Exam 2: Safety, Medication Administration, Integumentary/Nail Assessment, Musculoskeletal Assessment

A nurse is preparing to administer acetaminophen 320 mg oral solution to a schoolage child. The amount available is 160mg/5 mL acetaminophen oral solution. How many mL should be used?

10 mL

A nurse is preparing to administer phenytoin suspension 300 mg PO twice a day. The amount available is phenytoin suspension 125 mg/5 mL. How many mL should the nurse administer per dose?

12 mL

A nurse is preparing to administer clindamycin 0.3 g IM to a client. Available is clindamycin 150 mg/mL. How many mL should the nurse administer?

2 mL

A nurse is preparing to administer amikacin 7mg/kg/day IM to a client who weighs 165 lbs. Available is amikacin 250mg/mL solution for injection. How many mL should the nurse prepare to administer?

2.1 mL

A nurse is preparing to conduct a fall-risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply). A. Fall history B. Medical diagnosis C. Use of assistive devices D. Mental status E. Do-not-resuscitate status

A, B, C, D: Fall history is correct. A client who has fallen recently is at an increased risk for a fall. Medical diagnosis is correct. Certain medical diagnoses, such as a stroke, increase the client's risk for a fall. Use of assistive devices is correct. The use of assistive devices to ambulate is used to calculate the client's risk for falls. The score for assistive devices would range from 0 to 30. Mental status is correct. A client who is disoriented is at greater risk for a fall. Do-not-resuscitate status is incorrect. The client's do-not-resuscitate status is not used to evaluate a client's risk for a fall.

A nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the nurse include? (Select all that apply). a. Do not text and drive. b. Maintain spinal alignment when working at a desk. c. Remove loose rugs from the home. d. Use the back muscles when lifting objects. e. Wear a helmet when riding a bicycle.

A, B, C, E: Do not text and drive is correct. The nurse should instruct the adults to avoid texting and driving.Maintain spinal alignment when working at a desk is correct.The nurse should instruct the adults to be aware of their posture while working on a computer or sitting at a desk. Proper spinal alignment can prevent injury.Remove loose rugs from the home is correct.The nurse should instruct the adults to remove fall hazards such as loose rugs or electrical cords.Use the back muscles when lifting objects is incorrect.The nurse should instruct the adults to use the legs, not the back, when lifting objects.Wear a helmet when riding a bicyle is correct. The nurse should instruct the adults to wear a helmet and other protective gear when riding a bicycle or motorcycle.

A nurse is preparing to administer a premixed med to a client. The nurse should check the label for which of the following info? (Select all that apply). A. The date the medication was mixed B. The client's age C. The client's room number D. The dose of the mixed medication E. The time the medication was mixed

A, D, E: The date the medication was mixed is correct. The nurse should check the label of the premixed medication for the date the medication was mixed to make sure the mixed medication has not expired. The client's age is incorrect. The nurse does not need to check the label of the premixed medication for the client's age. The client's room number is incorrect. The nurse does not need to check the label of the premixed medication for the client's room number. The dose of the mixed medication is correct. The nurse should check the label of the premixed medication for the dose of the medication to reduce the risk for medication error. The time the medication was mixed is correct. The nurse should check the label of the premixed medication for the time the medication was mixed to make sure the mixed medication has not expired.

You are assessing the texture of a client's skin. Which of the following findings require additional investigation? a. smooth, velvety skin b. acne on back c. moisture in skin folds d. oily facial skin

A: Extremely smooth, soft skin may indicate a thyroid disorder

A nurse is providing teaching about adequate daily intake of vitamin D to a client. Which of the following intake amounts should the nurse recommend? a. 500 IU daily b. 800 IU daily c. 1,500 IU daily d. 1,800 IU daily

B: The nurse should recommend that the client consume 600 to 800 IU of vitamin D daily. Vitamin D protects bones by assisting with the absorption of calcium. Sources of vitamin D include egg yoks, fatty fish, and fortified foods. Exposure to sunlight triggers vitamin D synthesis.

A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following actions should the nurse take? a. Apply heat therapy after the first 24 hr following the injury. b. Place an ice pack directly on the injured area. c. Apply compression to the injured area of the extremity. d. Encourage the client to use the extremity as much as possible.

C: The nurse should apply prescribed compression to the injured area to limit edema, provide support, and ease discomfort.

A nurse is performing ROM exercises on a client's hips. The nurse is assessing which of the following motions by instructing the client to bend the knee and bring it up toward the chest? a. External rotation of the hip b. Adduction of the hip c. Flexion of the hip d. Hyperextension of the hip

C: To test flexion of the hip, the nurse should instruct the client to bend their knee and bring it up toward their chest.

A nurse planning to use ISBARR tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? A. Admitting diagnosis B. Medical history C. Lab results D. Response to treatment

General client impression and significant findings such as diagnostic tests, laboratory results, and vital signs are included in the assessment component of the ISBARR communication tool.

Put the definitions in order of the following terms: Erythema Edema Ecchymosis Diaphoresis Jaundice Cyanosis Hyperpigmentation Hypopigmentation Hematoma Blood clot in organ, space, or tissue Decrease in skin color Spot larger than petechiae, bruise Inflammation of skin area Profuse perspiration Increase in skin color Bluish color of skin Swelling, presence of excess interstitial fluid Yellowish color of skin

Inflammation of skin area Swelling, presence of excess interstitial fluid Spot larger than petechiae, bruise Profuse perspiration Yellowish color of skin Bluish color of skin Increase in skin color Decrease in skin color Blood clot in organ, space, or tissue

Place the steps for assessing a client's skin turgor and mobility in order: Pinch a large fold of skin between thumb and forefinger Position your hand with fingers just below the collar bone Note how quickly the skin returns to a flat position on chest Open the pinch and release the skin Note the ease with which you were able to move the client's skin

Position your hand with fingers just below the collar bone Pinch a large fold of skin between thumb and forefinger Note the ease with which you were able to move the client's skin Open the pinch and release the skin Note how quickly the skin returns to a flat position on chest

Put the definitions in order of the following terms: Vitiligo Petechiae Pruritus Pigmentation Pallor Xerosis Seborrhea Uticaria Nevus Oiley skin Reddish/purplish spots Mole Skin areas w/out usual brown pigment Intense itching Pale/lighter skin than normal Dry skin Skin color Hives

Skin areas w/out usual brown pigment Reddish/purplish spots Intense itching Skin color Pale/lighter skin than normal Dry skin Oiley skin Hives Mole

What is kyphosis?

The nurse should recognize this image as kyphosis, an exaggerated posterior curvature of the thoracic spine. Kyphosis is associated with aging.

You are collecting subjective data prior to performing a skin assessment on a client. Which of the following responses requires additional investigation? a. that birthmark on my thigh has always looked the same as it does not b. I have stretch marks on my abdomen from being pregnant c. I notice that my freckles get darker in the summertime d. One of my moles now has several colors on it

D

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply.) A. Throw rugs B. Missing smoke detectors C. Raised toilet seats D. Arm rails in shower

A & B: Rails and grab bars promote safety at home, especially in bathrooms, where floors and other surfaces are often slippery. Raised toilets seats make it easier for older adults to sit down on and get up from the toilet (ATI)

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select all that apply.) a. Client's full name b. Facility room number c. Provider's name d. Client's facility identification number

A & D: Client's full name and facility identification number are correct. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client. Facility room number is incorrect. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client. These can include the client's full name, an identification number assigned by the facility, and a telephone number. Provider's name is incorrect. To prevent medication errors, it is essential to perform the six rights of medication administration which includes the "correct client." The Joint Commission requires the use of two separate client identifiers to identify the correct client. These can include the client's full name, an identification number assigned by the facility, and a telephone number. (ATI)

A nurse is recommending sources of food with high calcium content to a client. Which of the following foods should the nurse recommend? (Select all that apply). a. Milk b. Apples c. Mustard greens d. Corn e. Legumes

A, C, E

Which of the following are characteristics of the dermis layer of the skin? (Select all that apply) a. contains blood vessels, hair follicles, nerve endings b. contains fat stores for energy c. composed of thick fibrous connective tissue d. prevents excessive H2O loss

A, C

A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include? a. To convert g to mg, move the decimal point 3 places to the right. b. Liters is a unit of measurement for distance. c. The metric system uses fractions rather than decimals. d. Grains is used as a measurement of weight in the metric system.

A: Calculation in the metric system moves the decimal either to the left or to the right. When converting from smaller to larger, move the decimal to the correct number of places to the left. When converting from larger to smaller, move the decimal the correct places to the right.

A nurse is planning care for a client who has a stage I pressure injury on their coccyx. Which of the following interventions should the nurse plan to include? a. Limit elevation of the head of the bed to 30º or less. b. Apply baby powder and massage the area every 2 hr. c. Reposition the client every 4 hr. d. Ensure that the client uses a donut-shaped cushion when sitting in a chair.

A: Raising the head of the bed more than 30º increases the risk for skin damage due to shearing forces. Shearing occurs when the client slides downward in the bed. The outer skin layer sticks to the bed linens while the deeper skin layers move downward. This results in twisting of blood vessels and can lead to skin damage.

A nurse is preparing to perform a skin assessment on a client. Which of the following tools should the nurse plan to use? a. Penlight b. Otoscope with a pneumatic bulb attachment c. Wide-tipped speculum d. Tongue blade

A: The nurse should plan to perform a skin assessment in an area with strong lighting for general visualization. A penlight is used to illuminate suspicious areas of the skin.

A nurse is assessing flexion of a client's elbows. The nurse should provide which o the following instructions to the client? a. "Start with your arms straight out in front of you with palms facing the floor then twist at your elbows so your palms are facing up toward the ceiling." b. "Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulders." c. "Start with your arms straight out in front of you with palms facing the ceiling then twist at your elbows so your palms are facing down toward the floor." d. "Start with your elbows bent and fingers at your shoulders then straighten your arms out in front of you."

B: To test flexion, the nurse should instruct the client to bend their elbows in front of them.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as the greatest risk for developing medication toxicitiy? a. A client who has a respiratory infection b. A client who has rheumatoid arthritis c. A client who has impaired kidney function d. A client who has hyperthyroidism

C: The nurse should identify that the client who has impaired kidney function is at the greatest risk for medication toxicity because many medications are excreted by the kidneys, A decrease in function of the kidneys can result in a buildup of medication metabolites.

A nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend? a. Increase the frequency of bathing. b. Use a dehumidifier to reduce air moisture. c. Apply an alcohol-free lotion. d. Cover the dry areas with a thin coating of powder.

C: The nurse should recommend an alcohol-free lotion that creates a film on the skin to decrease moisture evaporation and dryness. Lanolin, cocoa butter, and petroleum-based lotions are products that retain skin moisture.

A nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse? a. "The bruise on my leg is from running into the base of a chair." b. "I'm sleeping better since I gave up caffeine in the afternoon." c. "For some reason I have been experiencing falls." d. "I no longer have back pain since I started walking 2 miles every day."

C: This statement by the client is an unexpected finding and requires further questioning. Frequent falling can indicate that the client is experiencing a musculoskeletal or neurological disorder that needs to be investigated.

A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a UTI. Which of the following statements should the nurse make? a. "You can expect to experience a rash while taking this medication." b. "Natural supplements do not interact with antibiotics." c. "This medication is used to treat a viral infection." d. "Finish the entire course of the prescription."

D: The nurse should instruct the client to complete the entire course of the antibiotic prescription, even if they are feeling better, to eradicate the infection.

A nurse is preparing to transfer a client who has left-sided weakness from bed to chair. Which of the following actions should the nurse plan to take? A. Raise bed to nurse's was it level B. Instruct the client to wrap arms around nurse's neck when standing C. Place chair on clients weaker side D. Use gait bed to assist client to stand and pivot

D: The nurse should stand and pivot the client using a gait belt to reduce the risk for injury to the client or the nurse (ATI)

A nurse is evaluating assessment findings of a client's skin. The nurse should indentify that which of the following findings is associated with a possible infection? a. Wheals b. Vesicles c. Papules d. Bulla

B: Vesicles are small, serous, raised fluid-filled skin lesions. The nurse should identify that they are associated with both chickenpox and shingles infections, and should be reported to the provider.

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. Which of the following actions should the nurse take first? A. Active the fire alarm B. Extinguish the fire. C. Close the client's door. D. Rescue the client from immediate danger.

D: In the event of a fire, use the acronym RACE. Rescue the client first, then activate the alarm, contain the fire, and lastly extinguish the fire if possible. (ATI)

A nurse is preparing a client's evening dose of furosemide when the tablet falls on the countertop. Which of the following actions should the nurse take? a. Discard the tablet and obtain another dose of the medication. b. Pick up the tablet and administer it to the client. c. Rinse off the tablet and administer it to the client. D. Use the tablet's packaging to pick up the tablet and administer it to the client.

A: The nurse must adhere to medical asepsis when preparing and administering medications. If the nurse drops a tablet, contamination is possible and therefore must be discarded. (ATI).

A nurse is planning care for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physical restraints? (Select all that apply.) A. Ensure effective pain management. B. Assign the room farthest from the nurses station. C. Raise all side rails. D. Orient the client frequently to the environment.

A & D: Uncontrolled pain can increase anxiety, promote restlessness and confusion; Orienting the client frequently to the environment is beneficial in reducing a client's confusion. The nurse should use simple and direct statements when communicating with the client (ATI). Elevating all side rails is considered a restraint because it prohibits the free movement of the client into and out of the bed. Prior to the application of a restraint, the nurse should implement alternative measures that may alleviate the need for physical restraints. Assigning a client close to the nurses' station allows the nurse and other health care professionals more immediate observation of a client. Restraints are never used as a substitute for surveillance (ATI).

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client on round-the-clock surveillance. B. Remove objects from the room that the client could use to harm themselves. C. Search items brought into the client's room by visitors. D. Refrain from asking the client if they intend to harm themselves. E. Screen the client for suicidal ideation.

A, B, C, E MY ANSWER Place the client on round-the-clock surveillance is correct. The nurse should place the client on round-the-clock surveillance to reduce the risk of client injury. Remove objects from the room that the client could use to harm themselves is correct. The nurse should remove any objects in the client's room that the client could use to harm themselves to reduce the risk of client injury. Search items brought into the client's room by visitors is correct. The nurse should search and remove any items brought into the client's room by visitors that the client could use to harm themselves to reduce the risk of client injury. Refrain from asking the client if they intend to harm themselves is incorrect. The nurse should ask the client if they intend to harm themselves to assess the client and provide interventions to protect the client from injury. Screen the client for suicidal ideation is correct. The nurse should screen the client for suicidal ideation using a validated screening tool to assess the client and provide interventions to protect the client from injury.

A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is a hospital acquired injury? (Select all that apply.)

A, B, C: Blood transfusion incompatibility is correct. The nurse should identify that a blood transfusion incompatibility is a hospital-acquired injury that can occur to a client while in the hospital. Wrong site surgery is correct. The nurse should identify that a wrong site surgery is a hospital-acquired injury that can occur to a client while in the hospital. Ineffective insulin usage is correct. The nurse should identify that ineffective insulin usage is a hospital-acquired injury that can occur to a client while in the hospital. Dysphagia following a stroke is incorrect. The nurse should identify that dysphagia is an adverse effect of a stroke and not a hospital-acquired injury. Dehydration due to diarrhea is incorrect. The nurse should identify that dehydration is an adverse effect of diarrhea and not a hospital-acquired injury.

A nurse is preparing to administer meds to a client. WHich of the following information should the nurse use to identify the client? (Select all that apply.) A. The client's full name B. The client's date of birth C. The client's telephone number D. The client's diagnosis E. The client's room number

A, B, C: The client's full name is correct. The nurse should identify that the client's first and last name are unique to the client and can be used to identify the client prior to administering medications. The nurse should use two acceptable identifiers to reduce the risk for a medication error. The client's date of birth is correct. The nurse should identify that the client's date of birth is unique to the client and can be used to identify the client prior to administering medications. The nurse should use two acceptable identifiers to reduce the risk for a medication error. The client's telephone number is correct. The nurse should identify that the client's telephone number is unique to the client and is one standard identifier that can be used as to identify the client prior to administering medications. The client's diagnosis is incorrect. The nurse should identify that the client's diagnosis is not unique to the client and should not be used as a client identifier. The client's room number is incorrect. The nurse should identify that the client's room number is not unique to the client and should not be used as a client identifier.

A nurse is performing medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? Select all that apply a. Place the medication reconciliation form with the client's transfer documents. b. Reinforce teaching about the medications to the client upon discharge. c. Add medications the client is no longer taking in the medication reconciliation. d. Include over-the-counter medications in the medication reconciliation. e. Compare the client's home medications with prescribed discharge medications.

A, B, D, E: Place the medication reconciliation form with the client's transfer documents is correct. The nurse should include the medication reconciliation with the transfer documents to provide an accurate, up-to-date list of the client's medications and reduce the risk of medication error. Reinforce teaching about the medications with the client upon discharge is correct. The nurse should reinforce teaching about medications with the client upon discharge to promote safe and effective care. Add medications the client is no longer taking in the medication reconciliation is incorrect. The nurse should not include medications that the client no longer requires in the medication reconciliation. Include over-the-counter medications in the medication reconciliation is correct. The nurse should include all medications the client currently takes, including over-the-counter medications, herbal supplements, and vitamins. Compare the client's home medications with prescribed discharge medications is correct. The medication reconciliation process involves the comparison of the client's home medications against prescribed discharge medications. The nurse should note any duplications or discrepancies.

A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply) A. Provide discharge education on safety measures within the home. B. Lock beds and wheelchairs when not providing care. C. Place throw rugs on the floor to prevent walking on cold surfaces. D. Place the bedside table within reach.

A, B, D: Throw rugs increase the chance for falls and should not be a part of a safety plan (ATI).

A nurse is caring for a client who has a Stage I pressure injury. Which of the following info should the include when documenting the characteristics of the wound? (select all that apply) a. Location of the pressure injury b. Size of the injury in centimeters c. Depth of the injury in centimeters d. Color and odor of drainage from the wound e. Integrity of the skin surrounding the wound

A, B, E Location of the pressure injury is correct. The nurse should document the location of the pressure injury in relation to the adjacent bony prominence.Size of the injury in centimeters is correct. The nurse should document the length and width of the pressure injury in centimeters.Depth of the injury in centimeters is incorrect. A stage 1 pressure injury presents with intact, reddened skin. There is no loss of skin or drainage associated with this stage of pressure injury.Color and odor of drainage from the wound is incorrect. A stage 1 pressure injury presents with intact, non-blanchable, redness of the skin. There is no loss of skin or drainage associated with this stage of pressure injury.Integrity of the skin surrounding the wound is correct. The nurse should assess and document the condition of the wound edges and the area of skin surrounding the pressure injury. The nurse should also note any changes in temperature, sensation, or firmness in the area.

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (Select all that apply.) A. Locks the brakes on the client's bed B. Checks the maximum weight of the lift before using it C. Places the client on the edge of the sling D. Uses the lift without assistance from another team member E. Performs a safety check before lifting the client

A, B, E: Locks the brakes on the client's bed is correct. The nurse should secure the brakes on the client's bed to keep the bed from moving while transferring the client. Checks the maximum weight of the lift before using it is correct. The nurse should check the maximum weight of the lift to make sure the client is not too heavy to reduce the risk for injury to the client or the nurse. Places the client on the edge of the sling is incorrect. The nurse should place the client on the center of the sling to reduce the risk of the client falling. Uses the lift without assistance from another team member is incorrect. The nurse should have another team member assist with using a lift to transfer the client to reduce the risk of injury to the nurse or the client. Performs a safety check before lifting the client is correct. The nurse should perform a safety check before lifting the client to make sure the client is transferred safely.

A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (Select all that apply.) A. A client's visitor falls in the hallway. B. A nurse forgets their computer password. C. A client develops an unexpected reaction to a medication. D. A client's dentures are lost. E. An antibiotic was administered to a client 30 min after the scheduled time.

A, C, D: A client's visitor falls in the hallway is correct. The nurse should include that a fall by a client's visitor is an unexpected event that requires an occurrence report. A nurse forgets their computer password is incorrect. The nurse should include unexpected events that might result in harm to the client. Forgetting a computer password does not require an occurrence report. A client develops an unexpected reaction to a medication is correct. The nurse should include that an unexpected reaction to a medication is an unexpected event that requires an occurrence report. A client's dentures are lost is correct. The nurse should include that a loss of a client's dentures is an unexpected event that requires an occurrence report. An antibiotic was administered to a client 30 min after the scheduled time is incorrect. The nurse should include that incorrect administration of a medication requires an occurrence report. However, an antibiotic is considered a time-critical medication and should be administered within 30 min before or after the scheduled time. Therefore, this event does not require an occurrence report.

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint? A. The client's hands are cool and pale. B. The client's skin is pink and warm in both extremities. C. The client has capillary refill less than 2 seconds. D. The client has full range of motion of bilateral wrists.

A: This finding indicates a decrease in blood flow to the client's hand, which can be caused by applying a restraint too tightly. This is the finding that indicates a complication of the restraint. (ATI)

A nurse is reviewing the pharmacokinetics of a medication with a newly licensed nurse. The nurse should include that which of the following factors affect the rate of absorption? Select all that apply. a. Age of the client b. First pass effect c. Lipid solubility of a medication d. Route of administration e. Metabolism of the medication

A, C, D: Age of the client is correct. The nurse should include that the age of the client affects the rate of absorption of medications. In older adult clients, delayed gastric emptying can slow the absorption rate of oral medications.First-pass effect is incorrect. The first-pass effect affects the metabolism of a medication, rather than the absorption.Lipid solubility of a medication is correct. The lipid solubility of a medication affects the rate of absorption. A medication that is highly lipid soluble has a higher rate of absorption than one that has low lipid solubility.Route of administration is correct. The nurse should include that the route of administration affects the rate of absorption of medications. Oral or enteral medications are absorbed at a slower rate than intravenous medications.Metabolism of the medication is incorrect. Metabolism is the process where drugs are chemically changed to a form that allows for excretion. It does not affect the rate of absorption of a medication.

A nurse is teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? Select all that apply. a. Ask the client what they know about the nitroglycerin patch. b. Find out whether the client is able to pay for the medication. c. Determine the client's ability to apply the patch. d. Check the client's reading comprehension level. e. Use medical terminology to instruct the client about the patch.

A, C, D: Ask the client what they know about the nitroglycerin patch is correct. The nurse should check to determine what the client already knows about the medication when beginning to reinforce teaching. The nurse should build on the client's existing knowledge to provide effective teaching.Find out whether the client is able to pay for the medication is incorrect. Finding out whether the client is able to pay is not the nurse's responsibility when assisting with teaching a client about their medication.Determine the client's ability to apply the patch is correct. The nurse should determine the client's ability to perform the skill of applying the patch. The nurse should ask the client to provide a return demonstration to determine whether the client is able to perform the procedure.Check the client's reading comprehension level is correct. The nurse should check the client's reading comprehension level to make sure they can read and understand any written material.Use medical terminology to instruct the client about the patch is incorrect. The nurse should use simple terms when assisting with teaching a client to promote understanding.

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.) a. Verbally repeat orders to the provider. b. Obtain the provider's signature prior to client discharge. c. Transcribe the orders into the health record. d. Question the provider if any piece of the order is unclear.

A, C, D: Repeat the order back to the provider is correct. The nurse should read the order back and have the provider verbally confirm that it is correct. Question any part of the order that is unclear or inappropriate is correct. The nurse should question any part of the prescription or an order that is unclear or inappropriate. This is essential for any verbal or written prescription or order. The prescription should be entered in the health record as it is obtained and verified. Although the policy may vary with each facility, the usual rule is to obtain the provider's signature within 24 hr. (ATI)

A nurse is participating in a committee to reduce medication errors on a unit. Which of the following interventions should the nurse recommend? Select all that apply. a. Mark the area around the automated medication dispensing system. b. Encourage the use of cell phones while dispensing medications. c. Override the automated medication dispensing system during emergencies. d. Provide the nurse administering medications with a vest. e. Double check dosages of high-alert medications.

A, D, E: Mark the area around the automated medication dispensing system is correct. The nurse should recommend marking the area around the automated medication dispensing system to stop people from interrupting the nurse working in the labeled area. Interruptions while dispensing medications can result in medication administration errors. Encourage the use of cell phones while dispensing medications is incorrect. The nurse should recommend not to use cell phones while dispensing medications as this can result in an error. Interruptions while dispensing medications can result in medication administration errors.Override the automated medication dispensing system during emergencies is incorrect. The nurse should recommend not to override the automated medication dispensing system, even during an emergency, as this can result in an error.Provide the nurse administering medications with a vest is correct. The nurse should recommend providing the nurse administering medications with a vest to indicate they should not be interrupted. Interruptions while dispensing medications can result in medication administration errors.Double check dosages of high-alert medications is correct. The nurse should recommend to double check dosages and calculations for high-alert medications with a second nurse to reduce medication errors.

A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take? A. Rinse the client's skin with water. B. Remove the client's clothing by pulling it over their head. C. Dispose of the client's clothing in a single biohazard bag. D. Prepare to administer potassium iodide to the client.

A: The nurse should have the client shower to remove the chemical toxin from their skin, hair, and eyes to reduce the effects of exposure.

A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that med. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? A. Near-miss event B. Client safety event C. Adverse event D. Sentinel event

A: A near-miss event is an error that could have harmed the client which almost occurs, but was caught and avoided. The nurse noted the client had an allergy to the medication prior to administering it, avoiding harm to the client.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? A. Record the time and length of the seizure. B. Restrain the client's extremities. C. Place the client in the prone position. D. Monitor the client's hemoglobin level.

A: The nurse should monitor the length of time of the seizure to evaluate the type of seizure and determine treatment required.

A nurse is preparing to administer oral medication to a 3-month-old infant. Which of the following actions should the nurse plan to take? a. Draw up medication in a metered syringe and position it along the side of the infant's mouth. b. Prepare medication in a liquid measuring cup for administration. c. Mix the medication in the baby formula. d. Lay the infant in a supine position.

A: To accurately measure an infant dose, it is best to use a plastic, needleless syringe for small doses. This provides a reliable measurement, and is a convenient way to transport the medication to the infant. The nurse should not mix a medication with formula, because the infant may not take all of the formula, resulting in the infant not receiving the full dose of medication. This may also alter the taste of the formula, which may cause the infant to refuse future feedings. The infant should be held in a semi-reclining position to prevent aspiration. A child can aspirate a medication, especially when lying supine. The syringe should be placed along the side of the infant's tongue, and the liquid should be administered slowly in small amounts, allowing the child time to swallow (ATI).

A nurse ir performing ROM exercises on a client's feet. The nurse should provide which of the following instructions to the client to assess plantar flexion of the feet? a. "Point your toes toward the floor." b. "Turn the soles of your feet out, away from the body." c. "Point your toes up toward your nose." d. "Turn the bottoms of your feet in, toward the midline."

A: To assess plantar flexion, the nurse should instruct the client to point their toes toward the floor.

A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the right leg or arms. How should the nurse interpret this finding? a. The client might have a blood clot. b. The client might have an infection. c. The client is experiencing complications of kidney failure. d. The client's blood oxygen levels are lower than expected.

A: Unilateral coolness is associated with decreased blood flow to the extremity. This can occur when the client is experiencing a blood clot that is blocking the flow of blood. Additional causes of unilateral coolness of an extremity include chronic disease of the blood vessels or a physical obstruction of blood flow, such as from a cast that is too tight.

A nurse is assessing a client's skin color. Which of the following findings should the nurse report to the provider? (Select all that apply.) a. Patches of increased pigmentation on the client's cheeks b. Pinpoint areas of purplish-red coloration across the abdomen c. Pale-colored nailbeds d. Darkly pigmented area across the client's sacral area e. Light-colored jagged lines

B, C: Patches of increased pigmentation on the client's cheeks is incorrect. Areas of increased pigmentation on the face commonly occurs during pregnancy or in clients who are taking oral contraceptives. This is an expected finding.Pinpoint areas of purplish-red coloration across the abdomen is correct. Areas of purplish-red discoloration that are smaller than 3 mm in diameter are termed petechia. This is an unexpected finding. Petechia can be an indication of a bleeding disorder and should be reported to the provider.Pale-colored nailbeds is correct. Pale nailbeds is an unexpected finding. They can be an indication of low oxygen levels and should be reported to the provider.Darkly pigmented area across the client's sacral area is incorrect. Areas of darker pigmentation across the sacrum or buttocks is common in clients who have darker skin tones. This is termed Mongolian spots and is an expected finding.Light-colored jagged lines is incorrect. Silver-white jagged lines are atrophic scars that result from stretching of the skin, usually from pregnancy or weight gain. They are an expected finding.

A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent HAIs. Which of the following infections should the nurse include? (Select all that apply.) A. Influenza infection B. Catheter-associated urinary tract infection C. Mycobacterium tuberculosis infection D. Central line-associated bloodstream infection E. Surgical site infection

B, D, E: Influenza infection is incorrect. The nurse should identify that influenza is not an HAI identified by the CDC. A client who has influenza should be placed on droplet precautions to control disease transmission. Catheter-associated urinary tract infection is correct. The nurse should identify that catheter-associated infections are HAIs that the CDC has established evidence-based protocols to prevent. HAIs are infections that occur to clients who are being treated for other clinical conditions. Mycobacterium tuberculosis infection is incorrect. The nurse should identify that tuberculosis is not an HAI identified by the CDC. A client who has M. tuberculosis should be placed on airborne precautions to control disease transmission. Central line-associated bloodstream infection is correct. The nurse should identify that central line-associated infections are HAIs that the CDC has established evidence-based protocols to prevent. HAIs are infections that occur to clients who are being treated for other clinical conditions. Surgical site infection is correct. The nurse should identify that surgical site infections are HAIs that the CDC has established evidence-based protocols to prevent. HAIs are infections that occur to clients who are being treated for other clinical conditions.

A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? A. An extension cord is secured under a rug. B. The edges of stairs are marked with brightly colored tape. C. A toaster is plugged in when not in use. D. The water heater is set to 55° C (131° F).

B: The nurse should instruct the client to mark edges of stairs with brightly colored tape to alert the client of the steps and reduce the risk of fall.

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane? A. The client should move the stronger leg first, then the weaker one. B. When ambulating, the client should move the cane first. C. The grip should be at the client's waist. D. Place the client's cane on their weaker side.

B: When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg (ATI).

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment? a. Lateral to the umbilicus b. Inferior to the collar bone c. Dorsal side of the hand d. Anterior aspect of the neck

B: Assessing skin turgor is performed by pinching a large fold of skin just below the clavicle. Other reliable sites to assess skin turgor include over the sternum and the back of the forearm. In older adults, a natural loss of skin elasticity might slow the recoil time of the skin.

A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes a rash on the clients back, neck, and chest. Which of the following actions should the nurse take? a. Notify the client's provider. b. Stop the infusion of the vancomycin. c. Administer diphenhydramine to the client. d. Document the incident in the client's chart.

B: The greatest risk to the client is injury from an acute allergic reaction. Therefore, the first action the nurse should take is to stop the infusion of the vancomycin to reduce the risk of further injury.

A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene? a. The newly licensed nurse asks the clients about any known allergies. b. The newly licensed nurse documents the medication before administration. c. The newly licensed nurse uses 2 client identifiers prior to administration. d. The newly licensed nurse verifies the medication label against the provider order.

B: The nurse should document administering medications after they are given to reduce the risk of error (ATI)

A nurse is collecting data from a client about their skin and nails. Which of the following statements by the client should the nurse identify as needing further assessment? a. "When I was a child, I developed a rash after taking amoxicillin." b. "I noticed that my fingernails have changed recently." c. "I used to take baths, but I recently switched to showering." d. "In my family, one cousin had basal cell carcinoma."

B: The nurse should follow up with additional questions for the client to obtain specific information about nail changes the client has observed.

A nurse is teaching a client about self-administration of insulin. Which of the following actions should the nurse take? a. Repeat the least important information to the client. b. Have the client perform a return demonstration of the procedure. c. Provide the client with educational materials written at an 8th-grade reading level. d. Dim the lights in the client's room before beginning the teaching.

B: The nurse should have the client perform a return demonstration of the procedure to determine the client's understanding.

A nurse is administering an IM injection to a client who has HIV. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? a. Rinse the needle with water. b. Dispose of the needle uncapped. c. Use the "scoop" method to recap the needle. D. Wrap the needle in gauze before disposing.

B: The nurse should immediately place the uncapped needle in a puncture-resistant container to prevent a needle stick with the contaminated needle (ATI).

A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? A. The nurse plugs in a sequential compression device with wet hands. B. The nurse holds onto the plug to unplug a client's electronic blood pressure machine. C. The nurse rolls the client's bed over an electrical cord. D. The nurse uses an extension cord to plug in a client's smart infusion pump.

B: The nurse should instruct the newly licensed nurse to hold onto the plug, rather than the cord, to unplug electric cords. Pulling on the cord can damage the cord, and result in an electric shock that could injure the nurse or the client.

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure? A. The AP secures the restraints to the bedrail. B. Padding is placed under the restraints on client bony prominences. C. A double knot is used to secure the restraints. D. The restraints are tightly wrapped around the client's wrists.

B: The nurse should place the padding of the restraints against the client's bony prominences to protect the skin and underlying tissue from the friction the straps might cause. The nurse should be able to insert two fingers between the client's wrist and the restraint to prevent constriction and the possibility of neurovascular injury. Restraints are secured with a quick-release tie, not a double knot, to allow for rapid release in an emergency.The nurse should tie the restraint to the bed frame, because it moves with the client. (ATI)

A nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of the following intake amounts should the nurse recommend? a. 500 to 1,000 mg daily b. 1,000 to 1,200 mg daily c. 1,500 to 2,000 mg daily d. 2,000 to 2,200 mg daily

B: The nurse should recommend that the client consume 1,000 to 1,200 mg of calcium daily. This amount can decrease the risk for bone loss and protect bones against fractures.

A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? A. Tie the restraints to the siderails on the client's bed. B. Remove the restraints with each vital sign check. C. Use a square knot to secure the restraints. D. Make sure one finger can fit under the restraints.

B: The nurse should remove the restraints and check the client's skin and circulation with each vital sign and at least every 2 hr to monitor for client injury.

A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action? a. Intramuscular b. Oral c. Buccal d. Intravenous

B: The oral route, while convenient and most preferred by clients, has a slow onset of action.

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider? a. Skin tags on the neck b. Yellow discoloration of the palms c. Brown birthmark on the thigh d. Absent tenting of the skin

B: Yellow discoloration of the skin, or jaundice, should be reported to the provider. It is caused by an elevated level of bilirubin, which is a by-product of the breakdown of red blood cells. Jaundice can occur in clients who have disorders of the blood or liver. Jaundice is visible throughout the body of clients who have light skin tones and is visible on the palms and soles of clients who have darker skin tones. The color change can be seen on all clients in the sclera and on the hard palate.

A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make? a. "Sometimes medications come in different colors. " b. "The provider wants you to take this medication." c. "I will check your medication order again." d. "Let me explain the purpose of this medication."

C

A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for fire to occur? (Select all that apply.) A. Carbon dioxide B. Nitrogen C. Cooking oil D. Oxygen E. Heat

C, D, E Carbon dioxide is incorrect. Carbon dioxide is a nonflammable gas that is exhaled during respiration. This gas is used in class B fire extinguishers to extinguish oil, gas, grease, paints, and other caustic chemicals. Nitrogen is incorrect. Nitrogen is a nonflammable gas found in nature. It is not one of the three elements needed to make a fire. Cooking oil is correct. The nurse should include cooking oil on the poster as a flammable element. A component required for a fire to burn is a combustible material such as wood, paper, oil, gasoline, or paints. Oxygen is correct. The nurse should include oxygen on the poster as an essential element needed for fire to occur. Heat is correct. The nurse should include heat on the poster as an essential element needed for fire to occur.

A nurse is preparing to administer medication to a client. The nurse should identify which of the following contributes to medication errors? Select all that apply. a. The use of automated dispensing systems b. Administering a generic medication c. Administering medication outside of prescribed time intervals d. Failing to administer a medication e. Incorrect dose of the prescribed medication administered to the client

C, D, E: The use of automated dispensing systems is incorrect. The use of automated dispensing systems has produced a reduction of medication errors because these systems assist nurses in organization, provide an easier method of obtaining medications, and provide record keeping. Giving a generic medication is incorrect. A generic medication is essentially the same product as a brand name medication. Giving a generic medication is not one of the most common causes of medication errors. Administering medication outside of prescribed time intervals is correct. Medication administration outside of prescribed time intervals contributes to medication errors, also known as wrong-time errors. Wrong-time errors are one of the most common causes of medication errors. Failing to administer a medication is correct. The nurse failing to administer a medication to a client is one of the most common causes of medication errors. Incorrect dose of the prescribed medication administered to the client is correct. Administering the incorrect dose to a client is one of the most common causes of medication errors.

A nurse is assessing a client's wrist and hands. Which of the following indicates the client might have arthritis? (Select all that apply). a. Uneven skin tone b. Slight extension of the wrist c. Nodules on the joints d. A large mound below the thumb e. Fingers deviate toward the ulnar

C, E: MY ANSWER Uneven skin tone is incorrect. Uneven skin tone is an expected variation and is not an indication of arthritis. Slight extension of the wrist is incorrect. A slight extension of the wrist is an expected finding and is not an indication of arthritis. Nodules on the joints is correct. Nodules on the joints is an indication of arthritis. A large mound below the thumb is incorrect. A rounded palm with a large mound below the thumb is an expected finding and is not an indication of arthritis. Fingers deviate toward the ulnar is correct. Ulnar deviation, in which the fingers are not in alignment with the wrist and forearm but instead deviate toward the ulnar side of the arm, is an indication of arthritis.

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take? a. Contact the family to clarify the dose of medication. b. Administer the medication as prescribed. c. Contact the provider and question the order. d. Contact the pharmacy to determine if the dose if safe for this client.

C:

A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene? A. Rolls the client to one side of the bed. B. Lowers the bed rail on the side closest to the AP. C. Reaching over the bed to straighten sheets. D. Raises the bed to the AP's waist level.

C: Stretching over the bed demonstrates poor body mechanics. Fitting the sheet one side at a time will allow the AP to reach each part of the bed without straining her back. The AP should make sure the sheet fits securely on one side of the bed before going to the other side (ATI).

A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a HAI? A. Wipe down the client's bedside table with an antiseptic wipe. B. Conduct informal audits of medical records to identify the number of healthcare-associated infections. C. Perform hand hygiene. D. Instruct the client on ways to reduce the risk for infection.

C: According to evidence-based practice, hand hygiene among medical professionals, clients, and visitors is the priority intervention to reduce the risk for the client to develop a healthcare-associated infection.

A nurse is providing teaching to a client who reports acne on their face and chest. Which of the following statements indicates an understanding of the teaching? a. "Exposing these areas to a tanning bed twice a month will decrease the outbreaks." b. "Opening the acne lesions will make them drain and go away faster." c. "I should wash the areas frequently with warm water and soap." d. "Keeping the skin moist with oil-based creams will prevent acne outbreaks."

C: Frequent washing of the affected areas with warm water and soap will remove oil and dirt from the skin. This will reduce the risk of a secondary infection occurring in the lesions.

A nurse is assessing an older adult client while they walk. Which of the following findings should the nurse report to the provider? a. The client walks with small steps. b. The client walks with their legs spread out. c. The client walks with a shuffling gait. d. The client walks with a forward-bent posture.

C: It is an unexpected finding for an older adult client to walk with a shuffling gait. This finding could indicate a musculoskeletal or neurological disorder and should be reported to the provider.

A nurse is examining a lesion on a client's back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion? a. Smooth, defined border b. Uniform color c. Size of a pencil eraser d. Symmetrical appearance

C: Lesions that are greater than 6 mm, or the size of a pencil eraser, in diameter should be recognized as a possible malignant skin lesion and should be reported to the provider.

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take? a. Leave the medication at the client's bedside and administer it later. b. Ask another nurse to administer the medication. c. Lock the medication in the preparing room and continue preparing it after returning from the emergency. d. Ask an unlicensed assistive personnel to administer the medication.

C: No one else should have access to or administer medications the nurse has prepared. Securing them and returning later to finishing preparing and administering them decreases the risk of medication errors. Leaving the medication at the bedside is unsafe. The unlicensed team member is cannot administer medications. (ATI).

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider? a. Yellowed nail color b. White horizontal lines c. Spongy nail base d. Capillary refill 2 seconds

C: The base of the nail should be firm to palpation. Spongy nail bases are associated with clubbing of the nails, which is a manifestation of chronic hypoxia. The nurse should report this finding to the provider.

A nurse is preparing to administer insulin to a client. Which of the following actions should the nurse take first? a. Document the insulin administration. b. Assist with teaching the client about the insulin. c. Have a second nurse confirm the insulin dose. d. Monitor the client for adverse effects of the insulin.

C: The first action the nurse should take is to have a second nurse confirm the insulin dose to reduce the risk for a medication error. All forms of insulin are considered high alert medications that require a second nurse to confirm the dosage prior to medication administration.

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? a. Contact the charge nurse b. Call the family members c. Assess the client d. Call the provider

C: The first action the nurse should take using the nursing process is to assess the client. The nurse must first determine whether or not the error has caused the client any harm and also provide any relevant interventions. (ATI)

A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should the nurse take? a. Mix the medication with the client's feeding infusion. b. Flush the feeding tube with 10 mL of water prior to administration of the medication. c. Administer the medication to the client in a liquid form. d. Place the client in a supine position prior to administering the medication.

C: The nurse should administer the medication in a liquid form to reduce the risk of clogging the feeding tube. The nurse should consult with the pharmacist to determine which medications are available as a liquid and which can be crushed and mixed with water prior to administration.

A nurse is assessing the ROM of a client's hands. The nurse should provide which of the following instructions to assess abduction and adduction of the client's fingers? a. "Bend the thumb in toward the palm of the hand and then move it back out." b. "Make a fist and then straighten the fingers." c. "Spread the fingers apart and then move them back together." d. "Bend the thumb to touch the tip of each finger."

C: To assess abduction and adduction of the fingers, the nurse should instruct the client to spread the fingers apart (abduction) then move them back together (adduction).

A nurse is planning to implement the Transforming Care at the Bedside plan on a med-surg unit. Which of the following interventions should the nurse include in the plan? A. Require nurses to spend 50% of their time at the bedside of clients. B. Perform change-of-shift report at the nurses' station. C. Complete client rounds every 4 hr. D. Use a standardized communication tool.

D The Transforming Care at the Bedside plan recommends using a standardized communication tool, such as the Identity, Situation, Background, Assessment, Recommendation, and Readback (ISBARR) tool. Using a standardized communication tool enhances communication, which results in improved client outcomes.

A nurse is teaching a young adult about risk factors for developing melanoma. Which of the following client statements indicates an understanding of the teaching? a. "The fact that I have five moles increases my risk for developing melanoma." b. "My cousin had squamous cell carcinoma, which increases my risk for melanoma." c. "Having a light complexion decreases my risk for developing melanoma." d. "The blistering sunburns I had as a child increase my risk for melanoma as an adult."

D: Excessive sun exposure and severe or blistering sunburns in childhood increase the risk for developing melanoma as an adult. (A: Client who has 50 or more has increased risk not 5)

A nurse is assessing a client's head and neck. Which of the following findings should the nurse report to the provider? a. C-7 is the most prominent vertebrae. b. Clicking is noted in the temporomandibular joint. c. The muscles of the neck are firm. d. There is locking of the jaw joint.

D: It is an unexpected finding for the temporomandibular joint, or jaw, to have decreased range of motion or lock during assessment. This finding should be reported to the provider

The nurse is working with an older client that was alert and oriented at admission, but is now restless and intermittently confused. Which of the following actions should the nurse take to address the change? A. Apply wrist restraints to the client's upper extremities. B. Contact the family and request they come and sit with the client. C. Medicate the client with a sedative. D. Move the client closer to the nurses station.

D: Moving the client closer to the nurses station will make observation easier. It is the nurse's responsibility, not the family's, to ensure the client's during his time in the facility. Sedation may cause increase in confusion. Restraints are only used as a last resort to ensure safety (ATI).

A nurse is assessing a client's skin color. WHich of the following areas should the nurse check to determine the presence of pallor? a. Anterior chest b. Palms of hands c. Auricle of ear d. Mucous membranes

D: Pallor is a pale or lighter skin color than usual that can be caused by anemia or a circulatory problem. It is best observed by inspecting the color of the lips, mucous membranes, and nail beds.

A nurse received a prescription to administer a medication STAT to a client. What should the nurse do? a. Administer the medication whenever the client reports specific manifestations, such as pain. b. Administer the medication at specific times until directed by health care provider. c. Administer the medication at regular intervals of 4 hr. d. Administer the medication within 30 min of the health care provider prescribing the medication.

D: STAT medication prescriptions should be given immediately and usually one time. STAT prescriptions should be administered within 30 min of the health care provider prescribing the medication.

A nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider? a. Thin skin b. Brown macules on the back of the hands c. Silver-white depressed scars on the abdomen d. Velvety skin

D: Skin that feels smoother and softer than expected, similar to velvet, is associated with thyroid disorders. This is an unexpected finding that should be reported to the provider.

A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications? a. Verify the client's identity using their diagnosis. b. Use one identifier to confirm the client's identity. c. Use the client's room number to identify the client. d. Have the client confirm their name and date of birth.

D: The client's identity must be verified using two unique identifiers prior to medication administration to ensure the correct medication is being given to the right client. The nurse should confirm the client's identity and replace the client's identification band.

A nurse is preparing to administer medication to a preschool child. Which of the following information should the nurse keep in mind when administering meds to the client? a. The dosage is calculated by height. b. The preschooler is unable to take capsules. c. Preschoolers receive the same amount of medication as adults. d. The deltoid muscle can be used to administer intramuscular injections.

D: The deltoid muscle can be used to administer intramuscular injections in preschoolers as well as in adults.

A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? A. Extinguish the fire. B. Close the windows in the client's room. C. Close the client's door. D. Activate the fire alarm.

D: The greatest risk to this client is injury from a fire. Therefore, the next action the nurse should take is to activate the emergency fire alarm to alert emergency responders to extinguish the fire.

A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include? a. Use closed-ended questions. b. Provide written material at a 9th-grade reading level. c. Use passive listening skills. d. Encourage the client to ask questions.

D: The nurse should encourage the client to ask questions to facilitate an active role in their own care and promote an understanding of the education.

A nurse is assisting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? A. Legitimate absenteeism B. Strict adherence to facility policies C. Consistent adequate work performance D. Frequent reports of not being treated fairly

D: The nurse should include that persistent complaining and voicing that they are not being treated fairly is a warning sign for possible future workplace violence by a co-worker.

A nurse is preparing to administer an intradermal injection to a client. At which of the following degrees should the medication be administered? a. 60° angle b. 90° angle c. 45° angle d. 10° angle

D: The nurse should insert the needle at a 5° to 15° angle about 1/8 inch under the skin and observe for the tip of the needle, which would indicate that the needle is in the intradermal layer of the client's skin.

A nurse is performing a musculoskeletal and neurological assessment. Which of the following actions should the nurse take? a. Perform the assessment from the toes to the head. b. Assess the extremities from distal to proximal. c. Perform passive range of motion before active range-of-motion movements. d. Inspect for symmetry on both sides of the body.

D: The nurse should inspect the client for symmetry of range of motion, gait, muscle tone, and strength.

A nurse is scheduled to administer a medication to a client who is currently in the bathroom. Which of the following actions should the nurse plan to take? a. Leave the medication at the client's bedside. b. Prepare the medication to administer later. c. Document the medication was given prior to administration. d. Come back in a few minutes to administer the medication.

D: The nurse should wait for the client to finish in the bathroom or come back in a few minutes to administer the medication to ensure the medication is safely administered. The nurse should stay with the client until the medication is completely administered via the correct route.

A nurse is assisting teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include? a. Place a new transdermal patch over the same site as an old patch. b. Apply no more than two transdermal patches at a time. c. Expect the transdermal medication to absorb rapidly. d. Wear clean gloves to apply the transdermal medication.

D: The nurse should wear clean gloves to apply the transdermal patch to protect the nurse from accidentally absorbing the medication.

A nurse is planning to use the teach-back method to educate a client about anti-HTN medication. Which of the following methods should be used? a. Provide the client with an internet link to research the medications. b. Refer the client to the American Heart Association. c. Give the client written educational material about the medication. d. Ask the client to explain the information using their own words.

D: The teach-back method is a teaching approach in which the client repeats the instructions or information back to the nurse using their own words. This method allows the nurse to determine the client's understanding of the information and whether further education is required.

A nurse is assessing the ROM of a client's head and neck. The nurse should provide which of the following instructions to assess hyperextension? a. Turn the head from side to side and look back over the shoulders. b. Bend the neck to the side and bring the ear close to the shoulder. c. Lower the chin to the chest and raise it back up. d. Tilt the head back and look up at the ceiling.

D: To assess for hyperextension of the head, the nurse should instruct the client to tilt the head back and look up at the ceiling.

A nurse is assessing a client's spinal ROM. Which of the following motions is the nurse assessing by asking the client to bend backward as far as they can go? a. Flexion b. Rotation c. Lateral flexion d. Hyperextension

D: To assess hyperextension, the nurse should ask the client to bend backwards as far as they can go.