Comprehensive Practice B W/Rationales 🥶

A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique? A. Placing the glove package just below their waist level B. Putting a glove on their dominant hand first C. Unrolling the cuff of the glove up their wrist D. Holding both gloved hands close to their body

putting a glove on their dominant hand first. *The nurse is demonstrating sterile technique when they put a glove on their dominant hand first. Using the dominant hand to apply the second glove helps prevent contamination because the nurse's dominant hand is more likely to have better dexterity than their nondominant hand.

A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make? A. "Advance directives provide education on palliative care issues." B. "Advance directives require the provider's approval before changes can be implemented." C. "Advance directives are written instructions regarding end-of-life care." D. "Advance directives help determine legal competency."

"Advance directives are written instructions regarding end-of-life care." *The nurse should inform the client that advance directives allow the client to make decisions and provide written instructions regarding end-of-life care. These directives take effect if the client is unable to make their own health care decisions.

A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The client states, "I really thought I'd be back to my usual routines by now, but I can't think of anything else except that my son is gone." Which of the following responses should the nurse make? A. "Perhaps you should try not to keep thinking about how your son died. Focus instead on your pleasant memories of him." B. "You should schedule a time with the provider to discuss your relationship with your son." C. "It might be better to let go of your daily routines and start creating new patterns in your daily life." D. "Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss."

"Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss." *The nurse should encourage the client to take all the time they need to grieve. Although there is no specific timeline for working through the various stages of grief, it is common for it to take at least 1 year for people to learn to accept the loss of a loved one.

A nurse is caring for a client who has a prescription for famotidine 160 mg PO every 6 hr. Available is famotidine oral suspension 40 mg/5 mL. How many mL should the nurse administer per dose?

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A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and gained 0.23 kg (0.5 lb) overnight B. A client who is taking atenolol and has a blood pressure of 139/88 mm Hg C. A client who is 1 day postoperative and rates their pain as 4 on a scale of 0 to 10 D. A client who has pneumonia and a new onset of confusion

A client who has pneumonia and a new onset of confusion *A client who has pneumonia and displays a new onset of confusion is manifesting a decrease in oxygenation and is unstable. Therefore, the nurse should see this client first.

A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen? A. Immediately after the client brushes their teeth B. After the client's first ambulation of the day C. After the client's antibiotics have been administered D. As soon as the client awakens in the morning

As soon as the client awakens in the morning *Sputum from the base of the lungs provides the best specimen for collection. The AP should obtain the specimen early in the morning because overnight fluid accumulates in the base of the lungs while the client is sleeping.

A nurse is collecting data from a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Ptosis B. Photophobia C. Ataxia D. Bradykinesia

Ataxia *The nurse should expect a client who has multiple sclerosis to manifest ataxia, which is a lack of coordination and movement. Other manifestations include fatigue, impaired memory, diplopia, and bowel and bladder incontinence.

A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching? A. Increase fluid intake with meals. B. Avoid foods with a high sugar content. C. Sit upright for 30 min after each meal. D. Take a mild laxative each day.

Avoid foods with a high sugar content. *The nurse should instruct the client to avoid sweet foods, which often increase the manifestations of dumping syndrome. These manifestations include nausea, sweating, abdominal pain, diarrhea, and weakness.

A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal of one eye. Which of the following instructions should the nurse include? A. Do not bend at the knees. B. Change the eye patch dressing every other day. C. Avoid lying on the affected side. D. Expect visual acuity to return to normal within 24 hr of surgery.

Avoid lying on the affected side. *The client should avoid lying on the affected side because this increases intraocular pressure.

A nurse is reviewing a client's electronic medical record and finds that an assistive personnel (AP) recorded the client's temperature as 35.3C (95.5F) 2 hr earlier. Which of the following actions should the nurse take first? A. Check the client's temperature. B. Notify the client's provider. C. Instruct the AP to cover the client with a blanket. D. Review the procedure with the AP.

Check the client's temperature. *According to the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should retake the client's temperature.

A nurse is reviewing laboratory reports for a client who has an Escherichia coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose? A. Hematocrit 45% B. Creatinine 2.5 mg/dL C. Blood glucose 120 mg/dL D. Potassium 4.2 mEq/L

Creatinine 2.5 mg/dL *The nurse should report the creatinine level of 2.5 mg/dL to the provider prior to administering any further doses of the medication because gentamicin is nephrotoxic and can result in acute tubular necrosis. A creatinine level above the expected reference range is an indication of kidney impairment.

A nurse is collecting data from a client who is experiencing a situation crisis following the loss of a job. The client states, "I don't think I can go through this again." Which of the following actions is the nurse's priority? A. Identify the client's previously successful coping skills. B. Ask the client to explain the cause of the current crisis. C. Determine if the client is experiencing psychotic thinking. D. Verify if the client has a support system in place.

Determine if the client is experiencing psychotic thinking. *The nurse's priority action when using the safety vs. risk reduction approach to client care is to determine if the client is experiencing psychotic thinking, which can include suicidal and violent behavior. The client's statement indicates that the client could be suicidal or unable to take care of their own needs at this time and might require hospitalization.

A nurse is reinforcing teaching with a client who is bttle feeding their full term newborn with formula. Which of the following instructions should the nurse include in the teaching? A. Feed the newborn at least every 3 to 4 hr. B. Refrigerate formula that remains in the bottle. C. Wake the newborn if she falls asleep during a feeding. D. Prop the bottle with a folded towel for middle-of-the-night feedings.

Feed the newborn at least every 3 to 4 hr. *Although it is unnecessary to be rigid about feeding times, six to eight feedings every 24 hr should support a full-term newborn's nutrition needs adequately. Fewer feedings in the initial weeks could delay the establishment of an adequate weight-gain pattern.

A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take? A. Remove the client's dentures and place them in a container. B. Perform a complete bath for the client. C. Gently close the client's eyelids. D. Remove the pillow from under the client's head.

Gently close the client's eyelids. *The nurse should hold the client's eyelids closed for a few seconds to ensure that they remain closed.

A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which of the following manifestations should the nurse expect? A. Hematemesis B. Lanugo C. Elevated liver enzyme levels D. Neuropathy

Hematemesis *The nurse should expect hematemesis, or vomiting blood, in a client who was recently diagnosed with bulimia nervosa. Hematemesis is a result of esophageal tears caused by purging.

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect? A. Dependence B. Euphoria C. Memory loss D. Hypervigilance

Hypervigilance *Common manifestations of PTSD include recurrent recollections of the precipitating trauma, hypervigilance, irritability, insomnia, and difficulty concentrating.

A nurse is contributing to the plan of care for a client who is postoperative following a rhinopasty. Which of the following interventions should the nurse recommend? A. Apply warm compresses to the nose. B. Maintain the head of the bed below a 30° angle. C. Instruct the client to avoid the Valsalva maneuver. D. Provide supplemental oxygen via nasal cannula.

Instruct the client to avoid the Valsalva maneuver. *The nurse should instruct the client to avoid the Valsalva maneuver and other activities that increase pressure at the operative site, resulting in an increased risk for bleeding.

A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accomodation? A. Failure of the pupils to converge as the nurse moves an object closer to the client's face B. Lack of change in pupil size when the client looks from a far to a near object C. Inability to read printed material until the nurse moves it farther away D. Inability to follow an object through the six cardinal positions of gaze

Lack of change in pupil size when the client looks from a far to a near object *The nurse should expect the client's pupils to constrict when looking from a far to a near object. Lack of change in pupil size can indicate brain injury or increased intracranial pressure.

A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report? A. Provider's progress notes B. Physical therapy record C. List of potential complications to report D. Medication administration record (MAR)

List of potential complications to report *Discharge instructions are defined as any form of documentation provided to the client, upon discharge to home, which facilitates safe and appropriate continuity of care. The nurse should plan to include a list of potential complications that should be reported to the provider in the client's discharge instructions.

A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include? A. Pick ground beef that is 85% lean. B. Purchase beef that is a loin cut. C. Replace beef with fish once each week. PD. ick grades of beef that have large amounts of marbling.

Purchase beef that is a loin cut. *The nurse should instruct the client to select cuts of beef that are labeled loin or round to decrease saturated or solid fat found in the marbling of the beef.

A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity? A. Scan the client's facility identification band. B. Verify the client's room number outside the door. C. Ensure the client is oriented to time and place. D. Ask the client to validate medications listed on the Medication Administration Record (MAR).

Scan the client's facility identification band. *The nurse must use client-specific information to identify the client, such as an assigned identification number found on the client's facility identification band.

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching? A. Take up to three tablets during a single angina episode. B. Place the tablet in the buccal pocket of the mouth. C. Store the tablets in the refrigerator. D. Discard unused tablets after 2 months.

Take up to three tablets during a single angina episode. *The nurse should instruct the client to take up to three doses of the nitroglycerin, 5 min apart, if chest pain persists.

A nurse is collecting data from a client who has myasthenia gravis (MG. Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?

This is an example of ptosis, in which there is abnormal drooping of the upper eyelid. Ptosis, along with diplopia, are early manifestations of MG.

A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C? A. Tomatoes B. Apricots C. Avocados D. Carrots

Tomatoes *The nurse should recommend tomatoes, which are a food source that is high in vitamin C.

A nurse is preparing to administer a rectal suppository to a school-age child. Which of of the following actions should the nurse plan to take? A. Use one finger to insert the suppository past the anal sphincters. B. Place the child in a lithotomy position. C. Cut the suppository in half crosswise prior to insertion. D. Don sterile gloves prior to inserting the suppository.

Use one finger to insert the suppository past the anal sphincters. *The nurse should apply clean gloves and use one finger to gently insert the suppository past both anal sphincters to ensure that the child does not expel the suppository after insertion.

A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching? A. Wrap the lower legs with an elastic bandage at bedtime. B. Remove the elastic bandages for 15 min daily. C. Avoid sitting in chairs that recline. D. Walk for 1 to 2 hr each day.

Walk for 1 to 2 hr each day. *The nurse should instruct the client to walk for at least 1 to 2 hr per day after surgery to promote venous return.

A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A Cleanse the catheter at the insertion site with an alcohol wipe daily. B. Gently irrigate the catheter and bladder once per shift. C. Wipe the drainage port with an antiseptic wipe after emptying urine from the bag. D. Ensure the urinary catheter bag is maintained at the level of insertion.

Wipe the drainage port with an antiseptic wipe after emptying urine from the bag. *To prevent the spread of infection when emptying the drainage bag, the nurse should cleanse the client's drainage port with an antiseptic wipe to remove any residual urine prior to securing the spout back in place.

A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which Of the following findings is the nurse's priority to report to the provider? A. Client reports burning with urination. B. Client states they are hungrier than usual. C. Client reports uterine cramping when breastfeeding. D. Client states they have more vaginal bleeding when ambulating.

client reports burning with urination. *When using the urgent vs. nonurgent approach to client care, the nurse should determine that dysuria is a manifestation of a urinary tract infection. Therefore, the nurse should identify this as the priority finding to report to the provider.

A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take? A. Inform the client that a signed consent form is legally in effect for 24 hr. B. Report the situation to the provider who obtained the informed consent. C. Reinforce client teaching about the purpose of the procedure. D. Notify the client's family about the refusal of treatment.

report the situation to the provider who obtained informed consent. *The provider is responsible for obtaining the informed consent and has the legal responsibility to answer any questions or concerns the client has. Therefore, the nurse should report the client's refusal of the procedure to the provider.

A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist? A. "I do not know how I am going to pay my bills until I can return to work." B. "I don't understand why God let this happen to me." C. "Getting up the stairs to my bedroom is going to be difficult." D. "I am so frustrated. I cannot even open my milk carton for breakfast."

"I am so frustrated. I cannot even open my milk carton for breakfast." *For a client who is expressing concerns about performing ADLs, the nurse should recommend a referral to an occupational therapist. An occupational therapist can assist the client with becoming independent in the areas of dressing, grooming, bathing, and eating.

A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, "I am very upset and I want to be alone for a little while." Which of the following responses should the nurse make? A. "I understand how you are feeling. I have a family member who was diagnosed with MS last month." B. "I'm very sorry about your diagnosis. You must be devastated." C. "I will call someone to sit with you. I don't want you to be alone right now." D. "I see that you are feeling overwhelmed. I will come back when you are ready."

"I see that you are feeling overwhelmed. I will come back when you are ready." *This response by the nurse is therapeutic and uses the communication technique of sharing observations. This response meets the requirements of a trusting nurse-client relationship. It respects the client's right to privacy and allows them to have control over their personal space while encouraging the expression of feelings.

A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I should apply sterile saline to lubricate the suction catheter." B. "I should wait 30 seconds between each suction pass." C. "I will repeat the suction procedure for up to 4 suction passes." D. "I will apply suction for 10 seconds as I insert the catheter."

"I should apply sterile saline to lubricate the suction catheter." *The nurse should lubricate the suction catheter with sterile saline prior to suctioning.

A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent indicates an understanding of the teaching? A. should expect my child to have chronic constipation." B. "I should offer my child yogurt that has a probiotic as a snack." C. "I should limit my child's milk intake to 3 cups each day." D. "I should avoid giving my child lactase enzyme tablets."

"I should offer my child yogurt that has a probiotic as a snack." *Children who have lactose intolerance should be offered dairy products that have a probiotic, such as lactobacillus. The probiotic promotes tolerance of lactose in the colon.

A nurse is assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statement by a client indicates an understanding of cutaneous stimulation? A. "I should use counterpressure for back pain during labor." B. "I should use various breathing techniques throughout my labor to assist with pain." C. "I should use biofeedback to promote relaxation during labor." D. "I should use guided imagery during my labor."

"I should use counterpressure for back pain during labor." *Counterpressure is a cutaneous stimulation strategy to decrease pain resulting from pressure of the fetal occiput against the spinal nerves.

A nurse is reinforcing teaching with a client who has asthma and a new prescription for an ipratropium inhaler. Which of the following statements by the client indicates an understanding of the teaching? A. "I should wait 1 minute before taking a second puff of the medication." B. "This medication might cause me to have nose bleeds." C. "This medication can cause me to have increased saliva production." D. "I should use this inhaler as soon as I have trouble breathing."

"I should wait 1 minute before taking a second puff of the medication." *The client should wait 1 min between puffs of medication to increase absorption.

A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wear a mask when I change my baby's diaper." B. "I will offer fruit juice to my baby every hour she is awake." C. "I will use a rectal thermometer to check my baby's temperature." D. "I will apply diaper cream to my baby's skin during each diaper change."

"I will apply diaper cream to my baby's skin during each diaper change." *The nurse should reinforce to the parent that applying a skin barrier, such as zinc oxide, during diaper changes will minimize skin irritation from frequent stools.

A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions? A. "I will give our baby sponge baths until the cord falls off." B. "I will remove the cord clamp after 5 days." C. "I will wrap the cord in petroleum jelly gauze." D. "I will keep the cord protected by covering it with the diaper."

"I will give our baby sponge baths until the cord falls off." *Immersing the umbilical cord stump in water might delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.

A nurse is reinforcing teaching about stress managment techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching? A. "I will avoid writing about the things that trigger my anxiety in my journal." B. "I will imagine myself in a calm place when I can't concentrate." C. "I will avoid exercising more than 15 minutes when my neck muscles are tense." D. "I will act in a more passive manner to settle conflict with others."

"I will imagine myself in a calm place when I can't concentrate." *The client should imagine a comfortable, peaceful place in order to relax and take their mind off of the current stressor. This allows positive feelings to become stronger each time the client chooses to use this technique. The client can then return to previous activities with less anxiety.

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions? A. "I will receive the nutrients I need through my IV fluid." B. "I can eat sunflower seeds when I need a high-protein snack." C. "I should consume a diet that is high in fiber." D. "I must eat fresh fruits to increase my vitamin intake."

"I will receive the nutrients I need through my IV fluid." *During initial treatment of acute diverticulitis, the client is often kept NPO and receives parenteral nutrition to promote bowel rest. As the client's condition improves, they can progress to a soft, low-fiber diet. A high-fiber diet is prescribed once the client is fully recovered from the acute inflammation.

A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will try not to get pregnant while taking this medication." B. "I will report the presence of dark-colored stools." C. "I will limit high-fiber foods while on this medication." D. "I will rinse my mouth after taking this medication."

"I will rinse my mouth after taking this medication." *Iron preparations can stain the teeth. The nurse should instruct the client to use a straw to drink the medication and rinse the mouth immediately after taking the medication.

A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will secure the car seat in the car by using the seatbelt." B. "While traveling, I should use a blanket underneath my baby for padding." C. "When my baby is able to hold their head upright, I can turn the car seat forward-facing." D. "I can place the car seat in the front passenger seat as long as there is a working airbag."

"I will secure the car seat in the car by using the seatbelt." *The nurse should instruct the guardian to secure the car seat in the car by using the seatbelt.

A nurse is reinforcing teaching with a client who is scheduled for a colonscopy. Which of the following client statements indicates an understanding of the teaching? A. "The colonoscopy examination is limited to the lower part of my colon." B. "I will undergo bowel cleansing prior to the procedure." C. "I can eat a low-residue diet up until 8 hours before the colonoscopy." D. "I will receive a general anesthetic for the procedure."

"I will undergo bowel cleansing prior to the procedure." *The client will receive a bowel preparation prior to the procedure and an enema immediately before the procedure to ensure the bowel is free of stool to allow for visualization of the intestinal mucosa. Therefore, this statement indicates that the client understands the teaching.

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding an understanding of the teaching? A. "If I need to floss my teeth, I can use wax-coated floss twice a day." B. "I'll take ibuprofen if I get a headache." C. "I'll use a safety razor to shave each day." D. "If I forget to take a dose, I can take it later on the same day."

"If I forget to take a dose, I can take it later on the same day." *If the client misses a dose of medication, they can take it later the same day but should not double the dose the next day.

A nurse is reinforcing teaching with a female client who request information about how to lose weight. Which of the following statements should the nurse make? A. "Consume 1,800 calories per day." B. "Exercise for 120 minutes per week." C. "Keep fat intake to no more than 30 percent of your daily caloric intake." D. "Set a goal to lose 15 percent of your body weight over a 6-month period."

"Keep fat intake to no more than 30 percent of your daily caloric intake." *The nurse should instruct the client limit fat intake to no more than 30% of their daily caloric intake. Reducing fat consumption can help decrease caloric intake because fats typically have twice as many calories as proteins or carbohydrates.

A nurse is speaking with the patner of a client who has Alzheimer's disease. The partner states, "I love him, but caring for him is wearing me out." Which of the following reponses should the nurse make? A. "I think asking another family member to help you is a good idea." B. "I understand how difficult this is, but things will get better." C. "You should consider placing your partner in a long-term care facility." D. "Let's discuss how caring for your partner is affecting your health."

"Let's discuss how caring for your partner is affecting your health." *The nurse should use the therapeutic communication technique of offering self and giving broad openings to support the partner. This facilitates the caregiver in determining whether the current situation is having a negative effect on the partner's health.

A nurse is collecting data from an older adult client during a routine physical examination. Which of the following cliet statements should the nurse identify as a possible indication of maltreatment? A. "My son took my wallet so he can keep track of what I'm spending." B. "I've stopped attending bingo games regularly at the local senior center." C. "My son thinks I'm going to need to get a walker soon to help me get around." D. "It's been 6 months since I've had my eyes checked at the eye doctor."

"My son took my wallet so he can keep track of what I'm spending." *The nurse should identify taking the client's wallet and controlling the client's spending as possible indicators of financial maltreatment. The nurse should collect further data about this situation to determine if abuse is present.

A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching? A. "Drink up to 1,500 milliliters of fluid daily." B. "Contact your provider if you experience urine dribbling." C. "Perform Kegel exercises daily." D. "Take ibuprofen as needed for pain."

"Perform Kegel exercises daily." *The nurse should instruct the client to perform Kegel exercises to promote the control of urine flow and reduce incontinence.

A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions? A. "Cover your baby with a light blanket at bedtime." B. "Give your baby a bath once a day." C. "Keep your baby's umbilical cord stump covered with the diaper." D. "Place your baby's crib away from heat vents."

"Place your baby's crib away from heat vents." *The nurse should instruct the parent to position the newborn's crib or playpen away from windows, heat vents, and space heaters. Window blinds and curtains present a risk for strangulation. Heat vents and space heaters can cause the crib linens to catch fire.

A nurse is reinforcing teaching with a client who has tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? A. "I will take the TB medications for a total of 3 months." B. "The people I live with should be tested for TB." C. "The TB medication might turn my urine green." D. "I will need to use disposable utensils at home."

"The people I live with should be tested for TB." *Due to the highly contagious nature of TB, the client's family members, or members of the client's household, should be screened for the disease.

A nurse is reinforcing teaching with a client who is scheduled for a barium enema. Which of the following statements should the nurse make? A. "This procedure uses diagnostic imaging to locate an obstruction." B. "You won't be allowed to drink anything for 4 hours following this procedure." C. "You can't have this procedure if you have a history of colon cancer." D. "You will be asked to drink a contrast medium prior to this procedure."

"This procedure uses diagnostic imaging to locate an obstruction." *The nurse should reinforce with the client that a barium enema uses fluoroscopy, which is a type of diagnostic imaging, to locate and identify tumors or other causes of a bowel obstruction.

A school nurse is having a conversation with the parents of an adolescent. The nurse should identify which of the following situations as an ethical dilemma for the parent? A. "We think our child might be involved in a romantic relationship with an adult neighbor." B. "My child never studies, so they must be cheating to make good grades." C. "My child sleeps so much. I think they are probably depressed." D. "We can't decide whether to try to homeschool our child or move them to a private school."

"We can't decide whether to try to homeschool our child or move them to a private school." *The nurse should identify that this statement indicates an ethical dilemma because there are multiple valid solutions that could result in different outcomes.

A nurse is collecting data from a cient who is severe pain. Which of the following questions should the nurse ask first? A. "How have you managed pain in the past?" B. "Does anything make your pain worse?" C. "Where is your pain located?" D. "Is the pain preventing you from performing any activities?"

"Where is your pain located?" *When using the urgent vs. nonurgent approach to collect data from a client who is having acute and severe pain, the nurse should first ask the client about location, severity, and quality to identify appropriate nursing interventions for pain relief. The nurse should collect more detailed data about the client's pain experiences after administering pain medication, when the client's pain level is tolerable.

A nurse is reinforcing teaching with the adult children of a client who is dying. Which of the following statements should the nurse make? A. "You should continue offering your parent fluids until they pass." B. "Your parent will not be able to feel pain when they are nearing death." C. "You can continue talking to your parent until they are gone." D. "Tube feeding should be administered until your parent's death."

"You can continue talking to your parent until they are gone." *The nurse should reinforce with the client's children that hearing is thought to be the last sensory faculty to be lost when a person is dying. The children should be encouraged to keep speaking to their parent.

A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client? A. "You should stimulate both of your nipples for 5 minutes and rest 2 minutes to achieve contractions." B. "You should depress the button on the handheld marker when you feel your baby move." C. "You should lie on your back during the test." D. "You should have nothing to eat or drink throughout the procedure."

"You should depress the button on the handheld marker when you feel your baby move." *The nurse should instruct the client to depress the button on the handheld marker when they feel fetal movement. The nurse will note the mark on the fetal monitor tracing and the provider can review it. This test monitors fetal well-being.

A nurse is reinforcig teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasongraphy the following day. Which of the following statements should the nurse include in the teaching? A. "The doctor will insert a probe into your vagina." B. "The doctor will have to obtain a sample of amniotic fluid." C. "You will have a minimal amount of x-ray exposure." D. "You will need to have a full bladder for the procedure."

"You will need to have a full bladder for the procedure." *A full bladder is necessary because it moves the uterus upward for optimal visualization of the fetus and stabilizes the uterus for optimal reflection of sound waves.

A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching? A. "Stop taking the medication immediately if you experience tingling in your fingers." B. "You can expect the medication to darken your stool." C. "You will need to schedule a bone density test." D. "You should obtain the nasal spray flu vaccine annually."

"You will need to schedule a bone density test." *Long-term use of corticosteroids, such as prednisone, can induce osteoporosis. Therefore, the client should schedule a bone density test to establish a baseline evaluation.

A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions shoud the nurse include in the teaching? A. "You will need to take the medication for the rest of your life." B. "You should withhold the medication if you develop a low heart rate." C. "Take the medication just before bedtime." D. "Take the medication with meals."

"You will need to take the medication for the rest of your life." *Hypothyroidism is a chronic disorder that requires lifelong thyroid hormone replacement therapy.

A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not help me get better." Which of the following resposes should the nurse make? A. "You're saying that you are doubtful that this procedure will benefit you." "B. Do you want to talk to your family before this surgery?" C. "Having a positive outlook will improve your chances for recovery." D. "Why do you feel this surgery will not help you to get better?"

"You're saying that you are doubtful that this procedure will benefit you." *This response uses reflection as a therapeutic technique. This communication technique lets the client know that their concerns and feelings are heard and understood.

A nurse is discussing alopecia with a client who is scheduled to bring chemotherapy. Which of the following statements should the nurse make? A. "If you'd like to wear a wig, you should select it after hair loss occurs." B. "You can expect your hair to start growing back 3 to 4 months after your final treatment." C. "Your oncologist might prescribe a cold cap to wear during treatment to reduce hair loss." D. "When your hair regrows, it will look the same as it did before chemotherapy."

"Your oncologist might prescribe a cold cap to wear during treatment to reduce hair loss." *The nurse should inform the client that cold caps cause vasoconstriction, which can help to decrease hair loss by reducing the ability of the chemotherapy medication to reach the hair follicles.

A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. Which of the following responses should the nurse make? A. "Your weight gain should be the same as for someone without diabetes." B. "Weight gain should be 2 pounds during the first trimester and 2 pounds per week thereafter." C. "Weight reduction during pregnancy is often necessary for clients who have diabetes." D. "Your weight gain should average between 10 and 15 pounds."

"Your weight gain should be the same as for someone without diabetes." *A client who is pregnant and has diabetes mellitus should gain the same amount of weight as a client without diabetes mellitus.

A nurse is reinforcing teaching with a client who has a new diagosis of type 2 diabetes mellitus and inqures about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? select all that apply A. A pharmacist B. Personal testimonial websites C. Package inserts D. Other clients in a diabetes support group E. American Diabetes Association

1. A pharmacist 2. Package inserts 3. American Diabetes Association *A pharmacist is correct. Referring a client to a pharmacist for further information concerning oral antidiabetic agents is acceptable. Pharmacists are qualified to give information regarding medication to clients.Personal testimonial websites is incorrect. Referring a client to personal testimonial websites for further information concerning oral antidiabetic agents is not acceptable. These types of websites can contain information posted by unqualified persons.Package inserts is correct. Referring a client to package inserts for further information concerning oral antidiabetic agents is acceptable. Manufacturing companies are required to print and distribute accurate information regarding medications placed on the market.Other clients in a diabetes support group is incorrect. Referring a client to other clients in a support group for further information concerning oral antidiabetic agents is not acceptable. Members of the support group are not functioning as health care providers and therefore are not qualified to give information.American Diabetes Association is correct. Referring a client to the American Diabetes Association for further information concerning oral antidiabetic agents is acceptable. This organization is recognized as providing accurate, up-to-date information.

A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply.) A. Determine the facts related to the dilemma. B. Identify possible solutions. C. Seek an opinion from a family member. D. Use decisions made in similar situations. E. Consider the client's wishes.

1. Determine the facts related to the dilemma. 2. Identify possible solutions. 3. Consider the client's wishes. *Determine the facts related to the dilemma is correct. The nurse should determine the facts related to the dilemma because this is the first step in the ethical decision-making process. Identify possible solutions is correct. The nurse should identify possible solutions because this is part of the ethical decision-making process. Seek an opinion from a family member is incorrect. The nurse should not seek an opinion from a family member because they might be biased. In addition, the nurse should recognize that discussing the ethical dilemma without the client's permission is a violation of the client's right to confidentiality. Use decisions made in similar situations is incorrect. The nurse should not use decisions made in similar situations because every ethical dilemma is unique and requires individual consideration in decision making. Consider the client's wishes is correct. Within the law, the client's wishes should be honored.

A nurse is reinforcing teaching with a group of clients about the Heimlich maneuver during a first-aid class. The nurse should include in the teaching that which of the following manifestations indicates the need for the Heimlich maneuver to be performed? (Select all that apply.) A. Difficulty breathing B. Coughing C. Erythema D. Presence of stridor E. Thready pulse

1. Difficulty breathing 2. Coughing 3. Presence of stridor *Difficulty breathing is correct. The Heimlich maneuver is performed when the airway is obstructed by a foreign body. A client who has an obstructed airway might exhibit manifestations such as coughing, choking, gagging, difficulty breathing, cyanosis, and stridor. Coughing is correct. The Heimlich maneuver is performed when the airway is obstructed by a foreign body. A client who has an obstructed airway might exhibit manifestations such as coughing, choking, gagging, difficulty breathing, cyanosis, and stridor.Erythema is incorrect. Erythema is not an indication that the Heimlich maneuver is necessary. A client who has an obstructed airway might become cyanotic if the obstruction is not quickly relieved. Presence of stridor is correct. The Heimlich maneuver is performed when the airway is obstructed by a foreign body. A client who has an obstructed airway might exhibit manifestations such as coughing, choking, gagging, difficulty breathing, cyanosis, and stridor.Thready pulse is incorrect. A thready pulse is not an indication that the Heimlich maneuver is necessary. A client who has fluid volume deficit might exhibit a weak, thready pulse.

A nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. A. Cleanse the penis using an antiseptic swab B. Begin urination C. Pass the cup into the urine stream D. Exposethe glans of the penis E. Move the cup out of the urine stream D. Replace the foreskin

1. Expose the glans of the penis 2. Cleanse the penis using an antiseptic swab 3. Begin urination 4. Pass the cup into the urine stream 5. Move the cup out of the urine stream 6. Replace the foreskin

A nurse is preparing to administer metoclopraide 10 mg IM. Available is metoclopramide mg/mL. How many mL should the nurse administer? Round to the nearest whole number.

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A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first? A. A client who requests to be moved to a room closer to the nurses' station B. A client who is postoperative and has received morphine twice during the last 8 hr C. A client whose urinary output was 100 mL for the past 12 hr D. A client who insists on speaking with a provider prior to discharge

A client whose urinary output was 100 mL for the past 12 hr *When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a urine output of less than 30 mL/hr due to the risk for fluid imbalance. Therefore, the nurse should see this client first.

A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention? A. A school-age child who has allergic rhinitis and is taking diphenhydramine B. A toddler who has otitis media and is taking azithromycin C. A preschooler who has heart failure and is taking digoxin D. An adolescent who has asthma and is taking albuterol

A school-age child who has allergic rhinitis and is taking diphenhydramine *The nurse should identify this child as being at risk for urinary retention. Diphenhydramine is an antihistamine used to treat adverse effects of allergic rhinitis. Other adverse effects of diphenhydramine include dry mouth and constipation.

A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client? A. Naloxone B. Diphenhydramine C. Acetylcysteine D. Protamine sulfate

Acetylcysteine *Acetaminophen toxicity can result in liver damage or death and requires treatment with acetylcysteine as an antidote. The nurse should plan to mix the medication with water, juice, or cola and administer an oral dose every 4 hr for up to 72 hr.

A charge nurse on a long-term care unit is preparing to delegate tasks to a licensed practical nurse (LPN) and an asistive personnel (AP). Which of the following tasks should the charge nurse delegate to the LPN? A. Teaching a client who has a new diagnosis of diabetes mellitus how to self-administer insulin B. Creating a plan of care for a newly admitted client C. Obtaining a stool specimen from a client who has ulcerative colitis D. Administering an initial NG tube feeding to a client who had a stroke

Administering an initial NG tube feeding to a client who had a stroke *It is within the LPN's scope of practice to administer an initial NG tube feeding to a client who had a stroke. Because this task requires use of the nursing process, it is outside the range of function for an AP. Therefore, the LPN should expect to be assigned this task.

A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The nurse should instruct the client to use which of the following medications for treatment of an acute asthma attack? A. Zafirlukast B. Montelukast C. Albuterol D. Cromolyn

Albuterol *The nurse should instruct the client to use albuterol, a bronchodilator, to relieve the bronchospasms of an acute asthma attack.

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? A. Allow the weights to hang freely. B. Inspect the skin every 24 hr. C. Remove the weights every 24 hr. D. Assist the client to the bedside commode.

Allow the weights to hang freely. *The nurse should ensure the weights hang freely to provide the appropriate counterweight to facilitate reduction and alignment of the client's fracture.

A nurse is reinforcing teaching with a client who has coronary artery disease (CAD) and is takig a low-dose aspirin daily. The nurse should include that this medication has which of the following therapeutic effects? A. Antiplatelet B. Analgesic C. Antipyretic D. Antiarrhythmic

Antiplatelet *The therapeutic benefits of low-dose aspirin for a client who has CAD include inhibiting platelet aggregation and vasoconstriction, which will decrease the incidence of thrombosis.

A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take? A. Obtain a specimen culture of the amniotic fluid. B. Provide fundal pressure. C. Perform the McRoberts maneuver. D. Apply the external fetal heart rate monitor.

Apply the external fetal heart rate monitor. *The nurse should apply the external fetal heart rate monitor to evaluate the fetal heart rate and well-being. A prolapsed umbilical cord is a possible life-threatening complication for the fetus following rupture of membranes when the presenting part is not engaged in the lower uterine segment.

A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include? A. Adjust the prosthesis for comfort if there is an area of tenderness on the residual limb. B. Sleep with the affected leg elevated so that the hip is flexed. C. Apply the prosthesis immediately upon waking each day. D. Apply unscented lotion to the residual limb after bathing.

Apply the prosthesis immediately upon waking each day. *The nurse should reinforce with the client the importance of applying the prosthesis immediately upon waking to prevent swelling of the residual limb.

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill? A. Rolling the excess length of the stocking to just above the client's knee after application B. Placing the client's legs in a dependent position for 15 min prior to application C. Applying the stockings before the client gets out of bed D. Putting the stockings on the client after lightly massaging their legs

Applying the stockings before the client gets out of bed *The AP should apply antiembolic stockings while the client is in a supine position and before the client gets out of bed. Antiembolic stockings provide pressure to the lower extremities, which promotes venous return and reduces the risk of deep vein thrombosis formation in clients who are immobilized. Allowing the client to ambulate before applying the antiembolic stockings might cause lower extremity edema, making the stockings more difficult to apply.

A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which Of the following actions should the nurse take? A. Pinch the skin between the thumb and forefinger. B. Insert the needle at a 45° angle. C. Pull back on the plunger before injecting the vaccine. D. Avoid massaging the site after injecting the vaccine.

Avoid massaging the site after injecting the vaccine. *The nurse should not massage the site following an intradermal injection because this can spread the vaccine into the tissue or out through the needle insertion site.

A nurse is checking a newborn's vital signs. Which of the following methods of temperature measurement should the nurse use? A. Rectal B. Axillary C. Temporal D. Tympanic

Axillary *The nurse should obtain the newborn's temperature using the axillary method because this method is accurate and safe for newborns. Axillary temperatures are expected to range from 36.5º to 37.5º C (97.7º to 99.5º F) in newborns.

A nurse is reinforcing teaching with a client who has leftsided weakness and is learing how to ambulate with a cane. The nurse should identify that the client understands the twaching when the client places the cane in which of the following positions when advancing forward? A. left side B. right side

B. right side *A is incorrect. The client who has left-sided weakness and is learning how to ambulate with a cane should hold the cane on the stronger side of the body; in this scenario, it would be in the right hand.B is correct. The client should hold the cane on the stronger side of the body; in this scenario, it would be in the right hand. When ambulating forward, the client should move the cane forward first (in front of right foot) and then advance the weaker leg forward next so that the client's body weight is evenly distributed between the cane and stronger leg.

A nurse is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer? *Consumes a 2 g sodium diet. ; walks three times per week *Age: 45 years; BMI: 33 *Two episodes of cholecystitis in the past 12 months; Knee arthroplasty 3 years ago A. History of cholecystitis B. BMI C. Diet D. Age

BMI *The client's BMI of 33 indicates obesity, which increases the client's risk for colorectal cancer. Risk factors for colorectal cancer include high consumption of alcohol, tobacco use, a diet high in saturated fat that includes a high intake of red meat, being over 50 years of age, a family history of colon cancer or polyps, and a history of gastrectomy or inflammatory bowel disease.

A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the following foods should the nurse include in the plan as having the highest amount of iron? A. Cooked cabbage B. Plain yogurt C. Cooked white rice D. Boiled spinach

Boiled spinach *The nurse should determine that boiled spinach is the best food source to include in the plan because boiled spinach contains 6.43 mg of iron per cup.

A nurse is collecting data from a client who has a newly applied cast to the righ lower extremity. Which of the following findings should the nurse expect? A. Numbness in the client's toes B. Coolness of the skin distal to the cast C. Area of increased warmth on the cast D. Capillary refill of 5 seconds to the client's toes

Capillary refill of 5 seconds to the client's toes *A capillary refill of 3 to 5 seconds to the client's toes is an expected finding and indicates adequate circulation in the casted extremity.

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective? A. Blood volume increases B. Heart rate increases C. Cardiac workload decreases D. Urinary output decreases

Cardiac workload decreases *Digoxin reduces the effects of heart failure and improves cardiac output by improving the conduction of the heart. This action allows the heart to work less to provide adequate perfusion, reducing the overall oxygen demand on the heart.

A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include? A. Empty the pouch when it is three-fourths full. B. Change the appliance two times each week. C. Cleanse the stoma with hydrogen peroxide solution. D. Irrigate the pouch every 3 days with 250 mL of cold tap water.

Change the appliance two times each week. *The nurse should change the appliance two times each week to maintain an effective seal around the stoma. The nurse should remove the appliance carefully and cleanse the client's stoma.

A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first? A. Provide a warm saline gargle. B. Check for a gag reflex. C. Offer clear liquids to drink. D. Administer a throat lozenge.

Check for a gag reflex. *The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse should take is to check for a gag reflex.

A nurse is reinforcing teaching with a client who has fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving? A. Chopped carrots B. Green grapes C. Chopped broccoli D. Cherry tomatoes

Cherry tomatoes *The nurse should include cherry tomatoes in the teaching because they contain 141 g of water per 1 cup serving.

A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client? A. Methadone B. Varenicline C. Chlordiazepoxide D. Bupropion

Chlordiazepoxide *The nurse should expect to administer chlordiazepoxide to decrease anxiety and the risk for seizures associated with alcohol withdrawal.

A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure? A. Glasgow Coma Scale score of 15 B. Headache when lying down C. Confusion about knowing their own name D. Tympanic temperature of 37.6° C (99.68° F)

Confusion about knowing their own name *Confusion is a sign of a decreased level of consciousness and is an indication of increased intracranial pressure.

A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods? A. Transfusion with infected blood B. Consumption of contaminated food C. Sharing of needles and syringes D. Transmission from an infected mother to the fetus

Consumption of contaminated food *The nurse should include that hepatitis A is spread via the fecal-oral route through direct contact with stool or consumption of contaminated food and water.

A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider? A. An inguinal bulge when coughing B. Decreased bowel sounds C. Swelling of the left groin area D. Tenderness in the scrotum

Decreased bowel sounds *The greatest risk to this client is bowel necrosis or perforation due to bowel obstruction or strangulation. This is a surgical emergency. Therefore, decreased bowel sounds are the priority finding to report to the provider.

A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching? A. Demonstrate assertiveness. B. Refrain from engaging in power struggles. C. Permit expression of rituals. D. Avoid crowded environments.

Demonstrate assertiveness. *Clients who have dependent personality disorder demonstrate fear of separation and abandonment. Therefore, reinforcing assertive behaviors will allow the client to become more independent.

A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first? A. Talk to the client about developing a family support system. B. Assist the client to develop attainable, short-term goals. C. Reinforce teaching with the client about how to care for a surgical wound. D. Determine the client's mobility status.

Determine the client's mobility status. *The first action the nurse should take when using the nursing process is to determine the client's mobility status. The nurse should begin collecting data about the client's ability to move freely within their environment while preventing injury. The nurse should begin by placing the client in the position providing the most support, then moving in increments to positions requiring less support and higher levels of tolerance.

A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect? A. Bradycardia B. Decreased respiratory rate C. Pink mucous membranes D. Difficulty concentrating

Difficulty concentrating *In clients who have iron deficiency anemia, body cells do not receive the required oxygen because there is less hemoglobin for binding. The nurse should recognize that impaired oxygenation of brain tissue can lead to dizziness and difficulty concentrating.

A nurse manager is preparing to complete a performance analysis for a group of assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the following actions should the staff nurse take? A. Limit comments to information about each AP's performance in the last month. B. Focus the feedback on the strengths of each AP. C. Compare the AP to each other when describing their behaviors. D. Discuss how each AP's actions measure against the job description.

Discuss how each AP's actions measure against the job description. *To provide objective information, the staff nurse should compare the behavior of each AP to the facility job description. The nurse can provide specific information about how each AP either meets the standard or demonstrates a need for improvement.

A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take? A. Delegate the clients' oral care to another AP. B. Have the AP sign a written warning immediately. C. Discuss this behavior with the AP while reinforcing expectations. D. Suspend the AP for 3 days pending further investigation.

Discuss this behavior with the AP while reinforcing expectations. *The charge nurse should discuss this behavior with the AP and reinforce expectations moving forward. Evaluation of the AP's performance is a part of the nurse's delegation process. Teaching and counseling the AP about behaviors and expectations is an important component of leadership.

A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question? A. Dosage B. Time C. Route D. Medication

Dosage *The nurse should question the client about the actual prescribed dosage of the medication to ensure proper medication reconciliation. While the client has stated the amount taken, they have not specified the medication strength of the liquid.

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse include? A. Limit carbohydrates early in the day. B. Practice relaxation techniques. C. Eat a bedtime snack. D. Increase daily exercise.

Eat a bedtime snack *The symptoms described by the client indicate hypoglycemia. Eating a snack at bedtime will help prevent hypoglycemic episodes during the night.

A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take? A. Ensure the injection produces a wheal on the skin. B. Insert the needle at a 45° angle. C. Inject with the bevel of the needle pointing down. D. Aspirate the syringe prior to injecting the medication.

Ensure the injection produces a wheal on the skin. *The nurse should ensure that the injection of the PPD produces a wheal, or bleb, on the skin. This indicates the medication has been injected into the dermis of the skin.

A nurse is working with an interpreter to assist the provider with explaining a diagnostic procedure to a client who speaks a different language with the nurse. Which of the following actions should the nurse take? A. Speak in a loud tone to the interpreter. B. Ensure the interpreter is culturally compatible with the client. C. Use technical terms when explaining the procedure. D. Make eye contact with the interpreter when explaining the procedure.

Ensure the interpreter is culturally compatible with the client. *The nurse should ensure that the interpreter and client speak the same dialect and share similar cultural norms and practices.

A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include? A. Administer diphenhydramine at bedtime. B. Increase the bedroom's temperature to 26.7º C (80º F). C. Establish a regular exercise routine 2 hr or more before bedtime. D. Turn on the television in the bedroom at bedtime.

Establish a regular exercise routine 2 hr or more before bedtime. *The nurse should include in the plan to engage the client in moderate exercise activities during the day but at least 2 hr prior to bedtime to help promote a deep, restful sleep.

A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects? A. Hypoglycemia B. Dehydration C. Gastric ulcer formation D. Unexpected weight loss

Gastric ulcer formation *The nurse should monitor the client for indications of a gastric ulcer formation, which is a common adverse effect of prednisone.

A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommed for preparing a home disaster supply kit? A. Buy and freeze extra portions of lean meat. B. Stock enough supplies for 2 days per person. C. Have a supply of prescribed medications. D. Store 1,920 mL (65 oz) of water per person per day.

Have a supply of prescribed medications. *In a disaster situation, it could be difficult to obtain additional prescribed medication. Therefore, the nurse should recommend clients have a backup supply of prescribed medications to prevent a potentially harmful interruption in dosing.

A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider? A. Height 103 cm (40.5 in) B. Heart rate 146/min C. Tympanic temperature 37° C (98.6° F) D. Weight 16.5 kg (36.5 lb)

Heart rate 146/min *The nurse should identify that a heart rate of 146/min is above the expected reference range for a preschooler. Therefore, the nurse should report this finding to the provider.

A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula? A. Distilled water B. Dakin's solution C. Povidone-iodine 1% D. Hydrogen peroxide

Hydrogen peroxide *The nurse should identify that sterile hydrogen peroxide solution is used to loosen secretions from the inner cannula during cleansing. If the client's skin becomes irritated, the nurse should choose 9% sodium chloride solution.

A nurse is assisting with the admission of a client who has a latex allergy. The nurse should identify that which of the following supplies has the potential to contain latex? A. Indwelling urinary catheter B. Paper tape C. Nitrile gloves D. Gauze dressings

Indwelling urinary catheter *The nurse should identify that most indwelling urinary catheters are made of rubber, which is a form of latex. A rubber indwelling urinary catheter should not be used for a client who has a latex allergy. The nurse should obtain an indwelling urinary catheter made of silicone for a client who has a latex allergy.

A nurse is preparing to administer a medication to a client. The client states, "I'm sick of all these medications, and I'm not taking any more today!" Which of the following actions should the nurse take? A. Wait for the client's family to visit to administer the medication. B. Complete an incident report about the client's medication refusal. C. Administer the medication via an alternate route. D. Inform the client of the possible consequences of the medication refusal.

Inform the client of the possible consequences of the medication refusal. *The nurse's role is to ensure that the client is fully informed of the potential consequences of refusing medications.

A nurse in a long-term care facility is assisting with an inservice for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault? A. Telling another nurse rumors about a client newly admitted to the unit B. Informing a client that the nurse is going to administer an injection even though the client refuses C. Telling a clergy member that one of their church members has been admitted to the facility without the client's permission D. Placing a restraint on a client to keep them in bed before trying alternative measures

Informing a client that the nurse is going to administer an injection even though the client refuses *This is an example of assault, which is the threat of unlawful touching of an individual. The nurse should respect the client's right to refuse treatment and not administer an injection against the client's wishes.

A nurse is administering lorazepam to a client who is scheduled for surgery withing 1 hr. Which of the following actions should the nurse take after administering the medication? A. Instruct the client not to get out of the bed. B. Ensure that the informed consent form has been signed. C. Instruct the client to void prior to being transported to surgery. D. Reinforce teaching about deep breathing exercises.

Instruct the client not to get out of the bed. *Lorazepam causes sedation, placing the client at risk for injury due to falling. Therefore, the nurse should instruct the client not to get out of bed.

A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead ECG. Which f the following actions should the nurse include in the plan of care? A. Place the client in Sims' position. B. Put chest electrodes on the client's breast. C. Instruct the client to remain still while the test is performed. D. Cleanse the client's skin with povidone-iodine prior to electrode placement.

Instruct the client to remain still while the test is performed. *The nurse should instruct the client to remain still to prevent artifacts and a potentially inaccurate interpretation of the ECG.

A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago and has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend? A. Instruct the client to apply perineal pads from back to front. B. Administer a suppository to alleviate constipation. C. Encourage the client to sit on an inflatable donut cushion. D. Instruct the client to use a sitz bath at least twice a day.

Instruct the client to use a sitz bath at least twice a day. *The nurse should instruct the client to use a sitz bath for at least 20 min twice per day. For the first 24 hr following delivery, the sitz bath should contain cool water to reduce edema and pain. After 24 hr following delivery, the sitz bath should contain warm water to promote circulation and reduce pain.

A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include? A. Discontinue the urinary catheter 24 hr after surgery. B. Adjust the bladder irrigation to keep the urine a bright yellow color. C. Use 50 mL of sterile water to clear the urinary catheter of obstruction. D. Irrigate the bladder using sterile technique.

Irrigate the bladder using sterile technique. *The nurse should irrigate the bladder using strict sterile technique and maintain the closed catheter drainage system to minimize the risk of infection.

A nurse is collecting data from a newly-admitted infant who i s3 months old and has diarrhea. Which of the following findings should the nurse report to the provider? A. Irritability B. Flat anterior fontanel C. Heart rate 160/min D. Respiratory rate 30/min

Irritability *An infant who has hypovolemia will experience irritability due to decreased perfusion. The nurse should report this finding to the provider.

A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority? A. Pressured speech B. Flight of ideas C. Poor concentration D. Lack of sleep

Lack of sleep *The greatest risk for this client is exhaustion or death from lack of sleep; therefore, this is the priority finding. The nurse should encourage frequent periods of rest for the client throughout the day.

A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer? A. Tuna B. Lamb C. Chicken D. Turkey

Lamb *Increased consumption of red meats, such as beef or lamb, can increase the risk for cancer. The nurse should instruct the client to limit their consumption of lamb.

A nurse is positioning a client who is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions? A. Semi-Fowler's B. Lateral recumbent C. Reverse Trendelenburg D. Prone

Lateral recumbent *The nurse should assist the client into the lateral recumbent position for a lumbar puncture to ensure the proper placement of the needle.

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return? A. Encourage the client to cough and deep breathe. B. Maintain a sequential compression device. C. Elevate the head of the bed. D. Massage the client's legs.

Maintain a sequential compression device. *Sequential compression devices promote venous return by providing intermittent periods of compression on the legs.

A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include? A. Maintain the drainage system below the level of the client's chest. B. Reposition the client every 4 hr. C. Report drainage greater than 30 mL/hr to the provider. D. Clamp the drainage system when transporting the client.

Maintain the drainage system below the level of the client's chest. *The nurse should maintain the drainage system below the level of the client's chest to prevent the backflow of secretions and water from the system into the chest cavity.

A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse? A. Alprazolam 0.5 mg PO QHS for sleep B. Regular insulin 10 U SC at 0800 C. Docusate sodium 250 mg PO QOD ​D. Potassium chloride 20 mEq PO every morning

Potassium chloride 20 mEq PO every morning *This prescription is accurately transcribed by the nurse and does not include any error-prone abbreviations.

A nurse is preparing to administer medication to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider? A. Clopidogrel 75 mg per NG tube daily B. Metoprolol ER 50 mg per NG tube BID C. Levetiracetam 500 mg oral solution per NG tube BID D. Lovastatin 20 mg per NG tube daily

Metoprolol ER 50 mg per NG tube BID *The nurse should clarify the prescription for metoprolol ER with the provider because it is an extended-release tablet. The nurse should not crush extended-release medication because parts of the medication dissolve at variable rates and the client can receive an overdose of the medication in a short period of time.

A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy? A. Bulging fontanel B. Capillary refill 6 seconds C. Moist mucous membranes D. Slow bounding pulse

Moist mucous membranes *The condition of mucous membranes is an indicator of hydration status. Moist mucous membranes indicate adequate hydration and a positive response to IV fluid therapy.

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect? A. Hypertension B. Increased appetite C. Diarrhea D. Muscle weakness

Muscle weakness *The nurse should expect a client who has hypokalemia to have bilateral muscle weakness. Other manifestations of hypokalemia include hyporeflexia, muscle stiffness, cramping, and paralysis.

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? A. Administering a rectal suppository to a client B. Evaluating a client's use of an assistive walking device C. Obtaining a client's vital signs prior to discharge D. Reinforcing teaching with a client on how to perform finger stick blood glucose testing

Obtaining a client's vital signs prior to discharge *Obtaining vital signs does not require use of the nursing process and is within the range of function for an AP. Therefore, the nurse should delegate this task to the AP.

A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship witg tge client? A. Giving approval B. Changing the subject C. Providing personal advice D. Offering general leads

Offering general leads *Offering general leads is therapeutic and will enhance positive interaction with the client because it demonstrates to the client that the nurse is listening and is interested in what the client is sharing.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? A. Open the outer package flap of the catheterization kit away from their body. B. Place the tip of the catheter 1.3 cm (0.5 in) from the outer edge of the sterile field. C. Remove their nondominant hand from the labia prior to inserting the catheter. D. Apply the lubricating jelly into the catheter tray before donning sterile gloves.

Open the outer package flap of the catheterization kit away from their body. *The nurse should open the outer package flap of the catheterization kit away from their body to prevent their arm from crossing over the sterile field when opening the remaining flaps.

A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first? A. Obtain a CBC from the client. B. Perform a fundal massage for the client. C. Have the client empty their bladder. D. Administer carboprost to the client.

Perform a fundal massage for the client. *The least invasive and fastest way to stimulate uterine contractions to help control bleeding is to perform a fundal massage. Therefore, this is the first action the nurse should take.

A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include? A. Place the client in a 30° lateral position. B. Limit time spent sitting in a chair to 4 hr at a time. C. Cleanse the client's skin twice daily with soap and hot water. D. Massage inflamed areas over bony prominences every 2 hr.

Place the client in a 30° lateral position. *The nurse should place the client in a 30° lateral position to alleviate pressure over bony prominences.

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take? A. Perform Leopold maneuvers on the client. B. Place the client in a lateral position. C. Administer oxygen at 2 L/min via nonrebreather mask. D. Assist with an amnioinfusion.

Place the client in a lateral position. *Late decelerations occur due to utero-placental insufficiency. The nurse should assist the client into a lateral position to improve uterine perfusion and oxygen transfer to the fetus.

A nurse is transferring a client from a bed to a wheelchair. The client has right-sided weakness following a recent stroke. Which of the following actions should the nurse take? A. Position the wheelchair facing the client's bed. B. Place the wheelchair on the client's left side. C. Stand with feet side by side. D. Stand at or even with the client's left side during the transfer.

Place the wheelchair on the client's left side. *The nurse should place the wheelchair on the client's stronger side to reduce the risk of falling.

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider? A. Platelet count 95,000 mm3 B. BUN 15 mg/dL C. Hgb 11.3 g/dL D. WBC count 10,000/mm3

Platelet count 95,000 mm3 *The nurse should recognize that this platelet count is below the expected reference range for a client who is pregnant and might be indicative of HELLP syndrome. Other manifestations of HELLP syndrome include malaise and epigastric pain. The nurse should immediately notify the provider of this result.

A nurse is preparing to discharge a client who is immunocompromised. Which of the following vaccines should the nurse plan to administer? A. Measles, mumps, and rubella (MMR) B. Pneumococcal polysaccharide (PPSV) C. Varicella D. Herpes zoster

Pneumococcal polysaccharide (PPSV) *The PPSV vaccine is recommended at the time of discharge for a client who is immunocompromised.

A community health nurse is helping to reinforce teachng about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants? A. Presence of anxiety B. Developmental ability C. Poor lighting in the learning setting D. Reduced belief in the ability to learn

Poor lighting in the learning setting *The nurse should recognize that the physical learning setting is an external factor that can affect the participants' learning ability. Environmental factors that affect learning include lighting, comfort of seating, and the temperature of the room.

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse recommend? A. Perform oral care once every 12 hr. B. Position the head of the bed at a 30° angle. C. Deactivate alarms during suctioning. D. Instruct the client to avoid coughing.

Position the head of the bed at a 30° angle. *The nurse should elevate the head of the bed to a 30° to 45° angle to reduce the risk of ventilator-acquired pneumonia.

A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take? A. dminister the insulin injection. B. Wipe the needle with an antiseptic swab. C. Transfer the insulin to a new syringe. D. Prepare a new dose of insulin for injection.

Prepare a new dose of insulin for injection. *Insulin is administered using an insulin syringe with a preattached needle. Therefore, to ensure the sterility of the needle, the nurse should prepare a new dose of insulin for injection using a new syringe and new dose of insulin.

A nurse is receiving change-of-report for a group of clients. The nurse should plan to implement which of the following time-management strategies? A. Document medication administration within 1 hr of completion. B. Prepare a priority list of client needs for the shift. C. Ask an assistive personnel (AP) to check the dressings of postoperative clients. D. Save important tasks for the last hour of the workday.

Prepare a priority list of client needs for the shift. *The nurse should prepare a client priority to-do list, which could include administering time-critical medications. This will allow the nurse to determine which clients should receive care first.

A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which Of the following information should the nurse include? A. Older adults are resistant to pathogens that cause infections. B. Use alcohol-based antiseptic hand cleansers after caring for clients who have Clostridium difficile. C. Prolonged use of corticosteroids is a risk factor for infection. D. Blood pressure cuffs can be a source of endogenous infections.

Prolonged use of corticosteroids is a risk factor for infection. *Prolonged use of corticosteroids places the client at risk for a health care-associated infection.

A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following methods should the nurse use when communicating with the client? A. Ask open-ended questions. B. Speak slowly with a raised voice. C. Provide a picture board. D. Limit the use of gestures.

Provide a picture board. *A client who has expressive aphasia has difficulty expressing needs or wants through verbalization or writing. The use of a picture board provides an alternative means of communication that might be less frustrating for the client.

A nurse manager is providing an in-service on hand hygiene to assistive personnel. Which of the following information should the nurse manager include in the in-service? A. Keep artificial nails well-trimmed. B. Rub hands together for 10 seconds when using an alcohol-based hand rub. C. Perform hand hygiene with antiseptic hand rub when hands are visibly soiled. D. Remove rings when washing hands with soap and water.

Remove rings when washing hands with soap and water. *Removing rings and jewelry while washing hands is recommended to allow for proper cleaning of the hands.

A nurse notices an assistive personnel (AP) taking a nap in the break during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take? A. Keep a record of the AP's behavior over a period of time. B. Report the observations about the AP to the unit's nurse manager. C. Ask another unit staff member if they have observed the same behavior. D. Determine if the AP is having problems at home.

Report the observations about the AP to the unit's nurse manager. *The nurse should report their observations to the unit's nurse manager because they have a duty to report any behavior that poses a risk to client safety.

A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take? A. Interview the child with the parents in the room. B. Ask the provider to talk to the child and parents. C. Make a note in the chart to check the child during the next visit. D. Report the suspected abuse to the appropriate agency.

Report the suspected abuse to the appropriate agency. *It is the nurse's legal and professional responsibility to immediately report suspected abuse to the proper child protective service agency.

A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis (CF). Which of the following findings is the priority for the nurse to report to the provider? A. Reports lack of appetite B. Frothy stools with a foul odor C. Height at the 55th percentile for age and gender D. Report of gastroesophageal reflux

Reports lack of appetite *The nurse should identify that the greatest risk to a child who has a decreased appetite is pulmonary infection. Anorexia, along with other manifestations, such as loss of weight and lethargy, are commonly seen in children who have CF with an infection exacerbation. Typical manifestations of pulmonary infection, such as fever and tachypnea, might not be seen in a child who has CF. Additionally, a child who is anorexic is at increased risk for diminished lung function.

A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include? A. Maintain a warm compress on the affected eye at bedtime. B. Clean the eye from the outer to the inner canthus. C. Separate the child's used washcloth from those of others. D. Instill ointment in the child's affected eye each morning.

Separate the child's used washcloth from those of others. *Due to the contagious nature of the infection, it is necessary to separate the washcloth of a child who has conjunctivitis from those of others to prevent the spread of infection.

A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene? A. The AP documents morning care in the client's electronic health record at the bedside. B. The AP writes their own name on the client's message board in the room. C. The AP instructs the client to void prior to obtaining a daily weight. D. The AP reports client information to the oncoming AP in the hallway.

The AP reports client information to the oncoming AP in the hallway. *The nurse should intervene when observing the AP reporting client information in the hallway because it is a breach of client confidentiality.

A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characterisitics increases a child's risk of physical maltreatment? A. The child has 2 parents in the home B. The child is 13 years old C. The child has guardians who are unemployed D. The child was born at 34 weeks of gestation

The child was born at 34 weeks of gestation *The nurse should identify that children born prematurely are at an increased risk for physical maltreatment. This increased risk is due to possible impairment of bonding during infancy and an increased need for care due to medical concerns as a result of their premature delivery.

A nurse is reinforcing teaching with a client about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching? A. The client attempts to elevate the cylinder by inhaling deeply. B. The client attempts to elevate the cylinder by exhaling forcefully. C. The client assumes the orthopnea position. D. The client assumes the low-Fowler's position.

The client attempts to elevate the cylinder by inhaling deeply. *This is the correct action by the client. The cylinder should be elevated by the client inhaling deeply.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which of the following findings should the nurse notify the provider? A. The client has absent bowel sounds. B. The client is unable to sit for long periods of time. C. The client's incision is draining serous fluid. D. The client reports loss of appetite due to pain.

The client has absent bowel sounds. *Absence of bowel sounds can indicate absence of peristalsis, which is a manifestation of an ileus. The nurse should report this finding to the provider for reconsideration of the diet prescription.

A nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality? A. Staff at the facility worked 23% more overtime than in the previous year. B. The facility increased nurse-to-patient ratio by 1 resident per nurse over the past month. C. The facility had 12% fewer urinary tract infections over the past 6 months. D. Central supply ordered twice the number of dressing supplies than the prior year.

The facility had 12% fewer urinary tract infections over the past 6 months. *Quality improvement relates to improving outcomes for clients, staff, or the facility. The nurse should document a reduction in urinary tract infections as an improvement in care quality.

A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report? A. The nurse administered enalapril to a client who has a blood pressure of 162/90 mm Hg B. A client who received morphine for postoperative pain becomes somnolent C. The nurse administered insuling lispro to a client who has diabets mellitus and is NPO D. The nurse administered heparin to a client who has an aPTT of 60 seconds

The nurse administered insuling lispro to a client who has diabets mellitus and is NPO *Lispro is a rapid-acting insulin given with or just after meals because the onset of action is 15 to 30 min after administration. A client who is NPO will not receive a meal and can have a potentially serious drop in blood glucose levels. Therefore, the nurse should complete an incident report after ensuring the safety of the client and notifying the client's provider.

A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take? A.Place an N95 filter mask on the client during transport. B. Wear a surgical mask within 3 feet of the client. C. Remove fresh fruit from the client's room. D. Put on a gown when entering the client's room.

Wear a surgical mask within 3 feet of the client. *The nurse should wear a surgical mask within 3 feet of the client to prevent exposure to meningitis.

A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task? A. Water-soluble lubricant B. Yankauer catheter C. Chlorhexidine gluconate D. Artificial oral airway

Yankauer catheter *A Yankauer catheter is a clean suction catheter used when performing oral and oropharyngeal suctioning to remove secretions from the client's mouth to facilitate breathing or obtain a sample for diagnostic evaluation.

A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration? A. Haloperidol B. Lorazepam C. Zolpidem D. Alprazolam

Zolpidem *Zolpidem is a sedative-hypnotic medication used to treat insomnia. It is not indicated for treatment of confusion and aggressive behavior. Zolpidem can cause agitation and should be used with caution for clients who have a history of mental illness. Therefore, the nurse should clarify this prescription with the provider prior to administration.

A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. The nurse should report which of the following to the provider after hearing this sound? A. Pleural rub B. Vesicular C. Wheezes D. Fine crackles

fine crackles *Fine crackles are high-pitched popping sounds often caused by pulmonary edema, which can be a complication of heart failure.