include? A. Read back the prescription to the provider. B. Have the provider cosign the prescription within 48 hr. C. Write the abbreviation "TC" next to the prescription. D. Allow nursing students to take verbal prescriptions.
Read back the prescription to the provider
A nurse is preparing to administer acetaminophen drops 60 mg PO to an infant who has a fever. The amount available is 160mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a training zero.)
1.9mL
A nurse is preparing to administer furosemide 35 mg IV to a client. The amount available is 10mg/mL. How many mL should the nurse administer? (round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero
3.5mL
A nurse is teaching a client to self-administer 8 units of NPH insulin and 2 units of regular insulin in the same syringe. Which of the following client statements indicates an understanding of the teaching? A. "I'll draw up regular insulin into the syringe before the NPH insulin." B. "I'll inject air into the regular insulin vial before the NPH vial." C. "I'll inject 10 units of air into the regular insulin vial." D. "I'll inject 10 units of air into the NPH insulin vial."
A. "I'll draw up regular insulin into the syringe before the NPH insulin."
A nurse is discussing a wellness approach to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make? A. "Keep a record of cues that trigger a desire to eat." B. "Use distractions to decrease the pleasure associated with eating." C. "Eat on a regular schedule, even if you are not hungry." D. "Consume most of your calories in the evening."
A. "Keep a record of cues that trigger a desire to eat."
A nurse is teaching a client who has a new diagnosis of obstructive sleep apnea. Which of the following statements should the nurse include? A. "Obstructive sleep apnea occurs when you stop breathing for at least 10 seconds." B. "Obstructive sleep apnea is caused by a dysfunction in the brain." C. "Obstructive sleep apnea increases your risk for developing diabetes mellitus." D. "Obstructive sleep apnea causes excessive episodes of deep sleep."
A. "Obstructive sleep apnea occurs when you stop breathing for at least 10 seconds."
A nurse in a long-term care facility is performing an admission assessment on a client who reports that they are currently observing Lent. Which of the following questions should the nurse ask the client to identify ways to accommodate their religious practices in their plan of care? A. "Would you like to abstain from meat on Fridays?" B. "Do you plan to fast from sunrise to sunset during Lent?" C. "Are you currently fasting on Sundays?" D. "Will you be avoiding eating fish without scales during Lent?"
A. "Would you like to abstain from meat on Fridays?"
A nurse is caring for a group of client who had dark pigmented skin. For which of the following clients should the nurse notify the provider? A. A child who has red pinpoint dots on the palms of their hands B. An infant who has an oval-shaped, bluish-grey discoloration on their sacrum C. An adolescent who has slightly yellowed sclera without yellowing of the palate D. A child who has darker pigmented skin on their labia majora
A. A child who has red pinpoint dots on the palms of their hands
A nurse is providing change-of-shift report on a client using Situation Background Assessment Recommendation (SBAR) communication tool. The nurse should identify which of the following information is included in the background step? A. Admission diagnosis B. Current problem C. Recent vital signs D. Suggested nursing interventions
A. Admission diagnosis
A nurse is monitoring a client who is 3 days postoperative following amputation and reports phantom limb pain (PLP). Which of the following actions should the nurse take first? A. Ask the client to describe the pain sensations. B. Request a consult with physical therapy. C. Request a prescription for IV calcitonin. D. Ask if the client wants to learn about nonpharmacological pain relief strategies.
A. Ask the client to describe the pain sensations.
A nurse is teaching a class about cultural and religious differences in values and beliefs related to death. Which of the following information should the nurse include in the teaching regarding postmortem clients who devoutly practiced Orthodox Judaism? A. Clients' bodies should not be left alone until after the funeral. B. Clients should have autopsies. C. Clients' bodies should be bathed by the nurse. D. Clients' bodies should be positioned with the head facing north.
A. Clients' bodies should not be left alone until after the funeral.
A nurse is irrigating a client's infected surgical wound to promote wound healing. Which of the following actions should the nurse take? A. Continue irrigating until clear solution drains from the wound. B. Use a 10-mL syringe to flush the wound with the irrigating solution. C. Hold the irrigating tip about 0.6 cm (0.25 in) above the wound. D. Cool the irrigating solution in the refrigerator before use.
A. Continue irrigating until clear solution drains from the wound.
A nurse is teaching a group of assertive personnel about expected physical changes associated with aging. Which of the following information should the nurse include? A. Decrease in sense of taste B. Decrease in blood pressure C. Increase in subcutaneous fat D. Increase in perspiration
A. Decrease in sense of taste
A nurse is assessing a 10-month-old infant who has a urinary tract infection (UTI). which of the following findings should the nurse expect? A. Decreased appetite B. Generalized rash C. Decreased respiratory rate D. Constipation
A. Decreased appetite Manifestations of a UTI in an infant include poor feeding, irritability, fever, and vomiting
A nurse is preparing to calculate the medication dosage for andult client who has a prescription for a weight-based medication. Which of the following actions should the nurse plan to take? A. Divide the client's weight in pounds by 2.2 to obtain their weight in kilograms. B. Multiply liters by 100 to determine the volume in milliliters. C. Round the calculation results to the nearest hundredth. D. Determine the client's body mass index (BMI) in meters squared (m2).
A. Divide the client's weight in pounds by 2.2 to obtain their weight in kilograms.
A nurse on a mental health unit is planning an in-service for a newly hired staff about the use of restraints. Which of the following information should the nurse include? A. Document a client's condition every 15 min while in restraints. B. Request a prescription for PRN restraints for a client who has a history of violence. C. Restrain a client as a consequence of not following rules on the unit. D. Limit the time an adult client is in restraints to 5 hr.
A. Document a client's condition every 15 min while in restraints.
A nurse is planning to provide teaching for a client who has fibromyalgia and is experiencing chronic pain. The nurse should expect to teach the client about which of the following medications? A. Duloxetine B. Denosumab C. Montelukast D. Promethazine
A. Duloxetine Therefore, the nurse should prepare to provide information on the medication, a serotonin/norepinephrine reuptake inhibitor that decreases pain, fatigue, and stiffness in clients who have fibromyalgia. This medication is also approved for treating depression and generalized anxiety disorder
A nurse is assessing a client who has an infection of the upper urinary tract. In which of the following locations should the nurse expect the client to be experiencing pain? A. Flank or back pain B. Right lower quadrant of the abdomen C. Right upper quadrant of the abdomen
A. Flank or back pain
A nurse is assessing a client who has urolithiasis and is experiencing acute pain. Which of the following manifestations should the nurse expect? A. Flank pain B. Fever C. Hematuria D. Polyuria E. Rigid abdomen
A. Flank pain B. Fever C. Hematuria
A nurse is performing a health screening assessment on a client. Which of the following findings should the nurse identify as a risk factor for developing colorectal cancer? A. History of polyps B. History of GERD C. History of a high-fiber diet D. History of an inguinal hernia
A. History of polyps
A charge nurse is planning a presentation about electronic health records (EHR) for a group of newly licensed nurses. Which of the following information should the nurse include? A. Maintaining security of client information is a concern with EHRs. B. Determining trends in client data is difficult to do with EHRs. C. Developing a new EHR can occur with a few hours of work. D. Monitoring for medication interactions is not a feature of EHRs.
A. Maintaining security of client information is a concern with EHRs.
A nurse is initiating droplet precautions for a newly admitted client. Which of the following actions should the nurse take? A. Place the client in a private room. B. Provide an N95 respirator mask for the client to use when ambulating in the hallway. C. Ensure the client wears a face mask for transport to x-ray. D. Don sterile gloves when handling the client's soiled tissues. E. Wear a surgical gown when administering medications to the client.
A. Place the client in a private room. C. Ensure the client wears a face mask for transport to x-ray.
A nurse is caring for a client who has a recent diagnosis of iron deficiency. The client asks the nurse for food suggestions to increase iron in their diet. Which of the following foods should the nurse recommend? A. Raisins B. Cheddar cheese C. Yogurt D. Green tea
A. Raisins
A nurse is conducting a cultural assessment on a client to understand the clients values and beliefs. Which of the following actions should the nurse take first? A. Reflect on their own cultural values. B. Analyze the client's nonverbal communication. C. Establish trust with the client. D. Record the client's reaction to the nurse's movements.
A. Reflect on their own cultural values.
A nurse is caring for an unconscious client who was brought into the emergency department by a law enforcement agent. The law enforcement agent requests that the nurse obtain a blood sample for toxicity screening. Which of the following actions should the nurse take? A. Refuse to provide a blood sample. B. Perform the blood draw on the client's nondominant arm. C. Offer the blood draw supplies to the agent. D. Assign an assistive personnel to obtain the sample.
A. Refuse to provide a blood sample.
A nurse is reviewing the advance directives of a client who is being sustained on life support. The family disagrees regarding the continuation of life support measures. Which of the following individuals should the nurse identify as having the legal ability to determine the client's course Of treatment? A. The client's younger child, who is the client's health care proxy B. The client's older child, who manages the client's financial affairs C. The client's attorney, who manages the client's legal affairs D. The client's spouse, who resides in a long-term care facility
A. The client's younger child, who is the client's health care proxy
An employee health nurse is providing an in-service on infection control procedures. Which of the following infections should the nurse identify as requiring contact isolation precautions? Select all that apply A. Vancomycin-resistant enterococci (VRE) B. Influenza C. Methicillin-resistant Staphylococcus aureus (MRSA) D. Clostridium difficile E. Tuberculosis
A. Vancomycin-resistant enterococci (VRE) C. Methicillin-resistant Staphylococcus aureus (MRSA) D. Clostridium difficile
A nurse is assisting a client who is learning to use a walker following stroke. The client states, "I wasn't sure I could do this, but I talked to my friend who uses crutches and they think I can." Which of the following responses should the nurse make? A. "Your friend's experience with using crutches is very different from using a walker." B. "It sounds like your friend's encouragement about using a walker was helpful." C. "If you want to be independent, you will need to learn to use a walker." D. "My other clients who had a stroke learned to use a walker without any trouble."
B. "It sounds like your friend's encouragement about using a walker was helpful."
A nurse is teaching a client who has chronic fatigue syndrome. Which of the following statements should the nurse include? A. "Decrease your intake of dietary protein." B. "Reduce stress by taking tai chi classes." C. "Avoid taking ibuprofen to manage pain." D. "Plan to do high-impact aerobic exercises."
B. "Reduce stress by taking tai chi classes."
A nurse is assessing a client who has received laboratory confirmation of a Clostridium difficle infection. Which of the following findings should the nurse expect? A. Productive cough B. Abdominal pain C. Urinary frequency D. Peripheral edema
B. Abdominal pain
A nurse is preparing to administer enoxaparin to a client via subcutaneous injection. Which of the following actions should the nurse take? A. Expel the air from the syringe before administering the medication to the client. B. Administer the medication in the client's abdomen. C. Inject the needle at a 30° angle into the client's skin. D. Rub the injection site after administering the medication to the client.
B. Administer the medication in the client's abdomen.
A home health nurse is teaching a client about fire extinguishers. Which of the following instructions should the nurse include in the teaching? A. Store a fire extinguisher next to the kitchen stove. B. Call the fire department before using a fire extinguisher. C. Use a class A extinguisher to put out an electrical fire. D. Aim the hose of the fire extinguisher toward the top of the flames.
B. Call the fire department before using a fire extinguisher.
A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan? A. Place a folded cloth between the client's legs near the perineal area. B. Clean the client's perineal area with no-rinse cleanser. C. Apply powder or corn starch to the client's perineal area. D. Place a layer of towels under a standard draw sheet on the client's bed.
B. Clean the client's perineal area with no-rinse cleanser.
A nurse is submitting a dietary request for a client who devoutly follows Mormon dietary practices. The nurse should ask the client if they would like which of the following foods or beverages excluded from meals? A. Bacon B. Coffee C. Shrimp D. Milk
B. Coffee
A community health nurse is teaching a group of older adult clients at a senior center. Which of the following factors should the nurse include as an age-related changed that increases the risk for constipation in older adult clients? A. Decreased secretion of parathyroid hormones B. Delayed gastric emptying C. Heightened awareness of the urge to defecate D. Increased extracellular fluid volume
B. Delayed gastric emptying
A nurse is caring for a client who reports nausea. Which of the following actions should the nurse take? A. Instruct the client to eat a few unsalted nuts when nauseated. B. Encourage the client to suck on a spoon full of ice chips several times an hour. C. Tell the client to avoid using mouthwash. D. Remind the client not to snack in between mealtimes.
B. Encourage the client to suck on a spoon full of ice chips several times an hour.
A nurse is performing a health screening on a client. The nurse should identify that which of the following findings places the client at risk for type 2 diabetes mellitus? A. History of a ulcerative colitis B. History of a sedentary lifestyle C. History of long-term aspirin use D. History of group A beta-hemolytic E. Streptococci infection
B. History of a sedentary lifestyle
A nurse in a provider's office is caring for a client who has a new prescription for an opioid analgesic. the client states that they are concerned about developing constipation. Which of the following should the nurse take first? A. Encourage the client to increase their fluid intake while taking opioids. B. Identify the client's usual bowel elimination pattern. C. Request a prescription for a stool softener from the provider. D. Instruct the client to keep a record of their bowel movements.
B. Identify the client's usual bowel elimination pattern.
A nurse is preparing an in-service on different types of pain. Which of the following information should the nurse plan to include as a characteristic of acute pain? A. It can lead to social isolation. B. It is part of the body's attempt to protect itself. C. It lasts for an extended duration. D. It has no identifiable physical cause.
B. It is part of the body's attempt to protect itself.
A public health nurse is preparing to care for a community that has a large population of clients who practice the Islamic faith. Which of the following practices should the nurse anticipate when care for clients in this community? A. Requesting to face skyward when dying B. Moving to the floor to pray C. Gathering for group worship on Sundays D. Observing prayer times twice each day
B. Moving to the floor to pray
A nurse is providing teaching about negative pressure wound therapy (NPWT) to a client who has a chronic pressure ulcer. Which of the following information should the nurse include? A. NPWT reduces the amount of granulation tissue on the wound bed. B. NPWT promotes drainage of infectious materials from the wound. C. NPWT pushes clean air into the wound to promote oxygenation. D. NPWT eliminates moisture throughout the depth of the wound.
B. NPWT promotes drainage of infectious materials from the wound.
A nurse is discussing the Healthy People 2020 initiative with a group if newly licensed nurses. The nurse should identify that which of the following nursing interventions meets one of the Healthy People 202 objectives? A. Performing total care for a client who is undergoing rehabilitation for a permanent lumbar spinal cord injury B. Organizing an exercise program for a group of older adults in an independent living facility C. Turning an immobile client every 4 to 6 hr D. Performing catheter replacement every 72 hr for a client who has an indwelling urinary catheter
B. Organizing an exercise program for a group of older adults in an independent living facility
A nurse is updating the plan of care for a client who is experiencing chemotherapy-induced nausea and vomiting. Which of the following interventions should the nurse include? A. Serve additional beverages for the client at mealtimes. B. Provide the client with room-temperature foods. C. Request foods that have an increased fat content. D. Offer the client a variety of spices to enhance the flavor of bland foods.
B. Provide the client with room-temperature foods.
A nurse is planning to teach a class about standard precautions and preventing puncture injuries. Which of the following information should the nurse include in the plan? A. Break needles prior to disposal. B. Recap needles using the one-handed scoop method. C. Place broken glass in a paper bag before disposing in a wastebasket. D. Manually activate a passive safety device on a syringe.
B. Recap needles using the one-handed scoop method.
A nurse is assessing a client who has coughing frequently during meals? The nurse should initiate a referral to which of the following members of the inter-professional care team to evaluate the client for dysphagia? A. Registered dietitian B. Speech-language pathologist C. Occupational therapist D. Physical therapist
B. Speech-language pathologist
A nurse is caring for a client who has clostridium difficile. Th nurse should identify that C. difficile can be transmitted thought contact with which of the following? A. Blood and blood products B. Stool C. Saliva D. Respiratory secretions
B. Stool
A nurse is applying a belt restraint to a client. Which of the following actions should the nurse take? A. Offer toileting, nutrition, and fluids to the client every 4 hr. B. Tie the restraint to a moveable part of the client's bed frame. C. Monitor the client for injury once every hour. D. Use a double knot when tying the restraint.
B. Tie the restraint to a moveable part of the client's bed frame.
A nurse is a part of an informatics committee to improve safety with medications administration. Which of the following recommendations should the nurse make to decrease the risk of errors at the bedside? A. Disable Internet access from computers used for medication administration. B. Use an electronic medication administration record for documentation. C. Create a computer-specific password that staff share for each computer on the unit. D. Ask providers to handwrite prescriptions that are then scanned into the computer.
B. Use an electronic medication administration record for documentation.
A charge nurse is supervising a newly licensed nurse who is caring for a group of clients. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Raises all side rails on a bed when transporting a sedated client to another unit B. Uses a square knot to attach a wrist restraint to a client C. Applies mitten restraints to a client who is attempting to pull out the IV catheter D. Administers a prescribed sedative to a preoperative client
B. Uses a square knot to attach a wrist restraint to a client
A nurse is teaching a class about documenting client care in paper charts. Which of the following instructions should the nurse include in the teaching? A. "Document care before it is completed." B. "Leave blank spaces in the note for others to use." C. "Correct charting errors as they occur." D. "Do not document procedures that are omitted."
C. "Correct charting errors as they occur."
A nurse at a mental health clinic is interviewing a client who has depressive disorder and identified as religious during intake. Which of the following client statements should the nurse identify as indicating spiritual distress? A. "I have no control over my life." B. "I feel like I can't go on." C. "I am not even sure why I exist." D. "I feel like my thoughts get tangled in my head."
C. "I am not even sure why I exist."
A nurse is providing teaching to the guardians of a of a preschooler about preventing contact dermatitis. Which of the following guardian statements indicted an understanding of the teaching? A. "Using disposable wipes after urination will prevent irritation." B. "I will avoid touching others who have contact dermatitis." C. "Plants are among the most common causes of contact dermatitis." D. "Repeated exposure to the allergen can decrease sensitivity.
C. "Plants are among the most common causes of contact dermatitis."
A nurse is obtaining signatures on informed consent forms from a group of clients who are schedules for surgery. Which of the following individuals should the nurse identify as legally unable to provide informed consent? A. An adolescent who is divorced B. An older adult who has dysphagia C. A young adult who received morphine for pain D. A school-age child's grandparent who has legal guardianship
C. A young adult who received morphine for pain
A nurse is caring for a client who has a new diagnosis of diabetes mellitus and states that they cannot afford the prescribed insulin. The nurse offers to refer the client to the facility social worker. Which of the following principles is the nurse demonstrating? A. Fidelity B. Veracity C. Advocacy D. Nonmaleficenc
C. Advocacy
A nurse is teaching a group of newly licensed nurses about providing emotional support to a client who has experienced a loss. Which of the following information should the nurse include in the teaching? A. Express sadness to the client about a similar personal experience. B. Avoid crying with the client when negative emotions are expressed. C. Allow the client to express a negative response. D. Provide the client with advice on how to cope with the loss.
C. Allow the client to express a negative response.
A home health nurse is making an initial visit to a client who reports fecal incontinence. Which of the following actions should the nurse take first? A. Encourage the client in their efforts to complete other self-care tasks. B. Determine how the incontinence affects the client's socialization. C. Ask questions about the client's typical dietary intake. D. Review the procedure for perineal skin care with the client.
C. Ask questions about the client's typical dietary intake.
A nurse is teaching about applying the National Patient Safety Goals to reduce health care-associated infections in clients. Which of the following information should the nurse include in the teaching? A. Insert an indwelling catheter in clients who are incontinent. B. Use a safety razor to remove hair from surgical sites. C. Bathe clients using a chlorhexidine solution. D. Reposition clients who are immobile every 4 hr.
C. Bathe clients using a chlorhexidine solution.
A nurse is teaching a client about using nicotine gum for smoking cessation. Which of the following instructions should the nurse include? A. Drink water about 5 min before chewing the nicotine gum. B. Use the gum on an as-needed basis for best results. C. Chew a piece of nicotine gum slowly and intermittently. D. Keep using the nicotine gum for about 1 year.
C. Chew a piece of nicotine gum slowly and intermittently. For maximum effectiveness and achievement of abstinence, the client should chew nicotine gum on a regular schedule, every 2 to 3 hr. The client should chew the gum slowly and intermittently for about 30 min to avoid releasing too much nicotine all at once
A charge nurse is providing an educational session to a group of newly licensed nurses about the purpose of the National Patient Safety Goals. Which of the following objectives should the nurse include as the component of the National Patient Safety Goals? A. Enhance performance using evidence-based practice. B. Improve the facility's nurse-patient ratios. C. Decrease errors related to invasive procedures. D. Increase the facility's customer satisfaction ratings.
C. Decrease errors related to invasive procedures.
A nurse is providing teaching to the parent of a school-age child who has juvenile idiopathic about pain management. Which of the following statements should the nurse include? A. Keep the child home from school on days when pain is present. B. Instruct the child to take a nap after school each day. C. Encourage the child to participate in physical play activities. D. Place a cold pack on painful joints for 10 min every hr.
C. Encourage the child to participate in physical play activities.
A nurse is teaching a client who has acute ulcerative colitis and is prescribed a low-fiber diet. Which of the following foods should the nurse instruct the client to eat? A. Cooked spinach B. Whole-wheat bun C. Flavored gelatin D. Brown rice
C. Flavored gelatin
A nurse is reviewing the medical record of a client prior to medication administration. Which of the following actions should the nurse plan to take? A. Encourage client to assist with opening medication packages. B. Request the digoxin elixir be replaced with a tablet formulation. C. Instruct the client to refrain from taking St. John's wort. D. Recommend the client take a magnesium supplement.
C. Instruct the client to refrain from taking St. John's wort.
A nurse is administering a liquid oral medication from a multi dose bottle to a client. The nurse calculates that the does to me administered id 4 mL. Which of the following actions should the nurse take? A. Measure the medication in a medicine cup. B. Draw the medication up into a parenteral syringe. C. Label the medication after measuring the dosage. D. Return excess medication into the multidose container.
C. Label the medication after measuring the dosage.
A nurse in a provider's office is planning medications teaching for a client who has a urinary tract infection. The nurse should prepare teaching for which of the following medications? A. Propranolol B. Esomeprazole C. Nitrofurantoin D. Sildenafil
C. Nitrofurantoin
A nurse is reviewing the facility policy about occurrences that require an incident report with a newly licensed nurse. Which of the following examples should the nurse include? A. Staff shortage issues B. Verbal complaint from a client's partner C. Omission of a laboratory test D. Conflict with nursing peers
C. Omission of a laboratory test
A home health nurse is planning care for an older adult who lives alone and reports having difficulty adhering to their medication regimen. The nurse should include with of the following interventions in the plan? A. Provide medications in childproof containers. B. Recommend using divided daily medication doses. C. Organize daily medications in a divided pill box. D. Place different medications in the same bottle.
C. Organize daily medications in a divided pill box.
A nurse is teaching a group about cultural competence related to clients who follow Islamic dietary laws. Which of the following images of food should the nurse include in the teaching as appropriate for a client who devoutly follows Islamic dietary practices? A. Ham, eggs, and a hashbrown B. Hamburger C. Pizza D. Pork sandwich
C. Pizza
A nurse is reviewing the urinalysis report for a client who reports dysuria. Which of the following finding should the nurse identify as a manifestation of a urinary tract infection (UTI)? A. Absence of nitrites B. Presence of bilirubin C. Presence of crystals D. Absence of ketones
C. Presence of crystals
A nurse is caring for a client who has a pressure ulcer and a prescription for a culture to evaluate the effect of antibiotic therapy on wound healing. Which of the following actions should the nurse take first when obtaining the culture? A. Don sterile gloves. B. Cleanse the wound. C. Remove dressings covering the wound. D. Rotate culture swab over granulation tissue of wound.
C. Remove dressings covering the wound.
A nurse is teaching an assistive personnel (AP) about manifestations of dysphagia. Which of the following manifestations should the nurse include? A. Absence of tongue thrust B. Upward movement of the larynx during swallowing C. Storing food in the mouth after swallowing D. Decreased salivation
C. Storing food in the mouth after swallowing
A nurse is providing dietary teaching to a client who has diarrhea. Which of the following items should the nurse include in the teaching as an appropriate dietary choice? A. Prune juice B. Whole milk C. Tomato juice D. Ginger ale
C. Tomato juice because it is high in potassium
A nurse is assessing a client who has a rash on their hands and forearms after working in a garden. The nurse should identify that which of the following findings indicates contact dermatitis? A. Pustules in a scatter pattern across the erythematous area B. Elevations of the skin with darkened areas and irregular borders C. Well-defined margins of the erythematous area D. Straight, black, threadlike lesions
C. Well-defined margins of the erythematous area
A nurse is teaching the parent of a 5-month-old infant who is breastfed about the introductions of complementary foods. Which of the following statements should the nurse make? A. "Wait until your baby is 8 months old to begin solid foods." B. "Start by spoon-feeding your baby ¼ cup of a new food." C. "Introduce up to three new foods to your baby every week." D. "Give your baby iron-fortified infant rice cereals before starting other foods."
D. "Give your baby iron-fortified infant rice cereals before starting other foods."
A nurse is providing teaching to a group of newly licensed nurses about the legal scope of practice of nurses. Which of the following statements by a newly licensed nurse indicate an understanding of the teaching? A. "I must have a provider present when I perform suctioning on a tracheostomy." B. "I can assign a licensed practical nurse to obtain a Papanicolaou smear from a client." C. "I must obtain a provider's prescription before I can perform an ECG for a client who is experiencing chest pain." D. "I can reposition a client who has tetraplegia without a provider's prescription."
D. "I can reposition a client who has tetraplegia without a provider's prescription."
A nurse is providing teaching to a client who has a prescription fir risedronate to treat postmenopausal osteoporosis. Which of the following client statements indicates an understanding of the teaching? A. "I'll swallow my medication with an ounce or two of water." B. "I'll take my medication at bedtime every night." C. "I'll take my calcium pill right after I take this medication." D. "I won't lie down for 30 minutes after I take my medication."
D. "I won't lie down for 30 minutes after I take my medication." The nurse should ensure the client understands that they should remain upright for at least 30 min after taking risedronate to reduce the risk for esophageal injury. Take risedronate with 180 to 240 mL (6 to 8 oz) of water
A nurse is using the SOAP format to document in the electronic medical record of a client who is 2 days postoperative following an open cholecystectomy. Which of the following entries should the nurse practice in the "A" portion of the SOAP progress note? A. "Respiratory rate 22. Temperature 99.8º F. O2 sat 92%. Lung sounds diminished in bases bilaterally. Has not ambulated or used incentive spirometer since last evening." B. "Client states, 'I've been coughing up some thick mucus this morning.'" C. "Set up ambulation schedule and offer incentive spirometer hourly during the day and when awake at night." D. "Ineffective airway clearance due to inadequate use of spirometer.
D. "Ineffective airway clearance due to inadequate use of spirometer.
A nurse is supervising a newly licensed nurse who is documenting care on four clients in the client's electronic medical records. Th nurse should identify that which of the following notations indicates accurate documentation? A. "The client was uncooperative during morning care." B. "The client has large bruises that appear self-inflicted." C. "The client demanded to receive test results." D. "The client is disoriented to place and date."
D. "The client is disoriented to place and date."
A nurse is providing hand off report on a client. Which of the following information should the nurse include in the report? A. "The client had two visitors during the shift." B. "The client received a scheduled antibiotic during the shift." C. "The client's vital signs were taken at the beginning of the shift." D. "The client is scheduled for a chest x-ray on the next shift."
D. "The client is scheduled for a chest x-ray on the next shift."
A nurse is talking with the parents of a school-aged child about managing enuresis. Which of the following parent statements indicates an understand of the information? A. "We will have him bear down as if defecating to strengthen the pelvic muscles." B. "We will ask the provider to prescribe an antianxiety medication for his problem." C. "We will limit the amount of time he can watch television each time he has an episode." D. "We will have him help change the bed linens after he has an accident."
D. "We will have him help change the bed linens after he has an accident."
A nurse discovers a medication omission from the previous shift and notifies the charge nurse. which of the following statements should the charge nurse make? A. "You should document in the client's medical record that an incident report has been completed." B. "You should contact the nurse who neglected to administer the medication to complete the incident report." C. "You should document why you think the omission occurred." D. "You should monitor the client for injury."
D. "You should monitor the client for injury."
A nurse is providing teaching about infant nutrition to the guardian of a 1-month-old infant who is formula fed. Which of the following statements should the nurse include? A. "Your baby can start drinking fruit juice when she is 3 months old." B. "You can switch your baby to 2 percent milk when she is 9 months old." C. "You should start introducing solid foods to your baby in a few weeks." D. "Your baby should be consuming 18 to 21 ounces of formula per day."
D. "Your baby should be consuming 18 to 21 ounces of formula per day."
A nurse is planning care for a client who has dementia and continues to get out of bed without assistance. Which of the following actions should the nurse plan to take? A. Place the bed in the highest position. B. Raise all four side rails while in bed. C. Place the bedside table at the foot of the bed. D. Apply an electronic safety device to the bed.
D. Apply an electronic safety device to the bed.
A nurse is teaching a client about carbon monoxide and home safety. The nurse should instruct the client that which of the following is a manifestation of carbon monoxide exposure? A. Rotten-egg odor B. Metallic taste C. Paresthesia D. Blurred vision
D. Blurred vision
A nurse is applying a bed safety monitoring device for a client. Which of the following actions should the nurse take? A. Position the sensor pad below the client's calves. B. Place the sensor pad under the bottom sheet. C. Set the time delay for 20 seconds. D. Connect the sensor pad to the call system.
D. Connect the sensor pad to the call system.
A nurse is teaching a group of newly licensed nurses about using abbreviations when transcribing prescriptions. Which of the following transcriptions should the nurse use as an example of the correct usage of abbreviations? A. Eszopiclone 1 mg PO hs PRN for sleep B. Nebivolol 5 mg PO OD C. Atorvastatin 20 mg PO qd D. Docusate sodium 100 mg PO bid
D. Docusate sodium 100 mg PO bid
A nurse is planning care for a client who is actively dying and has previously expressed a desire to adhere to Buddhist practices related to death. Which of the following actions should the nurse anticipate and confirm with the client to accommodate their preferences? A. Leave the client's body alone in an empty room for 1 hr following death. B. Ask a female family member to prepare the client's body following death. C. Avoid discussing the option of organ donation with the client's family. D. Ensure that there is room for the family to stand at the head of the client's bed.
D. Ensure that there is room for the family to stand at the head of the client's bed.
A nurse is teaching a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following actions should the nurse include as an example of PSDA compliance? A. Requiring clients to complete advance directives B. Providing clients with the right to choose who has access to their health information C. Demonstrating to a client how to use the call light system D. Informing clients they can decline any treatment the provider prescribes
D. Informing clients they can decline any treatment the provider prescribes
A nurse is teaching a group of parents and guardians who have toddlers about home safety. Which of the following information should the nurse provide? A. Keep cleaning solutions and other poisonous substances in a high cupboard. B. Do not leave toddlers alone in a bathtub for more than 5 min. C. Use small, sturdy, reusable food containers for storing over-the-counter medications. D. Install deadbolts toward the top of doors leading outside.
D. Install deadbolts toward the top of doors leading outside.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following manifestations should indicate to the nurse that the client is developing a catheter-acquired infection? A. Bradycardia B. Increased fremitus C. Abdominal distention D. Low-back pain
D. Low-back pain Manifest low-back pain due to inflammation from the bladder infection. Other indications of a urinary catheter-acquired infection include urinary frequency, hematuria, and suprapubic tenderness
An operating room nurse is teaching an in-service about standardized procedures to reduce the risk for client injury during surgery. Which of the following information should the nurse include? A. Place electrocautery pads over the client's bony prominences. B. Use povidone-iodine for clients who are allergic to shellfish. C. Correct preoperative hyperkalemia after the initial skin incision. D. Mark the operative site prior to surgical procedures.
D. Mark the operative site prior to surgical procedures.
A nurse is providing teaching about a mechanically altered, or level 2, diet to the caregiver of a client who has dysphagia. Which of the following food selections should the nurse include? A. Coarsely ground peanut butter B. Casserole containing ½ inch cubes of meat C. Sliced bread D. Mashed bananas
D. Mashed bananas
A public health nurse is planning care to meet Healthy People 2020 objectives. Which of the following interventions should the nurse include to promote clients' access to health care? A. Assist with the selection of a new electronic records system for the health department. B. Ask a community health center to assist with preparing food for home meal delivery service. C. Organize neighborhood watch programs to improve the safety of residential areas. D. Set up workshops to help people who are uninsured sign up for health coverage.
D. Set up workshops to help people who are uninsured sign up for health coverage.
A nurse is performing a fall risk assessment for a client. Which of the following findings should the nurse identify as a fall risk? A. The client uses a raised toilet seat. B. The client takes a flaxseed supplement. C. The client looks at the ground while walking. D. The client has a history of urinary frequency.
D. The client has a history of urinary frequency. A client who has a history of urinary frequency is at risk for a fall due to frequently getting out of bed at night to go to the bathroom. The nurse should place a commode next to the client's bed to reduce the risk for injury
A nurse is participating in a community health screening. Which of the following information should the nurse include about the risk factors for breast cancer? A. The use of oral contraceptives lowers the risk for breast cancer. B. Clients who enter menopause at a later age have a lower risk for breast cancer. C. Clients between the ages of 50 and 60 years have the highest risk for breast cancer. D. The use of hormone replacement therapy increases the risk for breast cancer.
D. The use of hormone replacement therapy increases the risk for breast cancer.
A nurse is discussing informed consent with a group of newly licensed nurses. Which of the following actions is the responsibility of the nurses when obtaining informed consent? A. Answer a client's questions about the risks of a procedure. B. Provide information about alternative treatment options. C. Explain the steps of the medical procedure documented on the consent form. D. Verify that the client voluntarily gave consent for the procedure.
D. Verify that the client voluntarily gave consent for the procedure
A nurse is teaching a group of parents and guardians about identifying substance use disorder among adolescents. Which of the following adolescent behaviors should the nurse include as a possible indications of substance use disorder? A. Increased participation in social activities B. Wearing short sleeve shirts in cold weather C. Increased academic performance D. Wearing dark glasses indoors
D. Wearing dark glasses indoors
