christian music appreciation
A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40mg/mL. How many mL should the nurse administer? (Round answer to the nearest tenth. Do not use a trailing zero.)
0.4 mL
A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30 mg/dL. How many mL should the nurse administer per dose? (Round answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
0.5 mL
A nurse is preparing to administer acetaminophen 320 mg PO every 4 hr PRN for pain. The amount available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer per dose? (Round answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
10 mL
A nurse is preparing to administer dextrose 5% in water (D5W) 1,000 mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do nose use a trailing zero.)
100 mL/hr
A nurse is performing an admission assessment on a client. The nurse determines the clients radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the clients pulse deficit?
16/min
A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Do nose use a trailing zero.)
2 tablets
A nurse is preparing to administer LR IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do nose use a trailing zero.)
400mL/hr
A nurse is preparing to administer dextrose 5% in lactated Ringer's (D5LR) 1,000 mL to infuse over 6 hr. The drop factor of he manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do nose use a trailing zero.)
42 gtt/min
A nurse is preparing to administer 0.9% NaCl 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do nose use a trailing zero.)
83 gtt/min
A nurse of the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.) A. "A temperature around the IV site is cooler" B. "The rate of the infusion increases" C. "The skin at the IV site is red" D. "The IV dressing is damp." E. "The tissue around the veni puncture site is swollen"
A. "A temperature around the IV site is cooler" D. "The IV dressing is damp." E. "The tissue around the veni puncture site is swollen"
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the clients temperature rectally." B. " Count the client's radial pulse for 30 seconds and multiply by 2." C. "Do not let the client know you are counting their respirations." D. "Let the client rest for 5 minutes before you measure their blood pressure."
A. "Do not measure the clients temperature rectally."
A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? A. "Flush the tube before and after each medication." B. "Mix your medications with your enteral feeding." C. "Push tablets through the tube slowly." D. "Mix all the crushed medications prior to dissolving them in water."
A. "Flush the tube before and after each medication."
A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give to the client? A. "Get up and change positions slowly." B. "Avoid eating aged cheese and smoked meat" C. "Report any unusual bruising and bleeding to the doctor immediately." D. "Eat the same amount of foods that contain vitamin K every day."
A. "Get up and change positions slowly."
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. " I will review the past medical history on the client's record to get more information." C. "I will carryout new prescriptions form the provider." D. "I will ask the client if their nausea has resolved."
A. "I will determine the most important client problems that we should address."
A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply) A. "I will observe for adverse effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a medication if I believe it is unsafe."
A. "I will observe for adverse effects." B. "I will monitor for therapeutic effects." E. "I will refuse to give a medication if I believe it is unsafe."
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated."
A. "Water helps clear the tube so it doesn't get clogged."
A nurse is talking with caregiver of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority? A. "We just don't understand why our child can't keep up with the other kids in simple activities like running and jumping." B. "Our child keeps trying to find ways around our household rules. They always want to make deals with us." C. "We think our child is trying too hard to excel in math just to get the top grades in the class." D. "Our child likes to sing and worries it will make the other kids want to laugh."
A. "We just don't understand why our child can't keep up with the other kids in simple activities like running and jumping."
A nurse is caring for a client who asks what their Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."
A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30."
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took a toxic dose of sodium bicarbonate antacids
A. A client who has nasogastric suctioning
A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) A. A client who has terminal cancer requests hospice care in the home. B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client requests an electric wheelchair for use after discharge. E. A client states, "I do not understand how to use a nebulizer."
A. A client who has terminal cancer requests hospice care in the home. B. A client asks about community resources available for older adults. D. A client requests an electric wheelchair for use after discharge.
A nurse is reviewing a client's prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply.) A. A once-daily multivitamin B. Eye drops prescribed every 3 hr C. An antibiotic prescribed every 8 hr D. A blood pressure pill prescribed twice daily E. A subcutaneous injection prescribed once weekly
A. A once-daily multivitamin E. A subcutaneous injection prescribed once weekly
A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis every 2 to 3 hr C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Apply suction for 10 to 15 seconds
A. Apply suction while withdrawing the catheter D. Use a new catheter for each suctioning attempt E. Apply suction for 10 to 15 seconds
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean the inner cannula C. Clean the outer cannula surfaces in a circular motion from the stoma site outward D. Replace the tracheostomy ties with new ties E. Cut a slit in gauze squares to place beneath the tube holder
A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean the inner cannula C. Clean the outer cannula surfaces in a circular motion from the stoma site outward
A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy
A. Assault
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. The prescription reads every 4 hours PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps in the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
A. Assessment
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds B. Assist the client to an upright position C. Test the pH of gastric aspirate D. Warm the formula to body temperature E. Discard any residual gastric contents
A. Auscultate bowel sounds B. Assist the client to an upright position C. Test the pH of gastric aspirate
A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAS) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs
A. Bathing B. Ambulating C. Toileting E. Measuring vital signs
A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents should the nurse include as examples of the direct mode of transmission? (Select all that apply.) A. Blood spurting from an arterial wound splashes into a nurse's eye B. A nurse has a needlestick injury C. A mosquito bites a hiker in the woods D. A nurse finds a hole in their glove while handling a soiled dressing E. A person fails to wash their hands after using the bathroom and touches a client
A. Blood spurting from an arterial wound splashes into a nurse's eye E. A person fails to wash their hands after using the bathroom and touches a client
A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply) A. Building models B. Playing video games C. Reading books D. Using toy carpentry tools E. Playing board games
A. Building models B. Playing video games C. Reading books E. Playing board games
A nurse in a providers office is preparing to assess a clients skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both feet D. Thick skin on the soles of the feet E. Numerous macules on the face darker than the surrounding skin color
A. Capillary refill less than 3 seconds D. Thick skin on the soles of the feet E. Numerous macules on the face darker than the surrounding skin color
A nurse is assessing a client as part of an admission history. The client reports drinking a herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? A. Chamomile B. Ginseng C. Ginger D. Echinacea
A. Chamomile
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see wether the catheter is patent B. Reassure the client that is is not possible for them to urinate C. Recatheterize the bladder with a larger-gauge catheter D. Collect a urine specimen for analysis
A. Check to see wether the catheter is patent
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intra-operative training in surgical treatments for obesity D. Educating acute care nurses about postoperative complications related to obesity
A. Collaborating with providers to perform obesity screenings during routine office visits
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following action should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abdomen C. Use sterile gauze to apply gentle pressure to the exposed tissues D. Position the client supine with the hips and knees bent E. Offer the client a warm beverage (herbal tea)
A. Cover the area with saline-soaked sterile dressings D. Position the client supine with the hips and knees bent
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism
A. Crohn's disease
A nurse is caring for a client who has a prescription for a 24 hour urine collection. Which of the following actions should the nurse take? A. Discard the first voiding B. Keep the urine in a single container at room temperature C. Dispose of the last voiding D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
A. Discard the first voiding
A nurse is reviewing the medical record of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply.) A. Diuretics B. Corticosteroids C. Oral anticoagulants D. Opioid analgesics E. Antipsychotics
A. Diuretics B. Corticosteroids E. Antipsychotics
A nurse is planning care for a client who was on bedrest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform anti-embolic exercises every two hours B. Instruct the client to cough and deep breathe every four hours C. Restrict the client's food intake D. Reposition the client every four hours
A. Encourage the client to perform anti-embolic exercises every two hours
A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply.) A. Eye examination every 1 to 3 years B. Decrease intake of calcium supplements C. DXA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders
A. Eye examination every 1 to 3 years C. DXA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders
A nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? (SATA) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization
A. Frequent sexual intercourse D. Location of the urethra closer to the anus E. Frequent catheterization
A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone
A. Furosemide B. Ibuprofen
A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (SATA) A. Guided imagery B. Massage therapy C. Meditation D. Music therapy E. Therapeutic touch
A. Guided imagery C. Meditation D. Music therapy
A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretions D. Far vision E. Glomerular filtration
A. Metabolism C. Gastric secretions E. Glomerular filtration
Nurse in a providers office is caring for a client who states that for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the clients difficulty sleeping? (SATA) A. Have your working hours change recently? B. Do you feel confused in the late afternoon? C. Do you drink coffee tea or other caffeinated drinks? If so how many cups per day? D. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? E. Tell me about any personal stress you are experiencing.
A. Have your working hours change recently? C. Do you drink coffee tea or other caffeinated drinks? If so how many cups per day? D. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? E. Tell me about any personal stress you are experiencing.
A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings as a manifestation of dehydration? (Select all that apply.) A. Hct 55% B. Blood osmolarity 260 mOsm/kg C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035 E. Blood creatinine 0.6 mg/dL
A. Hct 55% C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035
A nurse is instructing a client who has an injury of the left lower extremity about the use of a cane. Which of the following instructions should the nurse include? (SATA) A. Hold the cane on the right side B. Keep two points of support on the floor C. Place the cane 38 cm in front of the feet before advancing D. After advancing the cane move the weaker leg forward E. Advance the stronger leg so that it aligns evenly with the cane
A. Hold the cane on the right side B. Keep two points of support on the floor D. After advancing the cane move the weaker leg forward
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers
A. Home health care B. Rehabilitation facilities D. Skilled nursing facilities
A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? A. Implement airborne precautions B. Obtain a sputum culture C. Administer antituberculosis medications D. Recommend a screening test for family members
A. Implement airborne precautions
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst
A. Increase in incisional pain B. Fever and chills C. Reddened wound edges
A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.
A. Increase protein intake to increase muscle mass. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.
A nurse is reviewing CDC immunization recommendations with a young adults client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply.) A. Influenza B. Measles, mumps, rubella C. Pertussis D. Tetanus E. Polio
A. Influenza C. Pertussis D. Tetanus
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene sulfonate
A. Infuse hypotonic IV fluids
A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (SATA) A. Inspect the feet daily B. Use moisturizing lotion on my feet C. Wash the feet with warm water and let them air dry D. Use over-the-counter products to treat abrasions E. Wear cotton socks
A. Inspect the feet daily B. Use moisturizing lotion on my feet E. Wear cotton socks
A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care
A. Intensive care unit B. Oncology treatment center C. Burn center
A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences frequently C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least every 3 hr while in bed
A. Keep the head of the bed elevated 30 degrees D. Have the client sit on a gel cushion when in a chair
A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery.
A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form.
A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching. (SATA) A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test
A. Medication error B. Needlesticks D. Omission of prescription
A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply.) A. Obtain a periodic mental status evaluation. B. Discuss prevention of sexually transmitted infections. C. Regularly screen for tuberculosis. D. Provide education about drug and alcohol use. E. Teach monthly breast examinations.
A. Obtain a periodic mental status evaluation. B. Discuss prevention of sexually transmitted infections. C. Regularly screen for tuberculosis. D. Provide education about drug and alcohol use.
A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and RR 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.
A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity. E. Assist the client with oral hygiene frequently.
A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? A. Offer information on a relaxation technique and ask the client if they are interested in trying it B. Request a social worker see the client to discuss meditation C. Attempt to use biofeedback techniques with the client D. Tell the client many people feel the same way before surgery and to think of something else
A. Offer information on a relaxation technique and ask the client if they are interested in trying it
A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take? A. Offer to assist the client who needs the bedpan. B. Administer the injection the other nurse prepared. C. Prepare another syringe and administer the injection. D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.
A. Offer to assist the client who needs the bedpan.
A nurse in the senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (SATA) A. Older adults are more prone to dehydration in younger adults B. Older adults need to same amount of most vitamins and minerals as younger adults C. Many older men and women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbohydrates
A. Older adults are more prone to dehydration in younger adults B. Older adults need to same amount of most vitamins and minerals as younger adults C. Many older men and women need calcium supplementation
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to their room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care.
A. Orient the client to their room.
A nurse is assessing a clients thyroid gland as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline
A. Palpating the thyroid in the lower half of the neck D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline
A nurse is instructing a group of assistive personnel in measuring a client's RR. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-fowlers position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 seconds if it is irregular. E. Count and report any sighs the client demonstrates.
A. Place the client in semi-fowlers position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate.
A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status
A. Posture B. Skin lesions C. Speech
The nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (SATA) A. Practice muscle relaxation techniques B. Exercise each morning C. Take an afternoon nap D. Alter the sleep environment for comfort E. Limit fluid intake at least two hours before bedtime
A. Practice muscle relaxation techniques B. Exercise each morning D. Alter the sleep environment for comfort E. Limit fluid intake at least two hours before bedtime
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors
A. Presence of associated manifestations
A nurse is performing an neurologic examination for client. Which of the following assessments should the nurse perform to test the client's balance? (SATA) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test
A. Romberg test B. Heel-to-toe walk
A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the clients plan of care? A. Scheduled rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client
A. Scheduled rest periods during morning care
A nurse is planning a health promotions and primary prevention class for the caregivers of school-age children. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Provide information about the risk of childhood obesity. B. Discuss the danger of substance use disorders. C. Promote discussion about sexual issues. D. Recommend the school-age child sit in the front seat of the car. E. Reinforce stranger awareness.
A. Provide information about the risk of childhood obesity. B. Discuss the danger of substance use disorders. C. Promote discussion about sexual issues. E. Reinforce stranger awareness.
A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist
A. Provider C. Pharmacist D. Registered nurse
The nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (SATA) A. REM sleep provides cognitive restoration B. REM sleep lasts about 90 min C. it is difficult to awaken a person in REM sleep D. sleepwalking occurs during REM sleep E. vivid dreams are common during REM sleep
A. REM sleep provides cognitive restoration C. it is difficult to awaken a person in REM sleep E. vivid dreams are common during REM sleep
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain
A. Reassess the client to determine the reasons for inadequate pain relief.
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (SATA) A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the provider's signature on the prescription within 24 hours D. Decline the verbal prescription because this is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone
A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the provider's signature on the prescription within 24 hours
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (SATA) A. Respiratory rate is 22/bpm with even, unlabored respirations B. The client's partner states, "they said they hurt after walking about 10 minutes. C. The client's pain rating is 3 on a scale of 0 to 10 D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp
A. Respiratory rate is 22/bpm with even, unlabored respirations D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp
A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension
A. Restlessness B. Tachypnea D. Confusion E. Hypertension
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain medication D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available
A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest
The nurse is collecting data from an older adult client as part of neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (SATA) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Decreased risk of depression
A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline
A nurse in a providers office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion
A. Smaller nipples D. More pendulous E. Nipple inversion
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area
A. Stage 3 pressure ulcer E. Open burn area
A nurse on a pediatric unit is caring for an adolescent who had multiple fractures. Which of the following interventions should the nurse take? (Select all that apply.) A. Suggest that the guardians bring in video games to play. B. Provide a television and movies for the adolescents to watch. C. Limit visitors to the adolescent's immediate family. D. Involve the adolescent in treatment decisions when possible. E. Allow the adolescent to perform morning self-care.
A. Suggest that the guardians bring in video games to play. B. Provide a television and movies for the adolescents to watch. D. Involve the adolescent in treatment decisions when possible. E. Allow the adolescent to perform morning self-care.
A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication.
A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. E. Urinate prior to taking the medication.
A nurse is performing mouth care for client who is unconscious. Which of the following actions should the nurse take? A. Turn the clients head to the side B. Place two fingers in the client's mouth to open C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the clients mouth
A. Turn the clients head to the side
A nurse in a providers office is preparing to auscultate and percuss a clients abdomen as part of a comprehensive exam. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits
A. Tympany B. High-pitched clicks
A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? (Select all that apply.) A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation
A. Urinary incontinence C. Acute confusion E. Agitation
Which of the following actions should the nurse take when demonstrating an empathetic presence to a client? (SATA) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Sit facing the client
A. Use an open posture C. Establish and maintain eye contact E. Sit facing the client
A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate interventions? A. Pallor B. Cyanosis C. Jaundice D. Erythema
B. Cyanosis
A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (SATA) A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Take calcium supplements D. Avoid drinking alcohol E. Use the Crede maneuver
B. Decrease or avoid caffeine D. Avoid drinking alcohol
A nurse is preparing to administer a cleansing enema to an adult client in preparation for diagnostic procedure. Which of the following steps should the nurse take? (SATA) A. Warm the enema solution prior to instillation B. Position the client on the left side with the right leg flexed forward C. Lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 5 cm (2 in.) E. Hang the enema container 61 cm (24 in.) above the client's anus
A. Warm the enema solution prior to instillation B. Position the client on the left side with the right leg flexed forward C. Lubricate the rectal tube or nozzle
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear
A. Weber test showing lateralization to the right ear D. Rinne test showing less time for air and bone conduction
The nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partners states,"I hate them for leaving me." Which of the following statements should the nurse made to facilitate mourning for the partner? (SATA) A. Would you like me to contact the chaplain to come and speak with you. B. You will feel better soon. You have been expecting this for a while now. C. Let's talk about your children and how they're going to react. D. You know it is quite normal to feel anger toward your loved one at this time E. Tell me more about how you are feeling.
A. Would you like me to contact the chaplain to come and speak with you. D. You know it is quite normal to feel anger toward your loved one at this time E. Tell me more about how you are feeling.
Nurse is beginning to complete bed Bath for a client. After removing the client down and placing a bath blanket over the body which of the following areas should the nurse wash first? A. face B. feet C. chest D. arms
A. face
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. role conflict B. role overload C. role ambiguity D. role strain
A. role conflict
A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A. "A second nurse enters the prescription into the client's medical record." B. "Another nurse should listen to the phone call." C. "The provider can clarify the prescription when they sign the health record." D. "I should omit the 'read back' if this is a one-time prescription."
B. "Another nurse should listen to the phone call."
A nurse is caring for a client receiving dextrose 5% in 0.9% NaCl IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) A. "I feel lightheaded" B. "I feel as though my heart is racing" C. "I feel a little short of breath" D. "The nurse technician told me that my blood pressure was 150/90" E. "I think my ankles are less swollen"
B. "I feel as though my heart is racing" C. "I feel a little short of breath" D. "The nurse technician told me that my blood pressure was 150/90"
A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands? A. "I will straighten my ear canal by pulling my ear down and back." B. "I will gently apply pressure with my finger to the front part of my ear (tragus) after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal."
B. "I will gently apply pressure with my finger to the front part of my ear (tragus) after putting in the drops."
A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity
B. Decreased height D. Nail thickening E. Decreased bladder capacity
A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." B. "I will insert the needle into the clients skin at an angle of 10-30 degrees with the bevel up." C. "I will apply pressure approximately 1.2 in below the insertion site prior to removing the needle." D. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."
B. "I will insert the needle into the clients skin at an angle of 10-30 degrees with the bevel up."
A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "I will just go to an urgent care center for my routine medical care." D. "There's no reason to seek help if I am feeling stressed because it's just part of life."
B. "It is important to schedule routine health care visits even if I am feeling well."
A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my child expects me to relive my parenting days."
B. "It's been so stressful for me to think about having intimate relationships."
A Nurse is caring for a group of clients on a medical surgical unit. Which of the following clients are at increased risk for body image disturbances? (SATA) A. A client who had a laparoscopic appendectomy B. A client who had a mastectomy C. A client who had a left above knee amputation D. A client who had a cardiac catheterization E. A client who had a stroke with right-sided hemiplegia
B. A client who had a mastectomy C. A client who had a left above knee amputation E. A client who had a stroke with right-sided hemiplegia
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites
B. A client who has heart failure
The nurse is using an interpreter to communicate with the client. Which of the following actions should the nurse use when communicating with the client and family members? (SATA) A. Talk to the interpreter about the family while the family is in the room B. Determine clients understanding several times during the conversation C. Look at that interpreter when asking the family questions D. Use lay terms is possible E. Do not interrupt the interpreter and the family as they talk
B. Determine clients understanding several times during the conversation D. Use lay terms is possible E. Do not interrupt the interpreter and the family as they talk
A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? Select all that apply. a. assembling puzzles b. pull wheeled toys c. use musical toys d. play with puppets e. color with crayons
a. assembling puzzles c. use musical toys d. play with puppets e. color with crayons
The nurses caring for a client who has a new diagnosis of type II diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to treatment plan should the nurse initiate at this time? (SATA) A. Suggest coping skills for the client to use in this situation B. Allow the client to provide input in the treatment plan C. Assist the client with time management and address the client's priorities D. Provide extensive instructions on the client's treatment regimen E. Encourage the client in the expression of feelings and concerns
B. Allow the client to provide input in the treatment plan C. Assist the client with time management and address the client's priorities E. Encourage the client in the expression of feelings and concerns
The nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (SATA) A. Instruct client not to perform the Valsalva maneuver B. Apply an elastic stockings C. Review laboratory values for total protein level D. Place pillows under the client's knees and lower extremities E. Assist client to change positions often
B. Apply an elastic stockings E. Assist client to change positions often
A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of HTN. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the clients BP.
B. Ask the client if they are having pain.
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body interventions? A. Tell the client the goal of the therapy is to promote healing B. Ask whether the client is comfortable with using prayer C. Encourage the client participate actively for best results D. Instruct the client to relax during the therapy
B. Ask whether the client is comfortable with using prayer
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority. A. Increase the oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases
B. Assist the client to Fowler's position
A nurse is collecting data for a client's comprehensive physical exam. After inspecting the client's abdomen, which of the following skills of the physical exam process should the nurse perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion
B. Auscultation
A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
B. Autonomy
Nurse is preparing to perform denture care for A client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the dentures with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean dry storage container after cleaning them
B. Brush the dentures with a toothbrush and denture cleaner
A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 20 mL/hr D. Encourage independent ambulation four times a day
B. Check the client's weight each morning
A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care
B. Chronic illness C. Low hemoglobin D. Malnutrition
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. have the client hold their breath briefly and bear down B. Clamp the enema tubing C. Remind the client that cramping is common at this time D. Raise the level of the enema fluid container
B. Clamp the enema tubing
During a cardiovascular exam, a nurse in a providers office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Apical heart rate E. Murmur
B. Closure of the mitral valve D. Apical heart rate
A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting
B. Confusion D. Bone pain E. Nausea and vomiting
Which of the following strategies should the nurse use to establish a healthy relationship with the client? A. Make sure the communication is equally distributed between the nurse's and client's desires B. Encourage the client to communicate their thoughts and feelings C. Give the nurse-client communication no time limits D. Allow communication to occur spontaneously throughout the nurse-client relationship
B. Encourage the client to communicate their thoughts and feelings
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients
B. Ensuring that health care providers comply with regulations
A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality
B. False imprisonment
A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit. B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of their medical record. E. A nurse can photocopy a client's medical record for transfer to another facility.
B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of their medical record. E. A nurse can photocopy a client's medical record for transfer to another facility.
a nurse at the providers office is talking about routine screenings with a 45 year old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. So I don't need the colon cancer procedure for another two to three years B. For now I should continue to have a mammogram each year C. Because the doctor just did a pap-smear I will come back next year for another one D. I had my blood glucose test next year so I won't need it for another four years
B. For now I should continue to have a mammogram each year
A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (SATA) A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral edema
B. Hypotension C. Elevated temperature D. Poor skin turgor
A nurse is discussing the plan of care for client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. I will make sure the menu includes Kosher options B. I will ask the client if they want to schedule some times to pray during the day C. I will avoid discussing care when the clients family is around D. I will make sure daily communion is available for this client
B. I will ask the client if they want to schedule some times to pray during the day
A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I'll add plenty of carbohydrates to my meals. B. I will take a short nap whenever I feel little sleepy. C. I will make sure I stay warm when I am at my desk at work. D. It is okay to drink alcohol as long as I limited to one drink per day.
B. I will take a short nap whenever I feel little sleepy.
Nurse nurse is teaching A group of clients how to care for their colostomies. Which of the following statements indicates an issue with self-concept? A. I was having difficulty with attaching the appliance at first but my partner was able to help B. I'll never be able to care for this at home, can't you just send a nurse to the house? C. I met my neighbor who also has a colostomy and they taught me a few things. D. It can take me a while to get the hang of this, I have to admit I am pretty nervous.
B. I'll never be able to care for this at home, can't you just send a nurse to the house?
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy six months ago. The client tells the nurse that there has been a decreased desire for sexual relations since the surgery, stating, "my body is so different now." Which of the following responses should the nurse make? A. Really you look just fine to me there's no need to feel undesirable B. I'm interested in finding out more about how your body feels to you C: Consider an afternoon at a spa, a facial will make you feel more attractive D. It's still too soon to expect to feel normal, give it a little more time
B. I'm interested in finding out more about how your body feels to you
A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply) A. Increased gastric acid production B. Immature liver C. Higher body water content D. Increased absorption of topical medications E. Increased gastric emptying time
B. Immature liver C. Higher body water content D. Increased absorption of topical medications
A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreases therapeutic effects of cimetidine. B. Increased risk of imipramine toxicity. C. Decreased risk of adverse effects of cimetidine. D. Increased therapeutic effects of imipramine
B. Increased risk of imipramine toxicity.
A client in a providers office tells the nurse that "I fast for several days each week to control my weight." The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? A. Increasing the metabolism of the medication over time. B. Increasing the protein-binding response. C. Increasing the medications' transit time through the intestines. D. Decreasing the excretion of the medications.
B. Increasing the protein-binding response.
A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in the cone shape
B. Insert the speculum slightly down and forward. D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in the cone shape
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck their chin when swallowing C. Have the client use a straw D. Encourage the client to lie down and rest after meals
B. Instruct the client to tuck their chin when swallowing
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my partner when I get home." Which of the following statements should the nurse make? A. Sounds like something you should discuss with him when you get home B. It sounds like you're concerned about sexual functioning, let's discuss your concerns C. Oh I wouldn't be too concerned things will be fine as soon as you get home D. Just make sure you take your medication as directed and you should be fine
B. It sounds like you're concerned about sexual functioning, let's discuss your concerns
A nurse is assessing an older adult client who has significant tenting of the skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling
B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity
A nurse is caring for a client who had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply.) A. Speak at a higher volume to the client. B. Make sure only one person speaks at a time. C. Avoid discouraging the client by indicating that they cannot be understood. D. Allow plenty of time for the client to respond. E. Use brief sentences with simple words.
B. Make sure only one person speaks at a time. D. Allow plenty of time for the client to respond. E. Use brief sentences with simple words.
A nurse is explaining the various types of health clients might have to a group care coverage of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid
B. Medicare E. Medicaid
A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Mac and cheese B. One medium apple with skin C. One cup of plain yogurt D. Roast chicken and white rice
B. One medium apple with skin
A nurse is caring for a client who is been sitting in a chair for one hour. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction
C. Pressure injury
To promote adherence to medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply) A. Adjust dosages according to daily weight. B. Place pills in daily pill holders. C. Ask for liquid form of the client has difficulty swallowing pills. D. Ask a relative to assist periodically. E. Request child-resistant caps on medication containers.
B. Place pills in daily pill holders. C. Ask for liquid form of the client has difficulty swallowing pills. D. Ask a relative to assist periodically.
A nurse is preparing to perform a comprehensive physical exam of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) A. Expect the session to be shorter than for the younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom before beginning the examination.
B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom before beginning the examination.
A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test
B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test
A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document
B. Put the date and time on all entries. C. Document objective data, leaving out opinions.
A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered Nurse C. Practical Nurse D. Assistive Personnel
B. Registered Nurse
A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation (SATA)? A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances
B. Right supervision and evaluation C. Right direction and communication E. Right circumstances
A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? A. Use a 22-gauge needle. B. Select a site on the client's abdomen C. Use the Z-track technique to displace the skin on the injection site. D. Observe for bleb formation to confirm proper placement.
B. Select a site on the client's abdomen
A nurses caring for a school-age child is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture
B. Sit at eye level with the child
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test which of the following? (Select all that apply.) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature
B. Skin color C. Edema E. Skin temperature
A nurse is collecting data to evaluate a middle adults psychosocial development. The nurse should expect muddle adults to demonstrate which of the following developmental tasks? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Spend time focusing on improving job performance. C. Welcome opportunities to be creative and productive. D. Commit to finding friendships and companionship. E. Become involved with community issues and activities.
B. Spend time focusing on improving job performance. C. Welcome opportunities to be creative and productive. E. Become involved with community issues and activities.
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest x-ray D. Initiate oxygen therapy
B. Stop the feeding
A nurse is delegating the ambulation of a client who had a knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (SATA) A. The roommate ambulates independently B. The client ambulates wearing slippers over anti embolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of breakfast this morning
B. The client ambulates wearing slippers over anti embolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Proteins C. Glycogen D. Carbohydrates
D. Carbohydrates
A nurse is evaluating a client understanding of the use of his sequential compression device. Which of the following client statements indicates client understanding? A. This device will keep me from getting sores on my skin. B. This device will keep the blood pumping through my leg. C. With this device on my leg muscles won't get weak. D. This device is going to keep my joints in good shape
B. This device will keep the blood pumping through my leg.
A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply) A. Orthostatic hypotension B. Tremors C. Acute dystonia D. Decreased level of consciousness E. Restlessness
B. Tremors C. Acute dystonia E. Restlessness
A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and their last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.
B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. E. Perform the general survey before the examination.
A nurse is reviewing the CDC's immunization recommendations with the guardians of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza
B. Varicella D. Human papilloma virus E. Seasonal influenza
A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open B. Verify the placement of the NG tube C. Confirm that the client does not have diarrhea D. Make sure the client is alert and oriented
B. Verify the placement of the NG tube
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home.
B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location.
Nurse is caring for a client whose partner passed away four months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "how could you possibly understand what I'm going through?" Would of the following responses should the nurse make? A. It takes time to get over the loss of loved one. B. You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling. C. Why don't you try something to take your mind off your troubles like watching a funny movie. D. I might not share your exact situation but I do know what people go through when they deal with a loss.
B. You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling.
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (SATA) A. restrict the client intake of fluids during the daytime B. have the client record urination times C. Gradually increase the urination intervals D. remind the client to hold urine until the next scheduled urination time E. Provide a sterile container for urine
B. have the client record urination times C. Gradually increase the urination intervals D. remind the client to hold urine until the next scheduled urination time
A nurses caring for a client who states, "I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. pacing B. reflecting C. paraphrasing D. restating
B. reflecting
I nurse is caring for a client who weighs 80 kg (176 lbs) and is 1.6 m (5'3'') tall. Calculate the body mass index and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.
BMI = weight/height(m^2) 1. Client's weight and height = 80 kg and 1.6 m 2. 1.6 x 1.6 = 2.56 m^2 3. 80 / 2.56 = 31.25 BMI greater than 30 = obesity
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with the family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting
D. Convening a family meeting
A nurse is talking with the caregivers of a 10-year-old who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the nurse make? A. "Perhaps you should try to find out what is happening behind those closed doors." B. "Suggest that the door be left ajar for safety reasons." C. "At this age, children tend to become modest and value their privacy." D. "You should establish a disciplinary plan to stop this behavior."
C. "At this age, children tend to become modest and value their privacy."
A nurse in a providers office is preparing to test a clients cranial nerve function. Which if the following directions should the nurse include when testing cranial nerve 7? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."
C. "Clench your teeth." E. "Tell me when you feel a touch."
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."
C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."
A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? A. "I kind of like this boy in my class, but he doesn't like me back." B. "I want to hang out with the kids in the science club, but the jocks pick on them." C. "I am so fat, I skip meals to try to lose weight." D. "My dad wants me to be a lawyer like him, but I just want to dance."
C. "I am so fat, I skip meals to try to lose weight."
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as a priority to assess further? A. "I have my own apartment now, but it's not easy living away from my guardians." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My partner is pregnant, and I don't think I have what it takes to be a good parent."
C. "I don't even know who I am yet, and now I'm supposed to know what to do."
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."
C. "I plan to write that I don't want them to keep me on a breathing machine."
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "i'll be careful about pushing the button too much so I don't overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping."
C. "I should tell the nurse if the pain doesn't stop while I am using this device."
A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will protect others from exposure when I transport the client outside the room." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."
C. "I will protect others from exposure when I transport the client outside the room."
A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment B. A nurse overhears another nurse telling an older adult client that if he does not stay in bed, she will have to apply restraints C. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form
C. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill
A nurse is caring for a client who is been following the facility's routine in bathing in the morning. However at home the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 minutes before bedtime B. Offer the client warm milk and crackers at 2100 C. Allow the client to take a bath in the evening D. Ask the provider for sleeping medication
C. Allow the client to take a bath in the evening
A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record
C. Bone scan scheduled for today
A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (SATA) A. Urinary Incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea
C. Bradypnea D. Orthostatic hypotension E. Nausea
A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares B. Remove the nasal cannula during mealtimes C. Check the position of the cannula frequently D. Report any nausea or difficulty breathing E. Post "No Smoking" signs in prominent locations
C. Check the position of the cannula frequently D. Report any nausea or difficulty breathing E. Post "No Smoking" signs in prominent locations
A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side
C. Concave lumbar spine posteriorly E. Muscles slightly larger on the dominant side
A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation. B. Adjusting to major changes in roles and relationships due to losses. C. Devoting time to establishing an occupation. D. Finding oneself "sandwiches" between and being responsible for two generations.
C. Devoting time to establishing an occupation.
A nurse in a provider's office is performing a physical examination of an older adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers
C. Dorsal surface
A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae C. Enlargement of the testes and scrotum D. Deepening of the voice
C. Enlargement of the testes and scrotum
Nurse enters The room of the client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital spiritual services B. Ask what is making the client cry C. Ensure no visitors or staff enters the room for a short time period D. Turn on the television for a distraction
C. Ensure no visitors or staff enters the room for a short time period
A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the clients ability to perform which of the following activities? A. Exercising the deltoid muscle when using hand weights B. Brushing their hair on the back of the head C. Fascinating or zipping closures on the back while dressing D. Reaching into a cabinet above the sink
C. Fascinating or zipping closures on the back while dressing
During an abdominal exam, a nurse in a providers office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias
C. Flatus
A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Perform SMBG once daily at bedtime B. Wipe the hand with an alcohol swab C. Hold the hand in a dependent position prior to the puncture D. Place the puncturing device perpendicular to the site E. Prick the outer edge of the fingertip for the blood sample
C. Hold the hand in a dependent position prior to the puncture D. Place the puncturing device perpendicular to the site E. Prick the outer edge of the fingertip for the blood sample
A nurse in an outpatient medical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering this medication, which of the following actions is the nurse's priority? A. Teaching the client about the purpose of this medication. B. Giving the medication at the administration time the provider prescribed. C. Identifying the clients medication allergies. D. Documenting the clients anxiety level.
C. Identifying the clients medication allergies.
A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage
C. Initiating continuous cardiac monitoring
A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of cared delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
C. Justice
A nurse is caring for a client who is 1 day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO
C. Morphine 2 mg IV
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain B. Question the client about the location fo pain C. Offer the client a pain scale to measure their pain D. Use open-ended questions to identify the client's pain sensations
C. Offer the client a pain scale to measure their pain
A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment. B. Encourage visitors to distract the client. C. Provide a private room, and limit stimulation. D. Speak at a higher volume to the client.
C. Provide a private room, and limit stimulation.
A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a LPN? A. Creating a plan of care for a client who is recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler
C. Providing nasopharyngeal suctioning for a client who has pneumonia
A nurse on a medical-surgical unit has received change-of-shift report and will care for four patients. Which of the following tasks should the nurse assign the assistive personnel (AP)? A. Updating the plan of care for a client who is post-op B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure injury
C. Reapplying a condom catheter for a client who has urinary incontinence
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? A. Alert the American Nurses Association. B. Fill out an incident report. C. Report the observations to the nurse manager on the unit. D. Leave the nurse alone to sleep.
C. Report the observations to the nurse manager on the unit.
A nurse in a providers office is preparing to auscultate and percuss a clients thorax as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds
C. Resonance E. Bronchovesicular sounds
A nurse reviewing a client's health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescriptions? A. Single B. Stat C. Routine D. Now
C. Routine
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (SATA) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting an NG tube to relieve gastric distention C. Showing a patient how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hours to reduce pressure injury risk
C. Showing a patient how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hours to reduce pressure injury risk
A nurse is about to perform postmortem care of the client. The family wishes to view the body. Which of the following actions should the nurse take? (SATA) A. Remove the dentures from the body B. Make sure the body is lying completely flat C. Supply fresh linens and place clean gown on the body D. Remove all equipment from the bedside E. Dim the lights in the room
C. Supply fresh linens and place clean gown on the body D. Remove all equipment from the bedside E. Dim the lights in the room
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor
C. Tachycardia D. Syncope E. Decreased skin turgor
A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? A. Drink 8 oz of milk with each dose of medication. B. Use medications that have an extended half-life. C. Take each dose right after breastfeeding. D. Pump breast milk and freeze it prior to feeding the newborn
C. Take each dose right after breastfeeding.
A nurse is caring for a client who has a terminal lung cancer. The nurse observed the client family and assisting with all activities of daily living. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen muscles and promote healing B. The client needs privacy and times for self reflecting and organizing life C. The client's sense of loss can be lessened if they're retaining control of some areas of life D. Performing activities of daily living is a requirement prior to discharge from acute care facility
C. The client's sense of loss can be lessened if they're retaining control of some areas of life
A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religions share similar feelings about their religion B. I Shared religious background generates mutual regard for one another C. The same religious beliefs can influence individuals differently D. The nurse and client should discuss the differences and commonalities in their beliefs
C. The same religious beliefs can influence individuals differently
A nurse is performing a head and neck exam for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened ear drums
C. Tooth loss D. Glare intolerance E. Thickened ear drums
The nurse is caring for a client who requires a low residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Puréed broccoli C. Vanilla custard D. Lentil soup
C. Vanilla custard
A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? A. Puncture another finger to obtain a capillary specimen B. Test the urine with a urine reagent strip C. Wrap the hand in a warm, moist cloth D. Perform a venipuncture to obtain a venous sample
C. Wrap the hand in a warm, moist cloth
A nurse is caring for a client who is concerned about being discharged home with the new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (SATA) A. You will do great you just have to get used to it! B. Why are you worried about going home? C. Your daily routines will be different when you get home. D. Tell me about the support system you'll have after you leave the hospital. E. It sounds like you're not sure how having a colostomy will affect swimming.
C. Your daily routines will be different when you get home. D. Tell me about the support system you'll have after you leave the hospital. E. It sounds like you're not sure how having a colostomy will affect swimming.
Nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transfer team arrives, the nurses take the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. exhaustion stage B. resistance stage C. alarm stage D. recovery stage
C. alarm stage
A nurses caring for a client who has a stage four lung cancer and is three days post operative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking if I could just live long enough to attend my child's wedding." Based on the Kubler Ross model which stage of grief is the client experiencing? A. anger B. denial C. bargaining D. acceptance
C. bargaining
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. " I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."
D. "I keep forgetting which medications I have taken during the day."
A nurse is reviewing instructions with a client who has hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned down so I can hear better." D. "I take the batteries out of my hearing aids when I take them off at night.
D. "I take the batteries out of my hearing aids when I take them off at night.
A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid medication to prepared package of pudding." C. "I can crush the enteric coated pill, if needed." D. "I will eat two crackers with the pain pills."
D. "I will eat two crackers with the pain pills."
During a new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventative strategies? A. "I will leave the IV catheter in place after the client completes the coarse of IV antibiotics." B. "As long as I am working with the same client, I can use the same IV catheter for the second insertion attempt." C. "If my client needs to use the restroom, it would be safer to disconnect their IV infusions as long as i can clean the injection ports thoroughly with an antiseptic swab." D. "I will replace any IV catheter when I suspect contamination during insertion."
D. "I will replace any IV catheter when I suspect contamination during insertion."
A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "Avoid green, leafy vegetables while taking this medication." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "Report diarrhea while taking this medication."
D. "Report diarrhea while taking this medication."
A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? A. "Our child wants to eat as much as we do, but we're afraid it will lead to becoming overweight." B. "Our child skips lunch sometimes, but we figure it's okay as long as we eat a healthy breakfast and dinner." C. "We limit fast-food restaurants meals to three times a week now." D. "We reward school achievements with a point system instead of pizza or ice cream."
D. "We reward school achievements with a point system instead of pizza or ice cream."
A nurse in an outpatient clinic is teaching a client who is in the first trimester of pregnancy. Which of the following statements should the nurse make? A. "You will need to get a rubella immunization if you haven't had one prior to pregnancy." B. "You can safely take OTC medications." C. "You should avoid any vitamin preparations containing iron." D. "Your provider can prescribe a medication for nausea if you need it."
D. "Your provider can prescribe a medication for nausea if you need it."
A nurse is discussing the care of a group of patients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hours following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping D. A client who has episodic back pain following a fall 2 years ago
D. A client who has episodic back pain following a fall 2 years ago
A nurse who is assessing a client's neurologic system, should ask the client to close their eyes and identify which of the following items? A. A word the nurse whispers 30 cm from the ear B. A number the nurse traces on the palm of the hand C. The vibration of a tuning fork the nurse places on the foot D. A familiar object the nurse places in the hand
D. A familiar object the nurse places in the hand
A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence
D. Beneficence
A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well'. The nurse notes warmth, edema, induration, and red, streaking on the clients arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? A. Obtain a specimen for culture. B. Apply a warm compress. C. Administer an analgesic. D. Discontinue the infusion.
D. Discontinue the infusion.
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply.) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella
D. Herpes simplex E. Varicella
A nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? A. Smear the blood onto the strip B. Squeeze the blood onto the strip C. Touch the puncture to stimulate bleeding D. Hold the test strip next to the blood on the fingertip
D. Hold the test strip next to the blood on the fingertip
A nurse is caring for a client who is three days post operative following a below- the-knee amputation as a result of a motor vehicle crash. Which of the following statements indicates the client has a distorted body image? A. I'll be able to function exactly as I did before the accident B. I just can't stop crying C. I am so mad at the guy who hit us I wish he lost his leg D. I don't even want to look at my leg. You can check the dressing.
D. I don't even want to look at my leg. You can check the dressing.
A nurse is caring for a client who tells the nurse that based on religious values and mandates a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. I believe in this case you should really make an exception and except the blood transfusion B. I know your family would approve of your decision to have a blood transfusion C. Why does your religion mandate that you cannot receive any blood transfusions? D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.
D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.
A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
D. Nonmaleficence
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist
D. Occupational therapist
A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia. A. Linear clusters of vesicles on the right shoulder B. Purulent drainage from both eyes C. Decreased white blood cell count D. Report of continued pain following resolution of the rash
D. Report of continued pain following resolution of the rash
A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates their behavior after a social interaction. B. The client states they are learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation.
D. The client expresses concerns about the next generation.
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. One stool specimen is sufficient for testing C. A red color change indicates a positive test D. The specimen cannot be contaminated with urine
D. The specimen cannot be contaminated with urine
The nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? A. regular breathing patterns B. warm extremities C. increased urine output D. decreased muscle tone
D. decreased muscle tone
A nurse is caring for a client who has a history of falls which of the following actions is the nurses priority? a. Complete a fall risk assessment b. educate the client and family about fall risks c. eliminate safety hazards from the clients environment d. make sure the client uses assistive aids in their possession
a. Complete a fall risk assessment
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) a. Fever b. malaise c. edema d. pain or tenderness e. increase in pulse and respiratory rate
a. Fever b. malaise e. increase in pulse and respiratory rate
A nurse in the clinic is planning health promotion on disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? Select all that apply. a. Help the client to see the benefits of their actions b. identify the clients support system c. suggest and recommend community resources d. device and set goals for the client e. teach stress management strategies
a. Help the client to see the benefits of their actions b. identify the clients support system c. suggest and recommend community resources e. teach stress management strategies
A nurse is reviewing safety measures with the parent of an 8 month old infant. Which of the following statements by the parent in the kids and understanding of safety for the infant? a. My baby loved to play with the crib gym but I took it out of the crib b. I just bought a soft mattress so my baby will sleep better c. my baby likes sleeping on the fluffy pillow we just got d. i put the baby's car seat out of the way on the table after i put him in it
a. My baby loved to play with the crib gym but I took it out of the crib
A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) a. Planning on devaluating control and prevention strategies b. determining public health priorities c. ensuring proper medical treatment d. identifying endemic disease e. monitoring for common source outbreaks
a. Planning on devaluating control and prevention strategies b. determining public health priorities c. ensuring proper medical treatment d. identifying endemic disease e. monitoring for common source outbreaks
A nurse manager is reviewing guidelines for preventing an injury with a staff nurse. Which of the following instructions should the nurse monitor include? Select all that apply. a. Request assistance when repositioning the client b. avoid twisting your spine or bending at the waist c. use smooth movements when lifting and moving clients d. take a break from repetitive movements every two to three hours to flex and stretch your joints and muscles
a. Request assistance when repositioning the client b. avoid twisting your spine or bending at the waist d. take a break from repetitive movements every two to three hours to flex and stretch your joints and muscles
A nurse is talking with the parents of a 6 month old infant about gross motor development. Which of the following gross motor skills are expected findings in the next three months? Select all that apply. a. Rolls from back to front b. Bears weight on legs c. walks holding onto furniture d. sits unsupported e. sit down from a standing position
a. Rolls from back to front b. Bears weight on legs d. sits unsupported
A nurse is assessing a two week old newborn during a routine checkup. Which of the following findings should the nurse expect? a. Sleeps 14 to 16 hours each day b. posterior fontanelle closed c. Hans remain in a closed position d. current weight is the same as birth weight
a. Sleeps 14 to 16 hours each day
A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident prevention strategies should the nurse include? Select all that apply. a. Store toxic agents in locked cabinets b. keep toilet seats up c. turn pot handles toward the back of the stove d. place safety gates across stairways e. make sure balloons are fully inflated
a. Store toxic agents in locked cabinets c. turn pot handles toward the back of the stove d. place safety gates across stairways
A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? a. establish consistent boundaries for the toddler b. place the toddler in a room with the doors closed c. inform the toddler how you feel when he misbehaves d. users favorite snacks to reward the toddler
a. establish consistent boundaries for the toddler
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? a. hypotension b. bradycardia c. clammy skin d. bradypnea
a. hypotension
A nurse in a health clinic is caring for a 21 year old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect from the provider to perform for this client? a. testicular examination b. blood glucose c. fecal occult blood d. prostate specific antigen
a. testicular examination
A mother tells the nurse that her two year old toddler has temper tantrums and says no every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development: a. trying to increase independence b. developing a sense of trust c. establishing a new identity d. attempting to master a skill
a. trying to increase independence
A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? a. I will place the client on their side b. I will go to the nurses station for assistance c. I will note the time that the seizure begins d. I will prepare to insert an airway
b. I will go to the nurses station for assistance
A nurse is talking with guardians about several issues with their preschooler. Which of the following issues should the nurse identify as a priority? a. My child mimics the way my partner and I dress b. My child has temper tantrums every time we tell him to do something they don't want to do c. I think my child believes that toys have personalities and can talk d. I feel bad when I see my child trying so hard to put in their shirt
b. My child has temper tantrums every time we tell him to do something they don't want to do
a nurse in a providers office is collecting data from the caregiver of a 12 month old infant who asks if the child is old enough for toilet training period following an educational session with the nurse comma the client agrees to postpone toilet training until the child is older . Learning has occurred in which of the following domains? a. cognitive b. affective c. psychomotor d. kinaesthetic
b. affective
A nurse is evaluating how well a client learned the information presented in an instructional session following a heart healthy diet. Which of the following actions should the nurse take to evaluate the clients learning? a. Encourage the client to ask questions b. ask the client to explain how to select or prepare meals c. encourage the client to fill out an evaluation form about how the nurse presented the information d. ask whether the client has resources for further instructions on the topic
b. ask the client to explain how to select or prepare meals
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (Select all that apply.) a. Most food poisoning is caused by a virus b. immuno compromised individuals are at increased risk for complications from food poisoning c. clients who are at high risk should eat or drink only pasteurized dairy products d. healthy individuals usually recover from the illness in a few weeks e. handling raw and fresh food separately can prevent food poisoning
b. immuno compromised individuals are at increased risk for complications from food poisoning c. clients who are at high risk should eat or drink only pasteurized dairy products e. handling raw and fresh food separately can prevent food poisoning
The mother of a 7 month old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruit and vegetables. Which of the following responses should the nurse make? Select all that apply. a. It might be good to add bananas as they can help with loose stools b. let's make a list of the foods your baby is eating so we can spot any problems c. did the changes begin after you started one particular food d. has your baby been vomiting since starting these new foods e. most babies react with a little indigestion when you start new foods
b. let's make a list of the foods your baby is eating so we can spot any problems c. did the changes begin after you started one particular food d. has your baby been vomiting since starting these new foods
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should a nurse include? (Select all that apply.) a. Family members who smoke must be at least 10 foot from the client when oxygen is in use b. nail Polish should not be used near a client who is receiving oxygen c. a no-smoking sign should be placed on the door d. cotton bedding and clothing should be replaced with items made from wool e. a fire extinguisher should be readily available in the home
b. nail Polish should not be used near a client who is receiving oxygen c. a no-smoking sign should be placed on the door e. a fire extinguisher should be readily available in the home
A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? Select all that apply. a. Open doors to client rooms b. place blankets over clients who are confined to beds c. move beds away from the windows d. draw shades and close drapes e. instruct ambulatory clients in the hallways to return to their rooms
b. place blankets over clients who are confined to beds c. move beds away from the windows d. draw shades and close drapes
A nurse is reviewing car seat seat safety with the parents of a one month old infant. When reviewing car seat use, which of the following instructions should the nurse include? a. use a car seat that has a 3 point harness system b. position the car seat so that the infant is rear facing c. secure the car seat in the front passenger seat of the vehicle d. convert to a booster seat after 12 months
b. position the car seat so that the infant is rear facing
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for CF care of this client? a. Supine b. semi fowlers c. semi prone d. trendelenburg
b. semi fowlers
A nurse at the health Department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? a. Providing cholesterol screenings b. teaching about healthy diet c. providing information about anti hypertensive medications d. developing a list of cardiac rehabilitation programs
b. teaching about healthy diet
A nurse is observing a client drawing upon mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique b. the client is able to demonstrate the appropriate technique c. the client states an understanding of the process d. the client is able to write the steps on a piece of paper
b. the client is able to demonstrate the appropriate technique
A nurse educator is reviewing proper body mechanics during employee orientation period which of the following statements should the nurse identify as an indication that an attendee understands the teaching? a. My line of gravity should fall outside my base of support b. the lower my center of gravity the more stability I have c. to broaden my base of support i should spread my feet apart d. when I left an object i should hold it as close to my body as possible e. when pulling an object i should move my front foot forward
b. the lower my center of gravity the more stability I have c. to broaden my base of support i should spread my feet apart d. when I left an object i should hold it as close to my body as possible
A nurse has prepared a sterile field for assisting a provider with chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) a. The provider drops a sterile instrument onto the near side of the sterile field b. the nurse poisons a cotton ball with sterile Saline and places it on the sterile field c. the procedure is delayed one hour because the provider receives an emergency call d. the nurse turns to speak to someone who enters through the door behind the nurse e. the clients hand brushes against the outer edge of the sterile field
b. the nurse poisons a cotton ball with sterile Saline and places it on the sterile field c. the procedure is delayed one hour because the provider receives an emergency call d. the nurse turns to speak to someone who enters through the door behind the nurse
A nurse is reviewing the Centers for Disease control and prevention's immunization recommendations with the guardians of preschoolers. Which of the following vaccines should the nurse include in the discussion? Select all that apply. a. influenza type B b. varicella c. polio d. hepatitis A e. seasonal influenza
b. varicella c. polio e. seasonal influenza
A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) a. Apply 3 to 5 milliliters of liquid soap to dry hands b. wash the hands with soap and water for at least 15 seconds c. rinse the hands with hot water d. use a clean paper towel to turn off hand faucets e. allow the hands to air dry after washing
b. wash the hands with soap and water for at least 15 seconds d. use a clean paper towel to turn off hand faucets
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) a. Place the client in a room that has negative air pressure of at least six exchanges per hour b. wear a mask when providing care within 3 foot of the client c. place a surgical mask on the client if transportation to another department is unavoidable d. use sterile gloves when handling soiled linens e. wear a gun when performing care that might result in contamination from secretions
b. wear a mask when providing care within 3 foot of the client c. place a surgical mask on the client if transportation to another department is unavoidable e. wear a gown when performing care that might result in contamination from secretions
A nurse is reviewing nutritional guidelines with the parents of a 2 year old toddler. Which of the following parent statements should indicate to the nurse that an understanding of the teaching has happened? a. I should keep feeding my son whole milk until he is 3 years old b. It is OK for me to give my son a cup of Apple juice with each meal c. I will give my son 2 tablespoons of food at mealtimes d. My son loves popcorn and I know it is better for him than sweets
c. I will give my son 2 tablespoons of food at mealtimes
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurses priority? a. a client who has received crush injuries to the chest and abdomen under is expected to die b. a client who has a four inch laceration to the head c. a client who has partial thickness on full thickness burns to his face, neck and chest d. a client who has a fractured fibula and tibia
c. a client who has partial thickness on full thickness burns to his face, neck and chest
A nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? Select all that apply. a. A client who is dehydrated on receiving IV fluid and electrolytes b. a client who has a nasal gastric tube to treat a small bowel obstruction c. a client who is scheduled for elective surgery d. a client who has chronic hypertension and blood pressure of 135/85 e. a client who has acute appendicitis under scheduled for an appendectomy
c. a client who is scheduled for elective surgery d. a client who has chronic hypertension and blood pressure of 135/85
An occupational health nurse is caring for an employee who is exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. Irrigate the affected area with running water b. wash the affected area with antibacterial soap c. brush the chemical off the skin and clothing d. leave the clothing in place until emergency personnel arrive
c. brush the chemical off the skin and clothing
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. I don't want my spouse to see my incision b. will you give me pain medicine after the surgery c. can you tell me about how long the surgery will take d. my roommate listens to everything I say
c. can you tell me about how long the surgery will take
A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? a. Give the client information about immunization against meningitis b. tell the client to have a TB skin test every two years c. determine the clients health risks d. teach the client about exercise recommendations
c. determine the clients health risks
A nurse is planning diversionary activities for toddlers on an inpatient unit which of the following activities should the nurse include? Select all that apply. a. Building models b. working with clay c. filling and emptying containers d. playing with blocks e. looking at books
c. filling and emptying containers d. playing with blocks e. looking at books
A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? a. Lie on your back with your head and shoulders supported by a pillow b. have your head turned to the side while you lie on your stomach c. have a table beside your bed so that you can sit on the bad side and rest your arms on the table d. lie on your side with your top arm resting on the bed and your wet on your head
c. have a table beside your bed so that you can sit on the bad side and rest your arms on the table
A nurse is talking with the Guardian of a four year old child who reports that the child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? a. offer the child a large snack before bedtime b. allow the child to watch 30 minutes extra of television c. have the child go to bed at a consistent time each day d. increase physical activity before bedtime
c. have the child go to bed at a consistent time each day
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following action should the nurse take to decrease the risk of another fall? (Select all that apply.) a. Place a belt restraint on the client when they were sitting on the bedside commode b. keep the bed in its lowest position with all side rails up c. make sure that the clients' call light is within reach d. provide the client with non skid footwear e. complete a fall risk assessment
c. make sure that the clients' call light is within reach d. provide the client with non skid footwear e. complete a fall risk assessment
A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurses priority? a. Extinguish the fire b. activate the fire alarm c. move clients who are nearby d. close all open doors on the unit
c. move clients who are nearby
When entering the client room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. Keep the sterile field at least 6 foot away from the clients bedside b. instruct the client to refrain from coughing and sneezing during the dressing change c. place a mask on the client to limit the spread of microorganisms into the surgical wound d. keep a box of facial tissues nearby for the client to use during the dressing change
c. place a mask on the client to limit the spread of microorganisms into the surgical wound
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) a. A bottle containing a sterile solution b. the edge of the sterile drip at the base of the field c. the inner wrapping of an item on the sterile field d. an irrigation syringe on the sterile field e. one gloved hand with the other gloved hand
c. the inner wrapping of an item on the sterile field d. an irrigation syringe on the sterile field e. one gloved hand with the other gloved hand
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding? a. I will get the caller off the phone as soon as possible so I can alert the staff b. I will begin evacuating clients using the elevators c. I will not ask any questions and just let the caller talk d. I will listen for background noises
d. I will listen for background noises
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include? a. Carbon monoxide has a distinct color b. water heaters should be inspected every five years c. the lungs are damaged from carbon monoxide inhalation d. carbon monoxide binds with hemoglobin in the body
d. carbon monoxide binds with hemoglobin in the body
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurses priority at this time? a. Obtain a Walker for the client to use to transfer back to bed b. call for additional staff to assist with the transfer c. use a transfer belt and assist the client back into bed d. determine the clients ability to help with the transfer
d. determine the clients ability to help with the transfer
A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. Encourage the client to participate actively in learning b. select instructional materials c. identify goals the nurse and the client agree or reasonable d. determine what the client knows about stress incontinence
d. determine what the client knows about stress incontinence
A nurse is preparing to administer medication to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation and taking medications? Select all that apply. a. Reassure the child that the injection will not hurt b. mix oral medications in a large glass of milk c. offer the child choices where possible d. have the guardians bring a favorite toy from home e. engage the child and pretend play with a toy medical kit
d. have the guardians bring a favorite toy from home e. engage the child and pretend play with a toy medical kit
A nurse is caring for a client who reports severe sore throat, pain when swallowing, on the swollen lymph nodes. The client is experiencing which of the following stages of infection? a. Prodromal b. incubation c. convalescence d. illness
d. illness
A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements by a participant indicates understanding? a. I will set my water heater at 130 degrees Fahrenheit b. once my baby can sit up they should be safe in the bathtub c. I will place my baby on their stomach to sleep d. once my infants start to push up I will remove the mobile from over the crib
d. once my infants start to push up I will remove the mobile from over the crib
A nurse discovers a small paper fire in a trash can in a client bathroom. The client has been taken to safety on the alarm has been activated. Which of the following actions should the nurse take? a. Open the windows in the clients room to allow smoke to escape b. obtain a Class C fire extinguisher to extinguish the fire c. remove all electrical equipment from the client room d. place wet towels along the base of the door to the clients room
d. place wet towels along the base of the door to the clients room
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? a. The flap closest to the body b. the right side flap c. the left side flap d. the flap farthest from the body
d. the flap farthest from the body
A nurse is caring for a client who has had a cough for three weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? a. Allergic reaction b. ringworm c. systemic lupus erythematous d. tuberculosis
d. tuberculosis
