Davis Advantage Study
Which statements by a nurse are correct when preventing needlesticks and blood exposure? Select all that apply. "I always place my used needles into a puncture-proof, labeled container." "I always recap my used insulin needles before disposing of them." "I confirm that the sharps container is not overfilled before placing the syringe inside." "It is okay to hand pass sharps if both people in the exchange are wearing gloves." "I only recap with a needle guard when available."
"I always place my used needles into a puncture-proof, labeled container." "I confirm that the sharps container is not overfilled before placing the syringe inside." "I only recap with a needle guard when available."
The home care nurse visits a client who wears oxygen at bedtime. She smells cigarette smoke when entering the home. What should she say to the client? "That's a strange smell; I wonder what it could be." "It smells like someone has been smoking in here. Do you realize that oxygen supports combustion?" "Have you been wearing your oxygen, or is it turned off?" "Have you been smoking? You shouldn't with oxygen present."
"It smells like someone has been smoking in here. Do you realize that oxygen supports combustion?"
The nurse is seeing a teenage client with a urinary tract infection (UTI) at the clinic. The client remarks, "It seems to me more women get urinary infections than men. Why is this?" What is the nurse's best response? "Because women are more sexually active than men, they are at higher risk for infections." "Men have a prostate gland that protects them against urinary tract infections." "The female urethra is shorter than that of the male, making women more prone to infections." "Pressure of the uterus on the bladder during pregnancy can make women more prone to UTIs."
"The female urethra is shorter than that of the male, making women more prone to infections."
Which objective measures can a nurse use to assess a person's dietary history. Select all that apply. Measure body composition Ask about diet 3-day food record diary Food questionnaire 24-hour memory recall
3-day food record diary Food questionnaire 24-hour memory recall
A nurse is teaching wellness to a church group. How many daily 8-ounce servings of water should be encouraged for normal bowel health? 4 to 6 servings 6 to 8 servings 8 to 10 servings 10 to 12 servings
6 to 8 servings
Which client would be at the highest risk for developing sensory deprivation? A client with quadriplegia on bedrest A client who wears corrective contact lenses A client who speaks English as a second language A client who has no visitors
A client with quadriplegia on bedrest
Which statements about bed making are correct? Select all that apply. - When making an occupied bed, the rails should be up on the side where the nurse is working. - Making the bed in a hospital is like making a bed at home. - A poorly made bed can contribute to the development of pressure ulcers. - Draw sheets are used to help lift and turn heavier patients. - The bed linens should be changed before the bath occurs.
A poorly made bed can contribute to the development of pressure ulcers. Draw sheets are used to help lift and turn heavier patients.
A client is admitted to the hospital with bloody sputum and night sweats, signs of tuberculosis. Which precautions must the nurse institute immediately? - Droplet - Airborne - Contact - Protective
Airborne
A child has an inflamed epiglottis from a viral infection, causing stridor and partially blocking the flow of air. Which type of breathing problem is present? Altered airway Altered breathing pattern Altered gas exchange Altered infection
Altered airway
A nursing unit is receiving report for five clients being newly admitted. Which client is at the highest risk for injury and best to place close to the nurse's station? A 9-year-old child who is tearful A 16-year-old adolescent who is depressed A 62-year-old patient who is anxious An 87-year-old patient who is confused
An 87-year-old patient who is confused
The nurse is about to move a client who is large and unsteady from the bed to a chair. Which actions should the nurse take? Select all that apply. Use a narrow base stance of support. Apply a lift belt. Get additional help. Clear area of obstacles. Place client in restraints.
Apply a lift belt. Get additional help. Clear area of obstacles.
How should the nurse deliver the breakfast tray to the bedside of a client in airborne isolation? - Place the tray on the table just inside the client's door. - Apply gloves and place the tray on the client's nightstand. - Apply respirator mask and gloves, then place the tray on the client's nightstand. - Set the tray outside the client's room.
Apply respirator mask and gloves, then place the tray on the client's nightstand.
The nurse is caring for a client who has recently migrated to this country. The interpreter shares that the client usually bathes once a week. When your assessment is finished, the nurse plans to have the client shower. What additional information needs to be gathered? Explain the importance of showering daily. Tell the client the shower schedule for patients of the facility. Ask about hygiene customs in the client's native land. Find out when the client last bathed.
Ask about hygiene customs in the client's native land.
The nurse is bathing a client with a raised red rash on the shoulders and back. What should be the nurse's next actions? Select all that apply. - Discuss the body image problems created by the presence of the rash. - Moisturize the skin to prevent drying. - Assess for further inflammatory reactions. - Wash the skin thoroughly each day with hot water and soap. - Ask whether the client has any allergies.
Assess for further inflammatory reactions. Ask whether the client has any allergies.
What are the parts of a comprehensive nutritional assessment? Select all that apply. Body composition Physical assessment Laboratory findings Body surface area Dietary history
Body composition Physical assessment Laboratory findings Dietary history
Mandy is collecting a urinary history for an older adult client admitted to the hospital with renal insufficiency and a urinary tract infection. What should be included in the questioning? Select all that apply. Dietary intake Changes in urinary habits History of urinary infection Frequency of urination Fluid intake
Changes in urinary habits History of urinary infection Frequency of urination Fluid intake
The nurse is reviewing the medical record of a client who has not had a bowel movement for 3 days. What factors are concerning? Select all that apply. Client has not eaten for 48 hours. Client is on bedrest. Client is receiving an iron supplement. Client is in a semiprivate room. Client took a laxative prior to hospitalization.
Client has not eaten for 48 hours. Client is on bedrest. Client is receiving an iron supplement. Client is in a semiprivate room. Client took a laxative prior to hospitalization.
For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take? Closely assess for nonverbal signs such as grimacing or rocking. Obtain baseline behavioral indicators from family members. Look at the medication record and chart to note the time of the last dose and response. Give the maximum dose ordered within the minimum time frame for relief.
Closely assess for nonverbal signs such as grimacing or rocking.
The nurse is preparing to give a bath to an older adult who is unconscious and has had a fever and night sweats. Which type of bath would be the best option? - Complete bed bath - Assist bath - Partial bath - Tub bath
Complete bed bath
The nurse is teaching a patient about the importance of reducing saturated fats in a cardiac diet. Which oils should the nurse recommend as options? Select all that apply. Palm oil Coconut oil Cottonseed oil Peanut oil Olive oil
Cottonseed oil Peanut oil Olive oil
The nurse is caring for an older adult who is hearing impaired and cannot wear his glasses because they are broken. What interventions would be appropriate? Select all that apply. Explain things before performing them. Talk in a quiet tone of voice. Speak slowly, articulating clearly. Validate understanding of verbal communication. Ask whether he has a "good ear."
Explain things before performing them. Speak slowly, articulating clearly. Validate understanding of verbal communication. Ask whether he has a "good ear."
Which pain scales are used to determine a client's level of pain? Select all that apply. OPQRST-AAA FACES Visual analog scale Numeric The intensity word scale
FACES Visual analog scale Numeric
Elenore is an older adult who lives alone and has fallen and fractured her hip. She cannot get to the phone to call for help. Her pain worsens as time passes and she becomes confused as she waits for someone to find her. What factors are exacerbating the situation? Select all that apply. Fear Helplessness Cognitive impairment Need to be independent Hunger
Fear Helplessness Cognitive impairment
Which diagnostic tests provide direct visualization of the intestinal tract? Select all that apply. Barium enema Fecal occult blood Anterior flat plate Fiberoptic colonoscopy Esophagastroduodenoscopy
Fiberoptic colonoscopy Esophagastroduodenoscopy
The nurse asks the unlicensed assistive personnel to complete morning care for an older adult. What is included with this request? Select all that apply. - Back massage - Hair care - Bathing - Toileting - Oral care
Hair care Bathing Toileting Oral care
Which objects are at greatest risk for infection transfer in the healthcare environment? Select all that apply. - Healthcare workers - Artificial fingernails - Vital sign equipment - Dietary trays - Public restrooms
Healthcare workers Artificial fingernails Vital sign equipment
The nurse is preparing for heat and cold application. Which of the following statements are true? Select all that apply. Heat/cold devices can cause superficial tissue damage. Heat/cold devices should never come in direct contact with the skin. Heat/cold devices are safe to use for all clients. Heat/cold devices should be used intermittently. Heat/cold devices should be in place for 30 minutes at a time.
Heat/cold devices can cause superficial tissue damage. Heat/cold devices should never come in direct contact with the skin. Heat/cold devices should be used intermittently.
The nurse is evaluating a urinalysis for a client. Which items can be found on this report? Select all that apply. Hemoglobin Potassium Protein Glucose Bilirubin
Hemoglobin Protein Glucose Bilirubin
The nurse is caring for a patient experiencing dyspnea. Which position would be most effective to support ventilation? Supine High Fowler's Low Fowler's Side-lying
High Fowler's
The nurse is caring for a client with untreated prolonged pain sustained in an automobile accident. Which assessment findings could result from the pain? Select all that apply. Increased urine output Hypertension Fever Nausea and vomiting Atelectasis
Hypertension Fever Nausea and vomiting Atelectasis
The nurse is teaching a group of elementary students about infection prevention. Which factors should be included in the discussion? Select all that apply - Importance of washing hands - Eating a diet with vitamin C at each meal - Regular physical activity - Getting an annual influenza immunization - Sleeping 6 to 9 hours a night
Importance of washing hands Regular physical activity Getting an annual influenza immunization Sleeping 6 to 9 hours a night
A client reports that he follows a strict vegetarian diet. What recommendations should the nurse give? Select all that apply. Increase intake of food fortified with vitamin B12 and B12 supplements. The client should add meat to the diet; a vegetarian diet is not advised. The client should use nonstick cookware to prepare food. Sun exposure can help compensate for lack of dietary vitamin D. Eat foods containing vitamin C to improve iron absorption.
Increase intake of food fortified with vitamin B12 and B12 supplements. Sun exposure can help compensate for lack of dietary vitamin D. Eat foods containing vitamin C to improve iron absorption.
Which action is most appropriate for a client experiencing constipation? Select all that apply. Increase intake of milk and cheese Increase intake of bread and pasta Increase intake of fruits and vegetables Increase intake of lean meats Increase intake of beans and legumes
Increase intake of fruits and vegetables Increase intake of beans and legumes
A nurse is a new employee in a facility learning about The Joint Commission's Patient Safety Goals. What is in included within these goals? Minimization of patient falls Elimination of never events Infection prevention Requirement of advanced technologies
Infection prevention
The nurse is tallying the intake and output record for the shift. What should be included on the intake record? Select all that apply. Intravenous fluids Hot tea Ice chips Ice cream Oatmeal
Intravenous fluids Hot tea Ice chips Ice cream
The nurse is teaching a group of parents of toddlers about safety. What should be included in the presentation? Select all that apply. Encourage child to sleep on his/her back at night. Keep the telephone number of the poison control center accessible. Have self-closing, locking swimming pool gates. Use a front-facing car seat placed in the back seat of the car. Cut food into small, bite-size pieces.
Keep the telephone number of the poison control center accessible. Have self-closing, locking swimming pool gates. Cut food into small, bite-size pieces.
The nurse is caring for a client with diabetic ketoacidosis, an acid-base disturbance. What type of breathing pattern should the nurse anticipate? Tachypnea Kussmaul's breathing Biot's breathing Cheyne-Stokes respiration
Kussmaul's breathing
The client has developed kidney infection following a bladder infection from the urinary catheter. How would the nurse describe this? Select all that apply. - Local - Systemic - Primary - Secondary - Healthcare-related
Local Secondary Healthcare-related
The nurse is teaching bowel health to a group of senior citizens. What are some common reasons for bowel changes in the older adult? Select all that apply. Increased peristalsis Loss of smooth muscle tone Weakened abdominal muscles Loss of dental structure Immobility
Loss of smooth muscle tone Weakened abdominal muscles Immobility
The nurse is speaking with a group of nursing students about the use of heat and ice for pain control. Which situations are best for this modality? Select all that apply. Acute abdominal pain Low back pain with spasticity Activity-induced muscle pain Pain from obstetric procedures Migraine headache
Low back pain with spasticity Activity-induced muscle pain Pain from obstetric procedures
Linda is recovering from arthroscopic knee surgery. Which nonpharmacological pain relief measures could be effective in treating her pain? Select all that apply. Expressive writing Massage Heat and cold Distraction Immobilization
Massage Heat and cold Distraction Immobilization
The nurse is providing comfort to a person who has fallen on the hiking trail and broken his ankle. Which techniques can be used until medical help arrives? Select all that apply. Massage Relaxation Meditation Controlled breathing Imager
Massage Relaxation Meditation Controlled breathing Imager
The nurse is caring for a confused client who is becoming more agitated. Which actions could should the nurse take? Select all that apply. Leave the television on to block out other noises. Minimize unnecessary light in the client's room. Plan care to provide uninterrupted periods of sleep. Speak calmly in a moderate tone. Awaken the client frequently to see whether the confusion is continuing.
Minimize unnecessary light in the client's room. Plan care to provide uninterrupted periods of sleep. Speak calmly in a moderate tone.
The nurse is encouraging a client to cough and deep breathe as well as use the incentive spirometer. She also performs chest physiotherapy twice a day. What is the purpose of these interventions? Reduce infection rate Increase oxygen levels Mobilize secretions Prevent aspiration
Mobilize secretions
The nurse is directing unlicensed assistive personnel in providing morning care to a comatose client. Besides a bed bath, what care should be provided? Select all that apply. Moisturizing skin Cleaning fingernails Brushing teeth Irrigating nose Shaving legs
Moisturizing skin Cleaning fingernails Brushing teeth
The nurse is caring for a client who says, "Food just doesn't taste good anymore." What priority action should the nurse take? Determine who fixes the client's meals. Ask what dietary restriction he follows. Monitor dietary intake. Determine what medications are taken.
Monitor dietary intake.
A client is prescribed the opioid morphine sulfate for postoperative pain. Which action should the nurse take before administering the medication? Select all that apply. Monitor the patient's respiratory status. Auscultate the patient's heart sounds. Check blood pressure in supine and sitting positions. Monitor the patient for psychological drug dependence. Assess the pain score.
Monitor the patient's respiratory status. Assess the pain score.
The basal metabolic rate is impacted by which factors? Select all that apply. Muscle mass Body temperature Environmental temperature Sleep patterns Disease process
Muscle mass Body temperature Environmental temperature Disease process
A patient develops a respiratory rate of 6 breaths/minute after receiving the opioid hydromorphone. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect? Physostigmine (Antilirium) Flumazenil (Romazicon) Naloxone (Narcan) Pentazocine (Talwin)
Naloxone (Narcan)
The client with severe pain is nauseated and vomiting. Which routes could be considered for administration of an opioid medication? Select all that apply. Nasal Transdermal Rectal Subcutaneous Intravenous
Nasal Transdermal Rectal Subcutaneous Intravenous
The nurse notes that the client is experiencing respiratory distress. Which assessment changes support this finding? Select all that apply. Nasal flaring Eupnea Grunting Stridor Wheezing
Nasal flaring Grunting Stridor Wheezing
Which oxygen delivery method can deliver the highest Fio2? Nasal cannula Partial rebreather mask Tent mask Nonrebreather mask
Nonrebreather mask
The nurse is speaking with her neighbor about the gout pain in his feet. What recommendations could be made for dealing with his chronic pain? Select all that apply. Patient-controlled analgesia Nonsteroidal anti-inflammatory medications Massage Epidural opioid medication Relaxation techniques
Nonsteroidal anti-inflammatory medications Massage Relaxation techniques
What best describes general understanding of the concept of pain? Select all that apply. Pain perception is different in every person. Pain is an objective sign of a more serious problem. Pain sensation can be affected by a client's anticipation of pain. Intractable pain may be relieved by treatment. Psychological factors often contribute to a client's pain perception
Pain perception is different in every person. Pain is an objective sign of a more serious problem. Pain sensation can be affected by a client's anticipation of pain. Psychological factors often contribute to a client's pain perception
Which statements about pain are correct? Select all that apply. Patients in pain rarely become addicted. Patients can have severe pain and not exhibit any signs. Pain is a normal component of aging. Babies don't feel pain like adults do. Pain medicine should be delivered after pain is severe.
Patients in pain rarely become addicted. Patients can have severe pain and not exhibit any signs.
The nurse is teaching a family about phantom pain. Which statement is correct? Phantom pain occurs before an amputation. The pain is deadened from the surgery. Phantom pain is a psychological condition. Phantom pain is real and should be treated as such.
Phantom pain is real and should be treated as such.
Which actions assist the nurse in orienting a confused client to time, place, person, or situation? Select all that apply. Place a clock in the client's room. Schedule activities at different times every day. Wear a readable name tag. Maintain a clean, uncluttered environment. Speak in a louder voice than usual.
Place a clock in the client's room. Wear a readable name tag. Maintain a clean, uncluttered environment.
Sallie Jo, an older adult, is being admitted with confusion. What actions should the nurse take in preparing for her stay? Place her in a semiprivate hospital room. Place her bed in the lowest position. Assign a team of caregivers. Restrict visitation
Place her bed in the lowest position.
Chest percussion and postural drainage would be an appropriate intervention for which conditions? Select all that apply. Congestive heart failure Pulmonary edema Pneumonia Pulmonary embolus Cystic fibrosis
Pneumonia Cystic fibrosis
A client is asking the nurse how he contracted a multidrug-resistant microorganism in his foot wound. What factors likely contributed? Select all that apply. - Previous use of antibiotics - Advanced age - First exposure to the hospital environment - Chronic illness - Incorrect dosing of antibiotics
Previous use of antibiotics Advanced age Chronic illness
The nurse is assisting a client in the emergency department who needs to use the restroom for a bowel movement. Which option is best? Bedpan Bedside commode Public restroom Private restroom
Private restroom
The nurse is caring for an older adult at risk for falls. What should be included in the plan of care? Select all that apply. Keep bed in highest position. Provide nonskid footwear. Keep call light within reach. Clear floor of obstacles. Keep bed wheels locked.
Provide nonskid footwear. Keep call light within reach. Clear floor of obstacles. Keep bed wheels locked.
The nurse is performing a painless, noninvasive procedure to measure SaO2. Which procedure is it? Incentive spirometry Arterial blood gas (ABG) measurement Pulse oximetry Capnography
Pulse oximetry
The nurse responds to a client's call light to find a fire in the bathroom trashcan. The client yells, "I just wanted a cigarette; I didn't think this would happen." What should be the nurse's first action? Pull the fire alarm. Relocate the client away from the fire. Call for additional help. Close the bathroom door
Relocate the client away from the fire.
A nurse is caring for a client who is at high risk for falling. The client is weak and confused. What are actions the nurse can take when caring for this client? Select all that apply. Repeat fall risk assessment every 8 hours. Place call light within reach. Request a social service consultation. Identify medications that increase falling risk. Restrain the patient to bed.
Repeat fall risk assessment every 8 hours. Place call light within reach. Identify medications that increase falling risk.
The nurse is assessing a client with a high fever and chills. What should be included in the assessment? Select all that apply. - Risk for compromised immune system - Abnormal white blood cell count - Regularity of bowel movements - Drainage from wounds - History of fevers
Risk for compromised immune system Abnormal white blood cell count Drainage from wounds History of fevers
The nurse is teaching nutrition counseling to a client with cholecystitis and discussing the need to avoid fatty foods. What foods should be avoided? Select all that apply. Salmon Beans Avocados Bread Oranges
Salmon Avocados
Which factors can impact a person's sensory alteration? Select all that apply. Sensory deprivation Sensory overload Sensory deficit Sensory withdrawal Sensory denial
Sensory deprivation Sensory overload Sensory deficit
The nurse is caring for a client who has been in the intensive care unit for a week. The nurse notes that the client is experiencing restlessness, anxiety, and intermittent confusion. What could be contributing to the behavior changes? Sensory deprivation Sensory overload Sensory deficit Sensory withdrawal
Sensory overload
The nurse is caring for a client after a large abdominal surgery. He is restless and uncomfortable. Which positioning change could be most beneficial? Select all that apply. Trendelenburg Side-lying Head of bed flat Fetal position Head elevation
Side-lying Head elevation
A 73-year-old client admitted after a stroke has expressive aphasia. Which pain intensity scales would be appropriate to use with this client? Select all that apply. Simple descriptor scale Numerical rating scale Visual analog scale Wong-Baker FACES Neonatal infant pain scale
Simple descriptor scale Visual analog scale Wong-Baker FACES
An instructor asks the student nurse about common reasons for urinary incontinence. How should the student respond? Select all that apply. Sneezing and laughing Overfilled bladder Physical disabilities Bladder infection Kidney stones
Sneezing and laughing Overfilled bladder Physical disabilities
A client tells the nurse that she passes urine whenever she sneezes or coughs and it's quite embarrassing. How would the nurse describe this type of incontinence? Transient incontinence Overflow incontinence Urge incontinence Stress incontinence
Stress incontinence
Which interventions are helpful when caring for a client with impaired vision? Select all that apply. Suggest the client use soft, diffuse lighting. Advise the client to avoid wearing sunglasses when outdoors. Offer large-print books and reading material. Clean the client's eyeglasses daily. Place call light and necessary items within reach.
Suggest the client use soft, diffuse lighting. Offer large-print books and reading material. Clean the client's eyeglasses daily. Place call light and necessary items within reach.
Which of these communication strategies are most useful when interacting with a client who has a hearing deficit? Select all that apply. Provide paper and pen for writing. Talk in an even tone of voice. Use gestures and facial expressions. Speak at a normal pace. Face the client directly when speaking.
Talk in an even tone of voice. Use gestures and facial expressions. Face the client directly when speaking.
The nurse assists unlicensed assistive personnel in providing morning care to a comatose client who is bowel and bladder incontinent. The nurse should intervene if which action is observed? The UAP answers the telephone while wearing gloves. The UAP logrolls the client to provide back care. The UAP places an incontinence pad under the client. The UAP performs oral care with suction attached.
The UAP answers the telephone while wearing gloves.
Which are anticipated changes in the urinary system that occur with normal aging in the older adult? Select all that apply. The number of functioning nephrons decreases with age. Bladder size decreases with age. Pelvic muscle tone increases with age. Bladder elasticity increases with age. Prostate size increases with age.
The number of functioning nephrons decreases with age. Prostate size increases with age.
The nurse would anticipate which symptoms for a client with a suspected urinary tract infection (UTI)? Select all that apply. Urinary frequency Urinary urgency Anuria Abdominal pain Polyuria
Urinary frequency Urinary urgency
What are the most important considerations when performing oral hygiene for an unconscious critical client? Select all that apply. - Use a padded tongue blade when providing oral care. - Perform oral hygiene at least twice a day. - Moisturize lips every 2 hours. - Avoid the use of mouthwash. - Use hydrogen peroxide to oral mucosa.
Use a padded tongue blade when providing oral care. Perform oral hygiene at least twice a day. Moisturize lips every 2 hours.
The nurse is bathing a client with senile dementia. What action will optimize the chance of cooperation? Complete the bath quickly. Use a quiet, calm manner, allowing for choices. Have other people present to assist. Avoid bathing more often than necessary
Use a quiet, calm manner, allowing for choices.
Which statements about nutrition are correct? Select all that apply. Fats are unhealthy and should be avoided. Vegetables can be eaten with other vegetables to make a complete protein. Carbohydrates raise blood glucose levels. Vitamin supplements are recommended for everyone. Micronutrients are foods that are consumed in small amounts.
Vegetables can be eaten with other vegetables to make a complete protein. Carbohydrates raise blood glucose levels.
A client with dementia becomes belligerent and combative when the nurse attempts to give him a tub bath. How should the nurse proceed? - Call for assistance to help the patient into the bathtub. - Wait for the patient to calm down, then give him a towel bath. - Allow the patient to go without bathing for a day or two. - Ask another staff member to attempt the tub bath.
Wait for the patient to calm down, then give him a towel bath.
The nurse is teaching a group of school-age children about diet and nutrition. What recommendations should the nurse make about the USDA dietary guidelines? Select all that apply. Wash hands before and after meals. Eat equal amounts of fruits, vegetables, protein, grains, and dairy. Avoid empty calorie snacks. Eat six meals a day. Eat until you are full and don't overeat
Wash hands before and after meals. Avoid empty calorie snacks
The nurse is speaking to her neighbor, whose child has had diarrhea for 24 hours. What suggestion should be made? Select all that apply. Eat apples and oranges. Wash hands often. Increase caffeinated soda use. Increase hydration with popsicles. Eat bananas, rice, applesauce, and toast.
Wash hands often. Increase hydration with popsicles. Eat bananas, rice, applesauce, and toast.
The nurse knows that falls most often occur in hospitals and long-term care facilities during which time frames? Select all that apply. Early mornings Midafternoons Weekends Nights Holidays
Weekends Nights Holidays
Which is the correct formula for calculating body mass index? Weight in pounds ÷ (height in inches)2 Weight in pounds ÷ (height in meters)2 Weight in kg ÷ (height in meters)2 Weight in kg ÷ (height in inches)2
Weight in kg ÷ (height in meters)2
To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. Which foods are incomplete proteins that should be consumed with a complementary protein? Select all that apply. Whole grain bread Peanut butter Turkey Cheese Refried beans
Whole grain bread Peanut butter Refried beans
The client arrives in the emergency department after a motor vehicle accident and was hemorrhaging at the scene. Nursing assessment includes BP 80/34 mmHg, pulse rate 120 beats/min, and respirations 20 breaths/min. Which is the cause of these assessment changes? A problem with the oxygen being delivered to the tissues A problem with the electrical conduction of the heart A problem with the volume of blood in circulation A problem with the strength of the heart's contractions
A problem with the volume of blood in circulation
The nurse is assessing a client for circulation and perfusion problems. Which findings would indicate poor perfusion to the tissues? Select all that apply. Blood pressure reading of 102/64 mm Hg Pulse rate of 104 beats/min Absence of hair on the lower legs and feet Shortness of breath when supine Slowed capillary refill
Absence of hair on the lower legs and feet Slowed capillary refill
The nurse is caring for a client with postsurgical pain. At what point is it important to assess the pain level? Select all that apply. After physical activity Before physical activity Every 30 minutes during the shift At the beginning of the shift When there are nonverbal cues of pain
After physical activity Before physical activity At the beginning of the shift When there are nonverbal cues of pain
What is needed for perfusion to the tissues to be adequate? Select all that apply. Good oral nutritional intake An adequate circulation system with good blood flow Oxygen-saturated hemoglobin traveling in the blood A balanced autonomic nervous system Baroreceptors and chemoreceptors
An adequate circulation system with good blood flow Oxygen-saturated hemoglobin traveling in the blood
The nurse is creating a plan of care for the reduction of the risk for clot formation. Which interventions should be included? Select all that apply. Keep the patient's hips and knees flexed while he or she is in bed. Apply sequential compression devices. Turn the patient frequently or encourage frequent position changes. Promote adequate hydration by encouraging oral intake. Deliver anticoagulant medications as ordered.
Apply sequential compression devices. Turn the patient frequently or encourage frequent position changes. Promote adequate hydration by encouraging oral intake. Deliver anticoagulant medications as ordered.
The nurse admits a client with fever and chills. The nurse is concerned the client may have a urinary tract infection, so which other symptoms should the nurse ask about? Select all that apply. Night sweats Back pain Painful urination Bladder spasms Urgency
Back pain Painful urination Bladder spasms Urgency
During an assessment, the nurse notices that a client's breathing pattern follows a cycle of progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which appropriately describes this respiratory pattern? Biot's breathing Kussmaul's breathing Cheyne-Stokes respiration Tachypnea
Biot's breathing
The nurse is assessing a client who does not speak English. He returned from surgery 3 hours ago. Which assessment finding might indicate that this client is experiencing pain? Blood pressure 165/88 mmHg Temperature 97.6°F Heart rate 84 beats/min Oxygen saturation 95% Respiration 18 breaths/min
Blood pressure 165/88 mmHg
A healthy older adult comes to the clinic reporting fatigue when walking up stairs and doing her normal household activities. What anticipated physiological changes in the cardiovascular system occur with aging? Select all that apply. Cardiac contractile strength is reduced. Heart valves become more rigid. Peripheral vessels lose elasticity. The heart responds to increased oxygen demands. Recovery time after exercise is shorter.
Cardiac contractile strength is reduced. Heart valves become more rigid. Peripheral vessels lose elasticity.
The nurse is assessing a client after an abdominal surgery who speaks a different language. Which nonverbal assessment changes could indicate pain is present? Select all that apply. Confusion Restlessness Poor eye contact Moaning Irritability
Confusion Restlessness Moaning Irritability
The nurse is teaching his client about laxative use. What should be included in the instructions? Select all that apply. If a client is having several bowel movements each day, he or she is taking too much laxative. If straining is needed to eliminate a bowel movement, a laxative is needed. Daily psyllium is preferred to an over-the-counter laxative. Do not ignore the urge to defecate. An uninterrupted time for bowel movement should be set aside each day
Daily psyllium is preferred to an over-the-counter laxative. Do not ignore the urge to defecate. An uninterrupted time for bowel movement should be set aside each day
A client is recovering from cardiac surgery in which vein grafts were taken from his lower leg. He informs the nurse that his leg is warm and tender in his right calf, just below the surgical incision site. The nurse notes erythema and swelling. What complication is suspected? Deep vein thrombosis Internal bleeding Infection at the incisional site Dehiscence of the wound Antibiotic reaction
Deep vein thrombosis Dehiscence of the wound
What is considered a risk factor for a urinary tract infection? Diabetes Heart disease Liver failure Hypertension
Diabetes
The nurse notices a blood pressure cuff in the client's room with spots of dried blood on it. What should be the nurse next action? - Clean it with a wet rag. - Disinfect it with a chemical cleaner. - Sterilize it with an autoclave. - Report it to the charge nurse
Disinfect it with a chemical cleaner.
The nurse needs an IV pole to begin a new medication for a client. There is a pole in another client's room that is not in use. What should be the nurse's next action? - Ask whether the pole has been cleaned. - Take the pole and begin using it. - Disinfect the pole and begin using it. - Send the pole to the sterilizing department
Disinfect the pole and begin using it.
What are considered "never events"? Select all that apply. An abdominal infection after a ruptured appendix surgery Administration of unmatched blood in an emergency situation Hypoglycemic episode after insulin administration Sponge left in a client after a hysterectomy Blood clot in the lungs after an orthopedic surgery
Hypoglycemic episode after insulin administration Sponge left in a client after a hysterectomy Blood clot in the lungs after an orthopedic surgery
After a hip fracture, Joseph has become more sedentary. He notices an area on his right calf that is painful, warm to the touch, red, and swollen, and he shows it to the visiting nurse. What action should the nurse take? Place a cool towel over the area Encourage Joseph to go to the emergency department Encourage additional activity Take and record his temperature
Encourage Joseph to go to the emergency department
Which events can create imbalance of circulation and perfusion? Select all that apply. Stress Pregnancy Obesity Medications Illness
Stress Pregnancy Obesity Medications Illness
The nurse knows that the electrical conduction in the heart can impact the process of circulation. What else can impact circulation? Select all that apply. The strength of the heart's contractions The volume of blood in the body The oxygen level in the blood The number of red blood cells The resistance that the heart pumps against
The strength of the heart's contractions The volume of blood in the body The resistance that the heart pumps against
Carl has poor arterial circulation, and the nurse is providing patient teaching regarding proper foot care. What should the nurse include in her teaching? Select all that apply. Wear loose-fitting shoes. Wear smooth, dry socks. Go barefoot as often as possible. Apply lotion to the feet. Wear well-fitting shoes
Wear smooth, dry socks. Apply lotion to the feet. Wear well-fitting shoes
In which situation would standard precautions be adequate? Select all that apply. - While talking with a client with a moist, productive cough - While assisting a client with oral care - While ambulating a client after a procedure - While inserting an intravenous catheter - When changing a dressing for a client with MRSA
While assisting a client with oral care While ambulating a client after a procedure While inserting an intravenous catheter
The nurse is asked for a list of bulk-forming foods to be included in a patient's diet. What should be included? Select all that apply. Whole grains Fruit juice Rare meats Milk products Dried beans
Whole grains Dried beans
A client is diagnosed with an intestinal infection after traveling to a developing country. The nurse should encourage the intake of which food to optimize the gut's normal flora, creating a healthier environment? Yogurt Bread Oatmeal Milk
Yogurt
