Fundamentals ATI - missed practice questions
A nurse is caring for a client who is 48 r postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? a. blood loss b. NPO status after surgery c. nasogastric tube suctioning d. impaired peristalsis of the intestines
d. Impaired peristalsis of the intestines
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? a. Redness at the infusion site b. edema at the infusion site c. warmth at the infusion site d. oozing of blood at the infusion site
b. edema at the infusion site (redness is indication of phlebitis, warmth is indication of phlebitis, oozing of blood is indication the IV system is not intact)
a nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. which of the following actions should the nurse take prior to the feeding? a. warm the feeding in a microwave oven b. elevate the head of the client's bed c. flush the tube with 0.9% sodium chloride for irrigation d. verify that the client's gastric pH is above 4
b. elevate the head of the client's bed (feed should be room temp, flush tube with water prior to inserting, gastric pH should below before 4)
A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? a. low battery power b. excessive wax in the ear canal c. a volume setting that is too low d. a crack in the ear tube
b. excessive wax in the ear canal
A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. which of the following actions should the nurse take? a. inform the guard that the warden must request this information b. ask the guard to sign a release of information form c. instruct the guard to ask the inmate d. complete an incident report
c. instruct the guard to ask the inmate
a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown? a. place the client in high-fowler's position b. increase the client's intake of carbohydrates c. massage reddened areas with unscented lotion d. have the client use a trapeze bar when changing position.
d. have the client use a trapeze bar when changing position
A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take? a. have the client urinate 20 min before the scan b. assist the client into a semi-fowler's position c. position the scanner head at the symphysis pubis d. apply light pressure to the scanner once it is in position
d. apply light pressure to the scanner once it is in position (should urinate 10 min before the scan, supine position with head slightly elevated, scanner head should be about 1-1.6 inches above the symphysis pubis)
A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? a. incontinence b. mental state c. nutrition d. general physical condition
c. nutrition (the parameters are: nutrition, sensory perception, moisture, activity, mobility, and friction and shear)
a nurse is teaching a client who reports stress urinary incontinence. which of the following instructions should the nurse include? (select all that apply) a. limit total daily fluid intake b. decrease or avoid caffeine c. take calcium suplements d. avoid drinking alcohol e. use the crede maneuver
b. decrease or avoid caffeine d. avoid drinking alcohol
A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (select all that apply.) a. gingivitis b. dry, brittle hair c. edema d. spoon-shaped nails e. poor wound healing
b. dry, brittle hair c. edema e. poor wound healing
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? a. leave the bag in place for 45 min b. fill the bag 2/3 with ice c. place the bag uncovered on the client's ankle d. tell the client that numbness is expected when the ice bag is in place
b. fill the bag 2/3 with ice
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? a. "lunch trays should be here within the hour" b. "I am going to listen to your abdomen" c. I'll get you some water to drink d. "I would wait a bit, or you could feel sick"
"I am going to listen to your abdomen" (make sure there is bowel sounds)
Things an AP should do for catheter care (4)
1. hang the collection bag below the level of the bladder 2. cleanse perineal area with soap and water at least 3 times per day 3. tape catheter to inner thigh of a female client 4. make sure no kinks in tubing to ensure proper drainage by gravity
urine specific gravity
1.005-1.030
hemoglobin expected range
12-18 g/dL
what is an appropriate amount of water to drink daily for active people?
2-3 L daily
how many mL's of fluid per day?
2000-3000 mL per day
A nurse is preparing to instill a vaginal medication suppository from to a client. which of the following actions should the nurse take during this procedure? a. don sterile gloves b. use the dominant hand to retract the labia c. use the index finger to insert the suppository d. ease the suppository along the anterior vaginal wall
c. CORRECT - use the index finger to insert the suppository (ease the suppository along the posterior vaginal wall)
a nurse is about to perform postmortem care of a client. the family wishes to view the body. which of the following actions should the nurse take? (select all that apply) a. remove the dentures from the body b. make sure the body is lying completely flat c. apply fresh linens and place a clean gown on the body d. remove all equipment from the bedside e. dim the lights in the room
c. apply fresh linens and place a clean gown on the body d. remove all equipment from the bedside e. dim the lights in the room
a nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I cold just live long enough to attend my child's wedding." What stage of grief is the client experiencing? a. anger b. denial c. bargaining d. acceptance
c. bargaining
a nurse is assessing a client who has required bed rest for the past month. which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. bladder distention b. decreased blood pressure c. calf swelling d. diminished bowel sounds
c. calf swelling
A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? a. eggs b. soybeans c. lentils d. yogurt
c. lentils
A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? a. managing a home b. establishing a sense of self in the world c. forming new friendships d. ceasing to compare personal identity with others
d. ceasing to compare personal identity with others (the other 3 are for young adults)
A nurse is caring for a client who has MRSA infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? a. Don a gown before entering the room and take off before exiting b. Wear a mask while in the client's room c. Don gloves when entering the room and use hand sanitizer when exiting d. take no special precautions unless coming into direct contact with the client
don gloves when entering the room and use hand sanitizer when exiting (requires contact precautions)
a nurse is talking with a client about ways to help sleep and rest. which of the following recommendations should the nurse give to the client to promote sleep and rest? (select all that apply) a. practice muscle relaxation techniques b. exercise each morning c. take an afternoon nap d. alter the sleep environment for comfort e. limit fluid intake at least 2 hr before bedtime
everything except c
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube b. Remove the NG tube if the client begins to gag or choke c. Apply suction to the NG tube prior to insertion d. Have the client take sips of water to promote the insertion of the NG tube into the esophagus
have the client take sips of water to promote the insertion of the NG tube into the esophagus
does tachycardia or bradycardia indicate fluid volume deficit?
tachycardia
how many ml's in 1 pint
480 mL
blood glucose expected range
70-110 mg/dL
A nurse is performing suctioning for a client who has a tracheostomy. which of the following actions should the nurse take? a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing b. allow 30 sec between suction passes c. hyperventilate the client with 50% oxygen for 30 sec d. perform a maximum of 4 passes with the suction catheter
a. CORRECT - pull suction catheter back 1 cm (0.5 in) if the client starts coughing b. (should allow at least 1 min) c. should hyperventilate with 100% oxygen for at least 2 min before d. a maximum of 3 passes
A nurse is preparing to administer 0.5 mL of oral single dose liquid medication to a client. Which of the following actions should the nurse take? a. Gently shake the container of medication prior to administration b. Transfer the medication to a medicine cup c. Place the client in a semi-fowler's position prior to medication administration d. Verify the dosage by measuring the liquid before administering it
a. Gently shake the container of medication prior to administration
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? a. use a 10 mL syringe b. attach a 22-gauge catheter to the syringe c. warm the irrigating solution to 37 degrees C (98.6 F) d. administer an analgesic 10 min before the irrigation
a. INCORRECT (should use a syringe with 30mL capacity) b. INCORRECT (18 or 19-gauge catheter) c. CORRECT (warm the irrigating solution to 37 degrees Celsius d. INCORRECT (give analgesic 20-30 min prior to irrigation)
A nurse is preparing to administer a unit of packed RBC's to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? (select all that apply) a. The client's ID number b. The client's room number c. The client's name d. ABO compatibility e. Rh compatability
a. The client's ID number c. The client's name d. ABO compatability e. Rh compatability
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly b. Riding a bicycle c. Performing isometric exercises d. Engaging in high-impact aerobics
a. Walking briskly (is weight bearing)
A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? a. air conduction is less than bone conduction in the left ear b. air conduction is greater than bone conduction in the left ear c. sound is lateralizing to the right ear d. sound is lateralizing to the left ear
a. air conduction is less than bone conduction in the left ear
A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? a. airborne b. droplet c. contact d. protective equipment
a. airborne
A nurse is administering IV fluids to a client. when monitoring for adverse effects which of the following is a priority a. auscultate lung sounds b. measure urine output c. monitor blood pressure readings d. monitor electrolyte levels
a. auscultate lung sounds
a client who has an indwelling catheter reports a need to urinate. which of the following actions should the nurse take? a. check to see whether the cathter is patent b. reassure the client that it is not possible for them to urinate c. recatheterize the bladder with a larger-gauge catheter d. collect a urine specimen for analysis
a. check to see whether the catheter is patent
A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (select all that apply.) a. coat the tip of the tube with a water-soluble lubricant b. ask the client to swallow water while the tube enters her throat c. place the coiled tube in ice chips prior to insertion d. tell the client to tilt her head backward as insertion begins e. instruct the client to bear down during insertion
a. coat the tip of the tube with a water-soluble lubricant b. ask the client to swallow water while the tube enters her throat d. tell the client to tilt her head backward as insertion begins
a nurse is caring for a client who has acute renal failure. which of the following assessments provides the most accurate measure of the client's fluid status? a. daily weight b. blood pressure c. specific gravity d. intake and output
a. daily weight
a nurse is planning care for a client who is on bed rest. which of the following interventions should the nurse plan to implement? a. encourage the client to perform antiembolic exercises every 2 hr. b. instruct the client to cough and deep breathe every 4 hr. c. restrict the client's fluid intake d. reposition the client every 4 hr
a. encourage the client to perform antiembolic exercises every 2 hr.
a nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTI's. which of the following factors should the nurse include? (select all that apply) a. frequent sexual intercourse b. lowering of testosterone levels c. wiping from front to back to clean the perineum d. location of the urethra closer to the anus e. frequent catheterization
a. frequent sexual intercourse d. location of the urethra closer to the anus e. frequent catheterization
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following PPE items should the nurse don prior to providing client care? (select all that apply) a. gown b. gloves c. mask d. hair cover e. goggles
a. gown b. gloves
a nurse is instructing a client who has an injury on the left lower extremity, about the use of a cane. which of the following instructions should the nurse include? (select all that apply) a. hold the cane on the right side b. keep two points of support on the floor c. place the cane 15 in in front of the feet before advancing d. after advancing the cane, move the weaker leg forward e. advance the stronger leg so that it aligns evenly with the cane
a. hold the cane on the right side b. keep two points of support on the floor d. after advancing the cane, move the weaker leg forward
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subutaneously. Determine the correct order of steps for this procedure. a. Withdraw the correct dose of regular insulin from the bottle b. inject 5 units of air into the bottle of regular insulin c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of NPH insulin from the bottle
a. inject 10 units of air into the bottle of NPH insulin b. inject 5 units of air into the bottle of regular insulin c. withdraw the correct dose of regular insulin from the bottle d. withdraw the correct dose of NPH insulin from the bottle
a nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. whihc of the following information should the nurse include? (select all that apply) a. older adults are more prone to dehydration than younger adults are b. older adults need the same amount of most vitamins and minerals as young adults do c. many older men and women need calcium supplementation d. older adults need more calories than they did when they were younger e. older adults should consume a diet low in carbohydrates
a. older adults are more prone to dehydration than younger adults are b. older adults need the same amount of most vitamins and minerals as younger adults do c. many older men and women need calcium supplementation
a nurse is caring for a client who has TB. which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative pressure airflow b. wear gloves when assisting the client with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing client care e. use antimicrobial sanitizer for hand hygiene
a. place the client in a room with negative pressure airflow b. wear gloves when assisting the client with oral care c. use antimicrobial sanitizer for hand hygiene
A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? a. playing in the sand b. playing dress-up with old clothes c. collecting and trading game cards d. describing interpersonal relationships
a. playing in the sand (sensorimotor stage, birth - 2 years) b. playing dress-up (preoperational thinking, ages 2-7) c. COLLECTING AND TRADING GAME CARDS d. describing interpersonal relationships (formal operational reasoning stage, ages 11 and beyond)
a nurse is planning to perform passive range of motion exercises for a client. which of the following actions should the nurse take? a. repeat each joint motion 5 times during each session b. move the joint to the point of considerable resistance c. sit approximately 2 ft from the side of the bed closest to the joint being exercised d. exercise the smaller joints first
a. repeat each joint motion 5 times during each session
A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? a. Perform tracheostomy care using medical asepsis b. allow enough slack under the tracheostomy ties to insert 3 fingers c. soak the inner cannula of the tracheostomy tube in normal saline d. cut a sterile gauze pad to place between the neck and tracheostomy tube.
a. should be sterile technique b. 1-2 fingers under the trach ties c. CORRECT (soak the inner cannula of the trach tube in NS) d. could aspirate on threads from cotton pad
a nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. which of the following steps should the nurse take? (select all that apply) a. warm the enema solution prior to instillation b. position the client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle d. slowly insert the rectal tube about 2 in e. hang the enema container 24 in above the client's anus
a. warm the enema solution prior to instillation b. position the client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle
A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? a. "I am comfortable with my decision to choose a lifelong partner" b. "I think I have done a good job with my children since they are all independent now" c. "As I look back over my life, I can see that I have achieved most of the goals I set for myself." d. "I love my work so much that it is difficult to think about retirement."
a. young adults (intimacy vs. isolation) b. "I think I have done a good job with my children since they are all independent now." c and d. older adults (integrity vs. despair)
hyponatremia symptom
abdominal crampig
a nurse in a provider's office is caring for a client who states that for the past week "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (select all that apply) a. have your work hors changed recently? b. do you feel confused in the late afternoon? c. do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day? d. has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? e. tell me about any personal stress you are experiencing
all except for b
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. Rinse the feeding bag with water between feedings b. Tell the client to keep the head of the bed elevated at least 30 degrees c. Make sure the enteral formula is at room temperature d. Wipe the top of the formula can with alcohol
b. Tell the client to keep the head of the bed elevated at least 30 degrees
A nurse on a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. Ensure sterilization of nondisposable items with ethylene oxide b. Wrap monitoring cords with stockinette and tape them in place c. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. Wear hypoallergenic latex gloves that contain powder.
b. Wrap monitoring cords with stockinette and tape them in place (contains latex)
A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? a. offer the client a nutritious snack b. accompany the client back to his room c. reorient the client to his surroundings d. administer a PRN antianxiety medication
b. accompany the client back to his room
a nurse is caring for a client who is postoperative. which of the following interventions should the nurse take to reduce the risk of thrombus development? (select all that apply) a. instruct the client not to perform the valsalva maneuver b. apply elastic stockings c. review laboratory values for total protein level d. place pillows under the client's knees and lower extremities e. assist the client to change positions often
b. apply elastic stockings e. assist the client to change positions often
a nurse is caring for a client who has a respiratory infection. which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a. insert the suction catheter while the client is swallowing b. apply intermittenet suction when withdrawing the catheter c. place the catheter in a location that is clean and dry for later use d. hold the suction catheter with her clean, nondominant hand
b. apply intermittent suction when withdrawing the catheter
while nurse is administering a cleansing enema, the client reports abdominal cramping. which of the following actions should the nurse take? a. have the client hold their breath briefly and bear down b. clamp the enema tubing c. remind the client that cramping is common at this time d. raise the level of the enema fluid container
b. clamp the enema tubing
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? a. wear sterile gloves when collecting the specimen b. cleanse the wound with 0.9% sodium chloride irrigation c. allow the collection swab to absorb old exudate d. rotate the collection swab over the edges of the wound
b. cleanse the wound with 0.9% sodium chloride irrigation
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? a. Blow into the spirometer to elevate the balls in the device b. cough deeply after each use c. clean the mouthpiece with an alcohol swab after each se d. use the spirometer every 8 hr
b. cough deeply after each use
a nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. which of the following actions should the nurse take? (select all that apply) a. restrict the client's intake of fluids during the daytime b. have the client record urination times c. gradually increase the urination intervals d. remind the client to hold urine until the next scheduled urination time e. provide a sterile container for urine
b. have the client record urination times c. gradually increase the urination intervals d. remind the client to hold urine until the next scheduled urination time
a nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. which of the following information should the nurse include in the teaching? a. exhale slowly to reach goal volume b. hold breath for 5 seconds after goal volume is reached c. continue to deep breathe between each cycle d. limit repeat pattern of breathing to 5 breaths.
b. hold breath for 5 seconds after goal volume is reached
a nurse is assessing a client who has had diarrhea for 4 days. which of the following findings should the nurse expect? (select all that apply) a. bradycardia b. hypotension c. elevated temperature d. poor skin turgor e. peripheral edema
b. hypotension c. elevated temperature d. poor skin turgor
a nurse is caring for a client who is at high risk for aspriation. which of the following actions should the nurse take? a. give the client thin liquids b. instruct the client to tuck their chin when swallowing c. have the client use a straw d. encourage the client to lie down and rest after meals
b. instruct the client to tuck their chin when swallowing
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? a. obtaining hydrogen peroxide for tracheostomy care b. obtaining cotton balls for tracheostomy care c. obtaining sterile gloves for tracheostomy care d. obtaining a sterile brush for tracheostomy care
b. obtaining cotton balls for tracheostomy care (could aspirate the particles)
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? a. encourage the client to drink fluids before swallowing food b. offer the client tart or sour foods first c. tilt the client's head backward when swallowing d. turn on the television
b. offer the client tart or sour foods first (stimulates saliva production which aids chewing and swallowing)
A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply) a. Carefully reinsert the intestine through the opening in the wound. b. place the client in a supine position with the hips and knees flexed c. leave the room to call the surgeon d. cover the wound and intestine with a sterile, moistened dressing e. monitor the client for manifestations of shock
b. place the client in a supine position with the hips and knees flexed. d. cover the wound and intestine with a sterile, moistened dressing. e. monitor the client for manifestations of shock
a nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. which of the following actions should the nurse plan to take? a. use a resuscitation bag with 80% oxygen prior to the precedure b. select a suction catheter half the size of the lumen c. place the end of the suction catheter in water-soluble lubricant d. adjust the wall suction apparatus to a pressure of 170 mm Hg
b. select a suction catheter that is half the size of the lumen. (need 100% oxygen prior to the procedure, should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride, should adjust the suction to 120-150 mm Hg)
A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (select all that apply) a. allowing the client to speak b. stabilizing the position of the tube c. preventing aspiration of secretions d. preventing air leaks e. preventing tracheal injury
b. stabilizing the position of the tube c. preventing aspiration of secretions d. preventing air leaks
A nurse is caring for a semiconscious client who had a small bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (select all that apply) a. auscultate injected air b. verify the initial x-ray examination c. measure the length of the exposed tube d. determine the ph of aspirated fluid e. check the aspirated fluid for glucose
b. verify the initial x-ray examination c. measure the length of the exposed tube d. determine the pH of aspirated fluid
a nurse is calculating a client's fluid intake over the past 8 hr. which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 coups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea
c. 8 oz of ice chips (half the volume and 1 oz = 30 ml)
A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? a. Select a vein in the client's dominant arm b. choose the most proximal vein in the extremity c. choose a vein that is soft on palpation d. select a site distal to previous venipuncture attempts
c. choose a vein that is soft on palpation
a nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful? a. increase in hematocrit b. increase in respiratory rate c. decrease in heart rate d. decrease in capillary refill time
c. decrease in heart rate
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? a. maintain suction while removing the NG tube b. instill 100 mL of air into the NG tube before removal c. pinch the NG tube while removing the tube d. instruct the client to breathe in and out during the removal of the NG tube
c. pinch the NG tube while removing the tube (should disconnect from suction during removal, 50 mL of air into the tube before removal, client should take and hold a deep breath during removal of the NG tube)
A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? a. deliver the formula at a slower rate b. request a lower fat formula c. provide more water with feedings d. instill a lactose-free formula
c. provide more water with feedings. (this gravity indicates dehydration)
A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? a. Remove the NG tube b. advance the NG tube quickly c. pull the NG tube slightly back d. ask the client to tilt his head backward
c. pull the NG tube back slightly
a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mm Hg
c. rapid heart rate (fluid volume deficit from dehydration)
a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82mm Hg
c. rapid heart rate (neck vein distention is for fluid volume excess, hypotension is usually a sign of fluid volume deficit)
A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client, Which of the following actions should the nurse plan to take? a. return the unused portion of the medication to the pharmacy b. dispose of the wasted medication into a sharps container c. record the amount of medication wasted on the controlled substance inventory record d. ask an assistive personal (AP) to witness the wasting of the controlled substance
c. record the amount of medication wasted on the controlled substance inventory record
a nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. the nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. which of the following actions should the nurse take? a. change the infusion tubing b. flush the IV catheter c. remove the IV catheter d. apply a cool compress to the site
c. remove the IV catheter
a nurse is caring for a client who is having difficulty with muscle coordination following a head injury. the nurse should suspect injury to which of the following areas of the brain? a. hypothalamus b. cerebral cortex c. pituitary d. cerebellum
d. cerebellum
A nurse is collecting a urine specimen for culture and sensitivity for who a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? a. withdraw the specimen from the drainage bag b. cleanse the collection port with soap and water c. place the specimen in a clean specimen cup d. clamp the tubing below the collection port
d. clamp the tubing below the collection port (c. the nurse should place the specimen in a sterile specimen cup to prevent contamination)
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? a. Irrigate the tubing with sterile normal water once during each shift b. cleanse the opening with soap and water after emptying c. maintain the tubing above the level of the surgical incision d. collapse the device to remove air after emptying
d. collapse the device to remove air after emptying
a nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins
d. distended neck veins (other 3 would be fluid volume deficit)
a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? a. dissolve each medication in 5 mL of sterile water b. draw up medications together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube with 15 mL of sterile water
d. flush the tube with 15 mL of sterile water (dissolve each medication in at least 30 mL of sterile water, should not mix medications, when encountering resistance the nurse should stop and contact the provider)
a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? a. dissolve each medication in 5 mL of sterile water b. draw up medications together in the syringe c. push the syringe plunger gently when felling resistance d. flush the tube with 15 mL of sterile water
d. flush the tube with 15 mL of sterile water (dissolve in 30 mL, stop and contact provider if feeling resistance)
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? a. tenderness when touched b. pink, shiny tissue with a granular appearance c. serosanguineous drainage d. halo of erythema on the surrounding skin
d. halo of erythema on the surrounding skin
A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAI's). Which of the following routes of infection should the manager identify as an iatrogenic HAI? a. infection acquired from improper hand hygeine b. infection acquired by drug resistance c. infection acquired by inappropriate waste disposal d. infection acquired from a diagnostic procedure
d. infection acquired from a diagnostic procedure
a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. which of the following actions should the nurse take next? a. document the provider's statement in the medical record b. complete an incident report c. consult the facility's risk manager d. notify the nursing manager
d. notify the nursing manager
a nurse is obtaining the blood pressure in a client's lower extremity. which of the following actions should the nurse take? a. auscultate for the blood pressure at the dorsalis pedis artery b. measure the blood pressure with the client sitting on the side of the bed c. place the cuff 3 in above the popliteal artery d. place the bladder of the cuff over the posterior aspect of the thigh
d. place the bladder of the cuff over the posterior aspect of the thigh
a nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include? a. "you should have an eye examiniation every 2 years" b. "you should receive a tetanus booster every 5 years" c. "you should receive a shingles vaccine when you are 70 years old" d. "you should receive a pneumonococcal vaccine when you are 65 years old"
d. you should receive a pneumococcal vaccine when you are 65 years old
a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. which of the following tasks should the nurse assign to an assistive personnel (AP)? (select all that apply) a. assist the client with a partial bed bath b. measure the client's BP after the nurse administers an antihypertensive medication c. test the client's swallowing ability by providing thickened liquids d. use a communication board to ask what the client wants for lunch e. irrigate the client's indwelling urinary catheter
a. assist the client with a partial bed bath b. measure the client's BP after the nurse administers an antihypertensive medication d. use a communication board to ask what the client wants for lunch
a nurse is evaluating a client's use of a cane. which of the following actions should the nurse identify as an indication of correct use? a. the top of the cane is parallel to the client's waist b. when walking the client moves the cane 18 inches forward c. the client holds the cane on the stronger side of her body d. the client moves her stronger limb forward with the cane
c. the client holds the cane on the stronger side of her body
