FUN 2
A nurse should understand the different types of isolation precautions necessary to prevent transmission of infection in a healthcare facility. For which of the following clients would contact precautions be indicated? A. 19-year-old client with TB B. 5-year-old client diagnosed with acute bronchitis C. 43-year-old who has MRSA D. 25-year-old client with community-acquired bacterial pneumonia
C
Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated. 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment
1, 4, 6
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs.) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal bowel function within 72 hours. 3.Patient's skin integrity will remain intact through discharge. 4. Erythema of skin will be mild to none within 48 hours.
4
The nurse writes an expected outcome statement in measurable terms. An example is: 1. Patient will have normal stool evacuation. 2. Patient will have fewer bowel movements. 3. will take stool softener every 4 hours. 4. Patient will report stool soft and formed with each defecation.
4
A nurse is caring for a client who is on a mechanical ventilator and who receives nutrition through a feeding tube. Which position will most likely reduce the risk of this client developing aspiration pneumonia? A. Supine with the head of the bed elevated 30 to 45 degrees B. Right-side laying C. Supine with the head of the bed elevated 15 degrees D. Left-side laying
A
A nurse is caring for a client with dysuria. A urine specimen is sent to the lab for routine urinalysis. Which of the following findings is most specific for a urinary tract infection? A. Nitrite B. Protein C. Bilirubin D. Erythrocytes
A
A nurse is caring for a diabetic client; she checks his feet and notes that the skin is clean, dry, and intact. What information will the nurse provide to the client about how best to prevent foot wounds associated with diabetes? A. "Call your doctor if you develop an ingrown toenail" B. "If you develop calluses, trim them carefully with a sterile pair of scissors" C. "Avoid excess physical activity, as this can be too hard on your feet" D. "Only clean your feet with hot water, never cold water"
A
A nurse is instructing a client on about a new prescription for Phenytoin (Dilantin). Why does the nurse emphasize the need for meticulous oral hygiene with Phenytoin? A: Causes hyperplasia of the gums. B: Increases alkalinity of oral secretions. C: Irritated gingival tissue and destroys tooth enamel. D: Causes increased plaque and bacterial growth along the gum lines.
A
A nurse is caring for a client who develops nausea, vomiting, and diarrhea 1 day after the initiation of enteral feeding with a hypertonic formula. Which of the following is the most appropriate initial intervention by the nurse? A. Send a stool sample for testing for C. difficile toxin B. Dilute the hypertonic formula with water C. Reduce the rate of feeding D. Discontinue feeding
C
A nurse is caring for a client who has an NG tube in place and a new prescription for a sublingual medication. Which of the following actions should the nurse take? A. Request a prescription for a different formulation of the medication B. Hold the medication until the NG tube is removed C. Administer the medication under the client's tongue D. Dissolve the medication in water and give it through the NG tube
C
A nurse is planning use of therapeutic music intervention while caring for a client who is experiencing anxiety and stress. Which best describes effective music intervention by the nurse? a. keeping the radio on the bed side b. Focused listening to music to pick out specific tones and notes c. Listening to music according to the clients preference d. allowing the client to being a musical instrument to her room
C
A nurse is providing information to two student nurses about hand hygiene. Which of the following statements regarding alcohol-based hand rubs shows correct understanding by the student nurse? A. Alcohol-based hand rubs are useful for convenience, but they are not as effective as soap and water. B. Alcohol-based hand rubs can cause dryness and skin chapping if used over time. C. Alcohol-based hand rubs should not be used if blood or other visible soil is present on the hands. D. Alcohol-based hand rubs that are rated at 99% concentration are most effective.
C
A patient has developed oral mucositis as a result of radiation to the head and neck. Which measure should the nurse teach the client to incorporate in a daily home care routine to help manage this condition? A. A glass of wine per day will introduce useful bacterial to the oral cavity. B. High-protein foods such as peanut butter should be incorporated in the diet. C. Clean teeth and rinse mouth with a weak saline and water solution before and after each meal. D. Oral hygiene, including brushing and flossing, should be performed in the morning and evening.
C
Which of the following activities must be considered when working with IV tubing used with total parenteral nutrition? A. An in-line filter is used with all solutions containing vitamins. B. Any dressing that gets wet at the insertion site is changed within 48 hours. C. Aseptic technique is used when tubing is changed. D. TPN tubing cannot be connected to an infusion pump.
C
A nurse in an assisted living facility is planning an exercise program for a group of older adult clients who are typically sedentary. Which of the following activities should the nurse plan to include in the program? a. tennis b. swimming c. running d. jumping rope
B
A nurse is assessing a client who is postoperative a hip replacement procedure and has been receiving morphine IV every 2 hours for pain. Why would the nurse discontinue q-2 hour medication administration? A. Blood pressure 104/70 mmHg B. Respiratory rate of 10/min C. Burning during injection D. Nausea
B
A nurse is providing education to a client about a new prescription for sublingual tablets. The nurse tells the client that sublingual medication has a more rapid onset than oral medication because of the way it enters circulation. Which of the following best describes how sublingual medicine enters the circulation? A. It targets the affected tissue directly B. It enters the circulation through the mucous membranes C. It is absorbed by the lymph system D. After swallowing, it is digested in the gastrointestinal tract
B
A nurse is providing education to a student nurse about oral hygiene. Which statement by a student nurse demonstrated understanding of proper oral hygiene? A. Use a hard-bristled toothbrush for brushing, brush tongue, and floss daily B. Use a soft-bristled toothbrush for brushing, brush tongue, and floss daily C. Use a hard-bristled toothbrush for brushing, brush the roof of the mouth, and rinse with mouthwash D. Use a soft-bristled toothbrush for brushing, brush the roof of the mouth, and rinse with mouthwash
B
A nurse is providing education to student nurses about hand hygiene? Which of the following statements by a student nurse demonstrates understanding of proper oral hygiene? A: Use a hard-bristled toothbrush for brushing, brush tongue, and floss daily. B: Use a soft-bristled toothbrush for brushing, brush tongue, and floss daily. C: Use a hard-bristled toothbrush for brushing, brush the roof of the mouth, and then rinse with mouth wash. D: Use a soft-bristled toothbrush for brushing, brush the roof of the mouth, and then rinse with mouth wash.
B
A nurse is providing home care for a toddler with multiple developmental disabilities who rarely goes outdoors because of photosensitivity. Which nutritional deficit is the client most likely to have? A. Vitamin C deficiency B. Vitamin D deficiency C. Magnesium deficiency D. Vitamin B deficiency
B
A nurse is visiting a client at home who is receiving parenteral nutrition. The nurse notes that the client has gained 6 pounds (2.7 kg) since last week's visit. Which of the following assessments will the nurse prioritize as a result of these findings? A. ask about increased thirst B. Auscultate lungs to check for crackles C. Check neurological status D. Check client's mouth for dryness
B
A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly? A. The mother cleans the ears and then moves to the eyes and the face. B. The mother begins to wash the newborn infant by starting with the eyes and face. C. The mother washes the arms, chest and back followed by the neck, arms and face. D. The mother washes the entire newborn infant's body and then washes the eyes, face an
B
An RN and an LPN are caring for a client admitted for control of pain due to metastatic cancer. The RN administers the prescribed dose of hydromorphone 2.0 mg IVP STAT. The client calls for the nurse in 2 hours and states his pain is 8 on a scale of 0-10 and requests pain medication. Which of the following is the priority action of the RN? A. Reposition the client B. Assess the client and notify the healthcare provider C. Give a second dose of hydromorphone D. Ask the LPN to take vital signs and administer the medication if vitals are within normal limits
B
The nurse is assessing a client's nutritional status before surgery. Which of the following observations would indicate poor nutrition in a 5 foot 7 inch female who is 21 years old? A. Poor posture B. Brittle nails C. Dull expression D. Weight of 128 lbs (57.6 kg)
B
The nurse is caring for a client who will be taking Pyridium for pain associated with a urinary tract infection. The nurse should instruct the client that this medication will cause: A. Constipation B. Bright orange urine C. Drowsiness and lethargy D. Urinary incontinence
B
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E
B
The nurse is discussing foot care w/ client who was recently diagnosed w/ diabetes. Which statement by client indicates need for further teaching? A. "I am going to use a mirror to check my feet." B. "I enjoy walking barefoot around the house." C. "I will file my nails." D. "I will increase the time that I wear new shoes each day."
B
What does the Braden Scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing
B
Which of the following interventions should be implemented as part of safe medication administration practices?(select all that apply) A. leave medications at the bed side to allow the client to take it when he feels ready B. Never administer medication that has been prepared by someone else C. Keep all controlled substances in a visible and accessible area D. Verbal orders from a health care provider are acceptable if repeated twice, slowly, and clearly, by the health care provider. E. Double check high-alert medications with another nurse before administering
B, E
A nurse is completing a pain assessment for a toddler and asks the toddler to self-report the pain. Which of the following pain scales should the nurse use? A. FACES B. FLACC C. Numerical Scale D. Children's hospital of Eastern Ohio Pain Scale (CHEOPS)
A
A nurse is caring for a elderly client who fell to the sidewalk and sustained a laceration that required sutures. The nurse understands that which of the following may impair wound healing in this client? A) There is increased circulation and oxygenation of tissues. B) The skin is more fragile C) There is an increase in the amount of collagen. D) There is faster tissue regeneration.
B
The nurse is caring for a client with a kidney stone who is withering in pain. Which of the following is the priority nursing intervention? A. Decreasing fluids B. Medicating for pain C. Increasing fluids D. Straining all urine
B
A nurse is completing a pain assessment of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Pain in the right upper quadrant radiating to the right shoulder B. Report of pain being worse when sitting upright C. Pain is intermittent D. Epigastric pain radiating to the left shoulder
D
A patient with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is: This is probably the result of A. Inadequate arterial blood supply B. Delayed healing of tissues after an injury C. Increased production of melanin of that area D. Leakage of RBCs through the vascular wall
D
The client is to receive a sedative via the buccal route. Which of the following is true? A. The medication is placed under the tongue. B. This route is probably more expensive than the intramuscular route. C. The nurse should offer the client a glass of orange juice after taking the sedative. D. This method of administration would be avoided in the event of facial injuries.
D
The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? a. Nuts and milk b. Coffee and tea c. Cooked rolled oats and fish d. Oranges and dark green leafy vegetables
D
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? a. neurotic tissue b. wound drainage c. wound circumference d. cleansed wound
D
When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) a. to relieve edema b. to reduce shivering c. to improve blood flow to an injured part d. to protect bony prominences from pressure ulcers e. to immobilize area
A, C
Which of the following statements correctly describes the evaluation process? (Select all that apply.) A. Evaluation is an ongoing process. B. Evaluation usually reveals obvious changes in patients. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills. E. Evaluation is only done when a patient's condition changes.
A, C, D
When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? Select all that apply. a. Oxygen saturation b. Heart rate c. Respirations d. Gag reflex e. Response to painful stimulus
C, D
A wound, ostomy and continence nurse screens women who are incontinent of urine to determine the best plan of care. The nurse knows that risk factors for urinary incontinence include which of the following? A. Age B. Smoking C. Menopause D. Kidney Disease E. All of the above
E
After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection. What should the nurse do next? (Select all that apply.) 1. Assess the injection site 2. Administer an oral medication for pain 3. Notify the patient's health care provider of assessment findings 4. Document assessment findings and related interventions in the patient's medical record 5. This is a normal finding so nothing needs to be done 6. Apply ice to the site for relief of burning pain
1, 3, 4
A nursing student is administering ampicillin PO. The expiration date on the medication wrapper was yesterday. What is the appropriate action for the nursing student to take next? 1. Ask the nursing professor for advice 2. Return the medication to pharmacy and get another tablet 3. Call the health care provider after discussing this situation with the charge nurse 4. Administer the medication since medications are good for 30 days after their expiration date
2
A nurse is caring for an 8-year-old client and administers a new medication through the oral route, as prescribed by the healthcare provider. After administration of the medication, the nurse notices that pediatric clients should receive the suppository form form of the medication. Which of the five rights of medication administration has this error violated? A. right drug B. right dose C. right route D. right client
C
A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child? a. A medication cup b. A teaspoon c. A 5-mL syringe d. An oral-dosing syringe
D
A nurse is reviewing the laboratory values for a client who had a stage 3 pressure ulcer. The nurse should identify that which of the following laboratory findings can delay wound healing? A. Prealbumin 14mg/dL B. Hemoglobin 16 g/dL C. WBC count 8,000/mm3 D. aPTT 32 seconds
A
The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses
2
A health care provider writes an order for 4mg morphine IV. The medication ampule contains 8 mg/mL. How many mL should the nurse prepare to administer to the client? A. 4 mL B. 5 mL C. 3.2 mL D. 0.5 mL
D
A nurse is assessing a client's wound and note that there is a small amount of yellow drainage that is watery in consistency. This drainage is most likely described as: a. sanguineous b. purulent c. serosanguineous d. serous
D
An HCP writes an order for 4 mg morphine IV. The medication ampule contains 8mg/mL. How many milliliters should the nurse prepare to administer to the client? A. 4mL B. 5mL C. 0.5mL D. 3.2mL
C
An RN is performing a sterile dressing change when a nursing assistant reports that a client who is a postoperative hip replacement asked when he would be receiving his PRN pain medication, as he anticipates pain when his current medication "wears off". What is the correct action by the RN? A. Ask the nursing assistant to tell the client he will be there shortly B. Direct the nursing assistant to take the client's postop vital signs C. Interrupt the dressing change to administer the pain medication to the postop client D. Ask the nursing assistant to find out how the client rates the pain on a scale of 1-10
A
The CDC recommends antimicrobial hand cleansing agents in all of the following situations except: A. When there are unknown multiple nonresistant bacteria. B. Before invasive procedures C. In special care units, such as a nursery or ICU D. Before caring for a severely immunocompromised client
A
The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? A. The client's pain rating B. Nonverbal cues from the client C. The nurse's impression of the client's pain D. Pain relief after appropriate nursing intervention
A
The parent of a toddler is cleaning the child's teeth. Which of the following statements indicates a need for further teaching? A. "I'll brush my child's teeth with a hard toothbrush." B. "I'll give a fluoride supplement daily or as recommended by the physician or dentist, unless my drinking water is fluoridated." C. "I'll schedule an initial dental visit for my child at about 2 or 3 years or as soon as all 20 primary teeth have erupted." D. "I'll seek professional dental attention for any problems such as discoloring of the teeth, chipping, or signs of infection such as redness and swelling."
A
Which of the following is included as part of the hand washing when performing hand hygiene? A. Always wash hands before and after a medical procedure B. Lather with soap and rub hands together for 5-10 seconds C. Carefully scrub under rings and bracelets D. Only dry hands using an air dryer
A
A nurse is caring for an elderly client who fell to the sidewalk and sustained a laceration that required sutures. The nurse understands that which of the following may impair wound healing in this client? A. There is increased circulation and oxygenation of tissues B. The skin is more fragile C. There is an increased amount of collagen D. There is faster tissue regeneration
B
The nurse is caring for a critically ill patient. What are the contraindications for administering medications by the oral route for this patient? (Select all that apply.) a. Vomiting b. Unconsciousness c. Fractured leg d. Penicillin allergy e. Family visitor f. Diarrhea
A, B
A postoperative client has been placed on a clear liquids diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. a. Broth b. Coffee c. Gelatin d. Pudding e. Vegetable juice f. Pureed vegetables
A, B, C
During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. a. Perineal skin irritation b. Fluid intake of less than 1,500 mL/day c. History of antihistamine intake d. History of frequent urinary tract infections e. A fecal impaction
A, B, D, E
A nurse is providing information to a client with renal calculi. Which of the following is true about renal calculi? A. proteus bacteria causes struvitre stones B. increased purine intake causes renal calculi C. cystine stones occurs in 15 to 20% of cases D. allopurinol is prescribed to treat oxalate calculi E. gout does not cause renal calculi F. acidic urine is a risk factor
A, B, F
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? A. An inflammation of the epidermis only. B. A skin infection of the dermis and underlying hypodermis. C. An acute superficial infection of the dermis and lymphatics. D. An epidermal and lymphatic infection caused by Staphylococcus.
B
A client with chronic low back pain has experienced an exacerbation after helping a friend move furniture over the weekend. When he calls the clinic, the nurse realizes the increased pain may be the result of inflammation. Which of the following non-pharmacological interventions should the nurse recommend? A. Changing position to a position of more comfort B. Resting from all activities that aggravate the pain C. Completing exercises that stretch the involved muscle group D. Using a heating pad.
B
You are assessing a new patient at a pediatric outpatient clinic. The child is 2 years old and has severe dental caries, dry mucous membranes, and poor hygiene, including a dirty diaper that appears soaked with urine and contains stool. What is the priority in management? A. An immediate report to CPS should be made if neglect is suspected B. Assess caregiver interactions with the child C. The child should be admitted immediately for safety D. Call another member of the family to determine if there is neglect
B
Which of the following interventions should be implemented as part of safe medication administration practices? (Select all that apply.) A. Leave medication at the bedside to allow the client to take it when he feels ready. B. Never administer medication that has been prepared by someone else. C. Keep all controlled substances in a visible and accessible area. D. Verbal orders from a healthcare provider are acceptable if repeated twice, slowly and clearly, by the healthcare provider. E. Double check high-alert medications with another nurse before administering
B, E
Which of the following points relating to personal hygiene and the activities of daily living should you emphasize during an educational session for a group of newly employed nursing assistants? A. The wholly compensatory client, according to Orem, benefits greatly from independent function in terms of enhancing the client's dignity and self-esteem. B. All bathing and shower water should be about 190 degrees Fahrenheit to prevent chilling and shivering during the bathing process. C. Culture and cultural practices greatly affect the client's personal hygiene and activities of daily living. D. Nursing assistants are not permitted to do any foot care or hygiene for clients who have diabetes.
C
A nurse is caring for an obese client postoperatively who has an abdominal incision that is healing poorly. After the client complains of coughing forcefully, the nurse notes protrusion of the intestine through the surgical wound. Which of the following in the priority action? A. Take the clients vital signs B. Cover the wound with a dry sterile towel C. Using a sterile towel, press the organs back into the body cavity D. Place the client in the low fowler's position
D
A nurse is reviewing postpartum nutrition needs with a client who is breast feeding. Which of the following statements by the client indicates an understanding of the instructions? a. "I can continue to smoke as long as I do it 30 minutes prior to breastfeeding." b. "I should take folic acid to increase my milk supply." c. "I will continue adding 200 calories per day to my diet." d. "I will continue taking my vitamins while I am breastfeeding."
D
The nurse is observing unlicensed assistive personnel (UAP) perform perineal care for client. Which action indicates that nurse needs to discuss additional teaching with UAP? A. Uses a clean portion of washcloth for each stroke. B. Wipes from pubis to rectum. C. Uses clean gloves. D. Does not retract foreskin.
D
When preparing to administer medications on the medical-surgical floor, which of the following actions should a nurse take to comply with client safety practices to prevent medication administration errors? A. ask the pharmacist to identify any unlabeled medications B. Wear gloves when preparing an unopened unit dose package C. Verify the client's primary healthcare provider D. Medications must be given within 1 hour of the time on the medication log E. Open all unit doses and place in a dispensing cup before taking to the bedside
D
Which of the following interventions is most appropriate in a hospitalized client at risk of impaired skin integrity? A. limit chair-sitting to 4 hours at a time B. break blisters and cover them with gauze C. encourage food intake of 4000 to 5000 calories oer day D. promote ambulation when the client is able
D
The nurse is administering an unpleasant-tasting liquid medication to a 2-year-old child. Which intervention should the nurse implement? 1. Use a dropper to place the medication between the gum and cheek. 2. Put the medication in 4 ounces of apple juice. 3. Prepare the medication in the child's favorite food. 4. Tell the child the medication will not taste bad.
1
A patient has been prescribed the medication spironolactone (aldasterone). When preparing the patient for discharge, the nurse should include which of the following instructions? SELECT ALL THAT APPLY: 1. "This medication will make you urinate more often." 2. "Remember to eat salt substitutes instead of actual sodium." 3. "Do not take this medication before bedtime." 4. "Check your weight daily and keep a record to bring with you to your next appointment." 5. "Be sure to take this with meals." 6. "It is important to increase your intake of dark leafy greens."
1, 3, 4, 5
The nurse caring for a patient receiving intravenous therapy monitors for which signs of infiltration of an intravenous (IV) infusion? (Select all that apply) A. Slowing of the IV rate B. Tenderness at the insertion site C. Edema around the insertion site D. Skin tightness at the insertion site E. Warmth of skin at the insertion site F. Fluid leaking from the insertion site
A, B, C, D, F
The nurse is developing a plan of care for a patient who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? (Select all that apply) A. Minimize the force and friction applied to the skin. B. Massage vigorously over bony prominences twice daily. C Perform a systematic skin inspection at least once a day. D. Cleanse the skin at the time of soling and at routine interval. E. Use pillows to keep the knees and other bony prominences from direct contact with one another. F. Use hot water and a mild cleansing agent that minimizes irritation and dryness of the skin when bathing the client.
A, C, D, E
An RN is supervising a student nurse who is applying a knee-length anti-embolism stockings (TED hose) for a client with venous insufficiency. Which of the following actions by the student nurse should cause the nurse to intervene? Select all that apply. A. The student nurse advises the client to remove the stockings during daytime hours. B. The student nurse measures from heel to the popliteal area. C. The student nurse chooses a size larger than required to prevent friction to a leg laceration. D. The student nurse smoothes out wrinkles and creases in the stocking. E. The student nurse rolls down excess length at the top of the stocking.
A, C, E
A nurse is caring for a client with a nursing diagnosis of impaired skin integrity, related to decreased mobility and mechanical factors. Which of the following interventions would be appropriate for this client? A. encourage food and fluid intake B. encourage chair sitting to keep the client out of bed C. use talcum powder to keep skin dry D. assist the client with ambulation and encourage mobility E. assist the client to change positions every four hours
A, D
A nurse is caring for a client with a nursing diagnosis of impaired skin integrity, related to decreased mobility and mechanical factors. Which of the following interventions would be appropriate for this client? (Select all that apply) A. Encourage food and fluid intake B. Encourage chair sitting to keep the client out of bed C. Use talcum powder to keep skin dry D. Assist the client with ambulation and encourage mobility E. Assist the client to change positions every four hours
A, D
Which of the following is a benefit associated with electronic medication administration records? (Select all that apply.) A. Improves access to information B. Eliminates the need for the nurse to verify client identification C. Eliminates the need for the nurse to verify dosage calculations D. Reduces the risk of medication administration errors E. Allow easy substitutions by the nurse
A, D
One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? (Select all that apply) a. A patient is receiving chemotherapy for bladder cancer. b. An adolescent is admitted to the hospital for an appendectomy. c. A patient is experiencing a ruptured aneurysm. d. A patient who has fibromyalgia requests pain medication. e. A patient has back pain related to an accident that occurred last year. f. A patient is experiencing pain from second-degree burns.
A, D, E
A patient receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic? A. Turn off the TPN for 30 min B. Ensure a separate IV access route. C. Flush the CVC with normal saline D. Check for compatibility with TPN.
B
A nurse is assessing a client's stoma during the initial postoperative period after colostomy. Which of the following observations should be reported immediately to the physician? A. The stoma is slightly edematous B. The stoma is white to bluish-white C. The stoma oozes a small amount of blood D. The stoma does not expel stool
B
A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? A. Heat the solution using a microwave before cleaning the wound. B. Reposition the client at least every 2 hours. C. Clean the wound with hydrogen peroxide solution. D. Massage reddened areas during dressing changes.
B
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site? A. Dry sterile dressing B. Hydrocolloid dressing C. Wet, sterile dressing D. One-half strength povidone-iodine dressing
C
A nurse in the ED is caring for a client with angina. The healthcare provider prescribes nitroglycerin 0.3mg given sublingually. This drug's principal effects are produced by: A. antispasmotic effects on the pericardium B. causing increased myocardial oxygen demand C. vasodilation of peripheral vasculature D. improved conductivity in the myocardium
C
A nurse is completing a pain assessment of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Pain in the right upper quadrant radiating to the right shoulder B. Report of pain being worse when sitting up right C. Pain is intermittent D. Epigastric pain radiating the left shoulder
D
A nurse is instructing a client with metastatic cancer who has received a prescription for oxycodone for pain. Which of the following should the nurse priorities to prevent long term complications associated with this medication? A. Use proper sleep hygiene techniques to improve rest B. Use emollients to relieve itching C. Take medication with some food to decrease the risk of nausea D. Drink an adequate amount of fluid and exercise or ambulate to help prevent constipation
D
A nurse is preparing to administer a newly prescribed medication to a client. Which of the following is one of the six "rights" of medication administration? A. The "Right" planning B. The "Right" Evaluation C. The "Right" Assessment D. The "Right" Documentation
D
The client has a stasis ulcer on the right heel. The most important primary intervention for this client is: A) Administer medication for the pain. B) Help the client sit up in the chair three times a day. C) "Float" the client's foot on a pillow to prevent contact with the bed. D) Apply lotion to the foot and ankle.
C
The nurse is caring for a patient who has been placed in skin traction. Which action by he nurse provides for countertraction to reduce shear and friction? A. Using a footboard B. Providing an overhead trapeze C. Slightly elevating the foot of the bed D. Slightly elevating the head of the bed
C
The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a patient. When administering the IV potassium chloride, which action should the nurse take? A. Inject it as a bolus B. Use a filter in the IV line C. Dilute it per medication instructions. D. Apply cool compress to the IV site
C
When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? A. Pale yellow urine B. Slightly cloudy urine C. Light pink urine D. Dark amber urine
C
Which of the following points relating to personal hygiene and the activities of daily living should you emphasize during an educational session for a group of newly employed nursing assistants? A. The wholly compensatory client, according to Orem, benefits greatly from independent functions in terms of enhancing the client's dignity and self-esteem B. All bathing and shower water should be about 190 degrees Fahrenheit to prevent chilling and shivering during the bathing process C. Culture and cultural practices greatly affect the client's personal hygiene and activities of daily living D. Nursing assistants are not permitted to do any foot care or hygiene for clients who have diabetes
C
While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? A. A patient who just returned to the nursing unit from a diagnostic test B. A patient who prefers a bath in the evening when his wife visits and can help him C. A patient who is experiencing frequent incontinent diarrheal stools and urine D. A patient who has been awake all night because of pain 8/10
C
A nurse receives laboratory results for serum electrolytes for a client with fluid and electrolyte imbalance. Which of the following represents a normal sodium serum level? A. 126mEq/L B. 138mEq/L C. 148mEq/L D. 152mEq/L
B
A nurse is caring for several clients on a medical ward. Which of the following clients would most likely need a hight protein nutrition supplement? A. a client with galactosemia B. a client in liver failure C. a client with pancreatic cancer D. a client with end stage renal disease
C
When giving a bath to a newborn, the nurse should: a. use mild soap such as ivory b. use powder after the bath c. put baby oil in the water d. wash with water only
D
A nurse is teaching a group of student nurses about administration of total parenteral nutrition. Which of the following statements by a student nurse indicates correct understanding? A. TPN should be administered through a designated port on a multi-lumen central venous catheter B. TPN can be administered through a central line or through a peripheral IV C. TPN requires an unfiltered tubing set except when the solution is administered by gravity D. TPN tubing must be changed every 72 hours to prevent the risk of infection.
A
A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? A. Have the patient perform a Valsalva maneuver B. Clamp the intravenous (IV) tubing to prevent more air from entering the line C. Have the patient take a deep breath and hold it D. Notify the health care provider immediately
A
Which of the following lifestyle factors may have the largest effect on the development of foot wounds in a diabetic? a. caffeine intake b. smoking c. decreased intake of potassium d. moderate exercise
B
A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness burns over 60% of his body 24 hours ago. Which of the following routes should the nurse use to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Intramuscular
C
A nurse is providing discharge teaching to a client who is post-op day 3 after an open cholecystectomy. When providing discharge teaching about wound care, which of the following will the nurse advise the client may indicate a wound infection? A. serous drainage from the incision B. Increased fatigue when performing daily activities C. Warmth and erythema at the wound site D. Pink skin at the incision
C
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? Select all that apply. a. Prone position b. Sims' position c. Semi-Fowler's position with head to side d. Trendelenburg position e. Supine position
B, C
Which of the following are appropriate client identifiers when a nurse is giving a medication? (Select all that apply). A. Room number B. Medical record number C. Date of birth D. Name of health care provider E. Last name
B, C
A nurse is providing discharge teaching to a client who is post-op day 3 after an open cholecystectomy. When providing discharge teaching about wound care, which of the following will the nurse advise the client may indicate a wound infection? A. Serous drainage from the incision B. Increased fatigue when performing daily activities C. Warmth and erythema at the wound site D. Pink skin at the incision
C
When administering IV morphine every 3-4 hours as needed for postoperative pain, the nurse knows to implement which of the following interventions? (SATA) A. Reassess the client in 1 hour after administration of the medication B. Administer stimulant laxatives daily to prevent constipation C. Tell the client to ask for assistance when getting out of bed D. Administer over 5 minutes E. Do not co administer with non opioid analgesics
C, D
Which of the following items in the focused pain assessment is correctly matched with a question asked by a nurse during that specific portion of the assessment? (SATA) A. provocative factors: "how often does the pain occur?" B. quality: "does the pain radiate anywhere else?" C. location: "where are you and what are you doing when symptoms occur?" D. timing: "is your pain constant, or does it come and go?" E. palliative factors: "is there anything that you notice improves your pain?"
D, E
