fundamentals ATI practice

a nurse is evaluating a client for conductive hearing loss. 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?

air conduction is less than bone conduction in the left ear

a nurse is assisting with the admission of a client who has tuberculosis. in addition to standard precautions which of the following transmission based precautions be added to the client's plan of care?

airborne

a nurse is assisting with the care of a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect an injury to which of the following areas of the brain?

cerebellum

a nurse is caring for a client who was transferred to the surgical unit by stretcher from PACU. which of the following actions should the nurse perform first after the transfer?

check the client's vital signs

a nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. which of the following steps should the nurse identify as the first response when performing CPR?

confirm unresponsiveness

a nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse take to reduce the client's risk for aspiration?

elevate the head of the bed by 30 to 45 degrees

a nurse is reinforcing teaching with a client about how to obtain a capillary finger-stick blood sample. which of the following actions by the client requires the nurse to intervene?

elevates the finger above heart level

a nurse is caring for a client who has cancer an dis experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief.

encourage the client to listen to soft music

a nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when explaining the procedure to the client?

ensure the interpreter and the client speak the same dialect

a nurse is caring for an older 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 of the sound?

excessive wax in the ear canal

a nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

face the client when speaking

a nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student indicates a potential problem with achieving Erickson's developmental task for the age group?

i go home on the weekends to be with my family because i don't have any good friends here on campus

a nurse is reinforcing teaching about heat therapy with a client who has low back pain. Which of the following statements by the client indicates an understanding of the teaching?

i need to place a towel between the heating pas and my skin

a nurse is teaching the client who has asthma about the proper use of an albuterol inhaler. which of the following clients statements indicates an understanding of the teaching?

i will shake the inhaler well right before using it

a nurse is reinforcing teaching with a client who is postoperative about the importance of turning, coughing, and breathing deeply. which of the following statements should the nurse identify as an indication that the client understands the instructions?

if i do this often, I won't get pneumonia

a nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. which of the following actions should the nurse take when collecting the specimen?

place the stool specimen collection container in a bio-hazard bag

a nurse is caring for a client who is dehydrated. an insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organ?

skin

a nurse is caring for a client who is exhibiting confusion. the nurse should identify that which of the following laboratory values can cause confusion?

sodium 123 mEq/L

as part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand,. and asks him to identify the object. which of the following abilities is the nurse evaluating with this technique?

stereognosis

A nurse is inserting an indwelling urinary catheter into a male client. which of the following actions should the nurse take?

use the non dominant hand to grasp the penile shaft

a nurse is collecting data about a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

vesicular

a nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection which of the following vitamins and or minerals should the nurse plan to increase in the client's diet?

vitamin C and zinc

a nurse is caring for an older client who becomes agitated when the nurse requests that the clients dentures be removed prior to surgery. which of the following responses should the nurse offer?

what worries you about being with out your teeth

a nurse is assessing the pH of a client's gastric fluid to confirm the placement of an Ng tube in the stomach. Which of the following pH values should the nurse expect?

2

a nurse is preparing to administer ondanseron 4 mg IM to a client who has postoperative nausea. ondansetron injection 2 mg/mL is available. how many mL should the nurse administer per dose?

2

a nurse is calculating a client's intake for a 12 hour shift. the client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr gentamicin 150 mg in 100 mL at 1400 ranitidine 50 mg in 50 Ml at 1000 and 1600, 250 mL of blood over 2 hours and a nasogastric flush of 30 mL every 2 hours. what is the total intake in milliters that the nurse should document for the client for this 12 hour period?

2130

a nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350mL, 200mL, 150mL; wound drainage 2 tsp; and emesis 2 oz. what is the total output in millilitres the nurse should document for this 8 hour period?

770

a nurse is caring for a client who has the head of his bed elevated to a 45 degree angle with his knees slightly flexed. which of the following positions should the nurse document for the client?

Fowlers

a nurse is caring for a client who is dehydrates. which of the following laboratory values should the nurse expect for this client?

Hct 55%

a nurse is reinforcing teaching with a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I can still use my TENS unit even though I'm pushing the PCA button

a nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties?

I often have a cup of coffee with my dessert before going to bed

a nurse is caring fir a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic enteral nutrition formula

a nurse is checking the iv insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch

a nurse is reviewing the laboratory results of a client who is preoperative. which of the following results should the nurse report to the surgeon

WBC count 18,000

a nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time?

a client who has end-stage cirrhosis

a nurse is caring for a group of clients who are receiving oxygen therapy. which of the following clients should the nurse plan to see first?

a client who has heart failure and is receiving 100% oxygen via a partial re-breather mask

a nurse is reinforcing discharge teaching with a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

a nurse will show me how to care for my wound

a nurse is reinforcing teaching with a preschooler about how much to use a metered-dose inhaler. which of the following methods should the nurse use during this instructional session?

a simple demonstration if inhaler use

by asking a client to explain the statement a bird i the hand is worth 2 in the bush the nurse is evaluating the clients ability in which of the following intellectual functions?

abstract reasoning

a nurse is planning a community presentation for young adults. which of the following behaviors should the nurse suggest incorporation into the presentation as part of Erickson's expected developmental task for this age group?

adjusting to living with a partner

a nurse is caring for a client who states that she does not want to get out of bed due to pain form arthritis. which of the following actions should the nurse take?

advise the client to perform range of motion exercises while in bed

a nurse is assisting a client who has dysphagia at mealtime. which of the following actions should the nurse take first?

advise the client to tuck his chin downward

a nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. a laboratory result within the expected reference range for which of the following substances is an indication that the client has adequate protein uptake and synthesis?

albumin

a nurse on a medical unit is caring for a client who has a difficulty sleeping. which of the following actions should the nurse take to promote the clients ability to fall asleep?

allow the client to maintain the same bedtime routine as at home

a nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis on transmission based precautions. which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

assigning another client with the same infection to share the room with the client

a nurse is caring for a client who is having difficulty breathing. the client is lying in bed with a nasal cannula delivering oxygen. which of the following interventions is the nurse's priority?

assist the client to an upright position

a nurse is reinforcing teaching to manage a chronic illness. which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

assist the client to identify ways that these changes will result in positive personal outcomes

a nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse perform to convey empathy when using the therapeutic communication technique of active listening?

assume an open position

a nurse is collecting data from a client who is undergoing a physical examination. following inspection, which of the following techniques should the nurse use next when evaluating the client's abdomen?

auscultation

a nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following intervention should the nurse suggest to this client?

avoid beverages that contain caffeine

a nurse is preparing to insert a indwelling urinary catheter. which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

bear down

a nurse in a provider's office is reinforcing teaching with a client about foods that are high in fiber. which of the following food choices made by the client indicate an understanding of the teaching?

black beans, whole-grain bread

a nurse is collecting data about the client's cutaneous and deep tendon reflexes. which of the following in=mages indicates the technique the nurse should use to elicit the plantar reflex?

bottom of the foot

a nurse is assisting with the care of a client who requires ventilatory assistance with breathing following a motor vehicle crash. the nurse should suspect that the client has an injury to which of the following parts of the brain?

brain stem

a nurse is administering medication to a client who ask the nurse to leave the medication at the bedside so she can take it at a later time. which of the following responses should the nurse provide?

call me when you are ready and I will return with the medication

during completions of a health history, a client reports having chest pain intermittently for the past week. Which of the following questions is the nurses priority?

can you tell me what the pain felt like and show me exactly where it was?

a nurse is reinforcing teaching with a client who needs to reduce cholesterol levels. which of the following foods should the nurse suggest that the client add to his diet?

carrot

a nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

ceasing to compare personal identity with those of others

a nurse is implementing cold therapy for a client who has an ankle sprain> which of the following actions should the nurse take?

check capillary refill before applying an ice pack to the affected area

a nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. the client states she slipped while getting out of bed. which of the following actions should the nurse take first?

check the client for injuries

a nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. before administering the medication which of the following actions should the nurse take?

check the medication dose and the clients identification

a nurse documents clubbing of the fingernails for a client who has emphysema. the nurse should identify that which of the following is the underlying cause of this finding?

chronic hypoxemia

a nurse is preparing to administer a tuberculin skin test to a client. after performing hand hygiene, which of the following actions should the nurse take?

circle the area of the injection with a pen

a nurse in a clinic is caring for a client who has returned for a follow-up visit after treatment of a laceration on her upper arm. which of the following actions should the nurse person when removing the sutures that the client received at her visit?

clip the suture as close to the skin as possible

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?

collapse air form the device after emptying

a nurse finds the client sitting on the floor by the toilet in the bathroom adjacent to his room. he states that he is fine after slipping on the tile floor but is having difficulty getting up. which of the following actions should the nurse take first?

collect data from the client about any health alterations before during or after the fall

a nurse is preparing to assist with a discharge planning for a client with a new colostomy who has low health literacy. when reinforcing teaching about changing the appliance, which of the following guidelines should the nurse follow?

connect new instruction with what the client already knows

a nurse is measuring vital signs for a client and notices a pulse irregularity. which of the following actions should the nurse take?

count the apical pulse rate fro 1 full min and describe the rhythm in the chart

a nurse is providing care for a client who is at the end of life. The client is having difficulty breathing and has audible respiratory gurgling. which of the following actions should the nurse take?

elevate the head of the clients bed

a nurse is discussing fore safety with a newly hired nurse. which of the following actions is the priority if a fire occurs in the healthcare facility?

evacuate clients from the unit

a nurse on a medical-surgical unit observes smoke billowing from a client's room. which of the following actions should the nurse take first?

evacuate the client from the room

a nurse is administering 3 liquid medications through a client's nasogastric tube. which of the following actions should the nurse take?

flush the tube with water before and after instilling each medication

a nurse is administering a controlled substance to a client who is postoperative. the IM dosage requires the nurse to use only part of the amount of medication in the vial. which of the following actions should the nurse take?

have another nurse witness the disposal of the medication

a nurse is changing the bed lines for a client who is on bed rest. Which of the following actions should the nurse plan to take?

hold the linens away from the body and clothing

a nurse is caring for a client who has a stage II pressure ulcer. which of the following wound dressings should the nurse apply to the ulcer

hydrocolloid

a nurseis collecting data fro a client whose calcium level is 7.1. which of the following findings should the nurse expect

hyperactive reflexes

a nurse is reinforcing teaching with a client who has a new colostomy. which of the following statements should the nurse identity as an indication that the client understands the instructions?

i will make sure to replace my pouch around 4 hours after I eat

a nurse is providing discharge teaching to an older adult about personal safety. which of the following statements by the client indicates an understanding of the teaching?

i will put a night-light in the hallway

a nurse is instruction a client about a 24-hours urine specimen for creatinine clearance. which of the following statements should the nurse identify as an indication that the client understands the procedure?

i'll make sure to keep the collection bottle in the container of ice they gave me

a nurse is reinforcing teaching with a client about how to remove a soiled dressing which of the following statements by the client indicates an understanding of the teaching

i'll wear non sterile gloves

a nurse is caring for a client who requires a chest x-ray prior the client being transported for the procedure which of the following actions should the nurse take first?

identify the client using 2 identifiers

a nurse is collecting data from a client who is experiencing stress over a near fall out of a bed. which of the following physiological responses should the nurse expect to observe due to the client's fight or flight response?

increased blood pressure

a nurse in a provider's office is collecting data from an older adult client. Which of the following findings should the nurse expect?

increased cerumen

a nurse is performing a breast examination for a female client. which of the following techniques should the nurse use first?

inspect both breasts simultaneously

a nurse in a provider's office is caring for a client who has blepharitis. which of the following actions should the nurse take first?

inspect the eyes for drainage or redness

a nurse in an acute care facility with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. which of the following interventions should the nurse suggest to prevent a complication of immobility

instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis

a nurse is reinforcing teaching with a group of unit nurses about the experiences of the experiences of clients who are having surgery. which phase of care begins with transferring the client to the surgical suite table and ends with the transfer to PACU?

intraoperative

a nurse is presenting an in-service session about nutrition. which of the following simple sugars should the nurse identify as the carbohydrate dound in milk?

lactose

a nurse is auscultating breath sound for a client who has fine crackles. at which of the following areas of the lung field should the nurse place the stethoscope?

lower left lobe

a nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. which of the following actions should the nurse take first?

lower the client to the floor

a nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client body?

lungs

a nurse is caring for a client who requires the insertion of a NG tube. which of the following actions should the nurse take when preparing to insert the tube?

measure the distance from the nose to the earlobe to the xiphoid

a nurse on a medical surgical unit is caring for a client who develops deep rapid respiration. arterial blood gas analysis includes the following values: ph 7.25, paco2 40, hco3 18. which of the following acid base imbalances should the nurse identify and report to the provider?

metabolic acidosis

a nurse enters a clients room and finds smoke coming form under the bed. what sequence of actions should the nurse take in this situation

move the client out of the room pull the unit fire alarm shut all surrounding windows and doors attempt to put out the smoke with a fire extinguisher

a nurse is using the braden scale to predict the pressure ulcer risk for a client in a long term care facility. using this scale which of the following parameters should the nurse evaluate?

nutrition

during the insertion of a urinary catheter for a client the tip of the catheter brushes against the nurses arm. which of the following actions should the nurse take?

obtain a new catheter and reattempt insertion

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?

obtaining cotton balls for the tracheostomy care

a nurse in a providers office is measuring an adult client and notes a decrease in height from the previous year. the nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

osteoporosis

a nurse is preparing to attend a care plan conference for a client who has severe burns. which of the following criteria should the nurse identify as a part of an effective conference?

other health care professionals are in attendance at the conference

a nurse is preparing to administer a tap water enema to a client. which of the following actions should the nurse take?

place the client in a left sims position

a home health nurse enters a clients home and finds a used insulin syringe without a cap on the table. which of the following action should the nurse take?

place the syringe in a puncture proof disposal container

a nurse on rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. which of the following techniques should the nurse use?

place the wheelchair at a 45 degree angle to the bed

a nurse in a long-term care facility is feeding a client. Which of the following observations should the nurse identify as an indication that the client requires an evaluation for dysphagia?

pocketing food

a nurse is contributing to the planning of an in-service session about nutrition. which of the following pieces of information should the nurse recommend for the teaching?

protein serves as an energy source when other sources are inadequate

a nurse is caring for a group of clients which of the following task should the nurse assign to an assistive personnel

provide oral car to a client who can not take oral fluids

a nurse is preparing to perform oral care for a client who is unresponsive. which of the following actions should the nurse plan to take?

raise the level of the bed

a nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

raise your index finger if you need to pause during the insertion

a nurse is caring for a client who has chronic kidney disease. the kidneys regulate body fluid and assist with which of the following functions?

regulation of acid-base balance

a nurse is caring for a client who requires wrist restraints. which of the following actions should the nurse take?

remove the restraints at least every 2 hr

a nurse is contributing to the plan of fare for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

renew the prescription for the restraints within 24 hours

a nurse is preparing to administer a bolus feeding to a client through and NH tine and observes that the exit mark on the tube has moved since the last feeding. which of the following actions should the nurse plan to take?

request an x ray of the clients abdomen

a nurse is collecting baseline data about a client's respiration as part of a comprehensive physical examination. which of the following types of breath sounds should the nurse report to the provider?

rhonchi

a nurse is collecting data about a client who is unconscious. family members are present and answer the nurses questions about the clients medical history. the nurse should document this information as which of the following types of data?

secondary source data

a nurse is planning to instructional session about walking with a cane for a client who has a moderate sensorineural hearing loss. which of the following action should the nurse take?

sit at the same level as the client

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 trachesostomy care for the client?

soak the inner cannula of the tracheostomy tube in normal saline

a nurse is caring for a client who has peripheral edema. the nurse should identify that which of the following nutrients regulates extracellular fluid volume?

sodium

a nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. the client states that no one has spoken to her about this procedure before. which of the following actions should the nurse take?

stop reinforcing the teaching and check with the surgeon about informed consent

a nurse is caring for a client who is receiving an IV infusion of 5% dextrose in lactated ringer's. the nurse notices that the area around the catheter insertion site is edematous and cooler than the surrounding skin on the forearm. which of the following actions should the nurse take?

stop the infusion

a nurse is caring for a client who has breast cancer. the client has been receiving radiation therapy for several months and now refuses to undergo further treatment/ which of the following actions should the nurse take?

support the client's decision

while in the hospital a client who has a terminal illness tells the nurse, i can't believe i'm dying. there are a lot of bad people in the world who are healthy and here i am dying! which of the following responses should the nurse offer?

tell me more about how you feel about dying

a nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self injection insulin methods. which of the following statements should the nurse provide?

tell me what i can do to help you overcome your fear of giving yourself injections

a nurse is reinforcing teaching about nutrition with a middle adult client who has a sedentary job. which of the following factors should the nurse consider?

the basal metabolic rate could decrease

a nurse is evaluating a client's use of crutches. the nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

the client has slightly flexed elbows when ambulating with the crutches

a nurse is reinforcing teaching with a client about the use of a straight-legged cane. which of the following client actions indicates an understanding of the teaching?

the client holds the cane on the unaffected side

a nurse is reinforcing teaching about range of motion exercise with a client who has osteoarthritis. which of the following positions indicates the clients correct understanding of supination of the hand?

the client holds the hand with the palm up

a nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. which of the following statements indicates a lack of readiness to learn by the client?

the client reports severe pain

a hospice nurse is visiting with the family member states that eh client has insomnia almost nightly. which of the following practices should the nurse identify as contributing to the client's insomnia?

the client watches television in bed during the day

a nurse is developing a plan of care for a client. which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

the meaning of disease can vary widely across cultures

a nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. which of the following explanations should the nurse give the AP?

using a cuff that is too small will result in an inaccurately high reading

a nurse is caring for a client who reports using several; herbal supplements. which of the following actions should the nurse take?

verify that the herbal supplements do not interact with medications the provider has prescribed

a nurse is reinforcing teaching for a client about managing her tracheostomy care which of the following instruction should the nurse include

wear trachesotomy cover when outdoors

a nurse is collecting data from a client who has an onset of severe pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

what do you think caused the onset of your pain

a nurse is caring for a client who has a deficiency in vitamin D. which of the following foods should the nurse recommend the client include in his diet?

whole milk

a nurse is performing a straight urinary catheterization for a female client who has urinary retention. which of the following actions indicates the nurse is maintaining sterile technique?

wiping the labia minora in an anteroposterior direction

a nurse is reinforcing teaching for a client about performing range of motion exercises of the wrist. to have the client demonstrate adduction which of the following instructions shoudl the nurse give?

with your palm facing down move your wrist sideways toward your thumb

a nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. which of the following comments should the nurse make?

would you like to talk about how you feel

a nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client?

wrap IV tubing with tape

a nurse is caring for a client who is receiving dextrose 5% in water IV at 150mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hour fluid intake in mil liters that the nurse should document for this client?

1560

after collecting data form a client, the nurse document "1+ pedal edema bilaterally" this indicates the nurse observed an indentation of which of the following depths after applying pressure?

2 mm

a nurse is reinforcing teaching with the parent of a child who is to take 30 mL of a liquid medication. the parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. how many tablespoons of mediation should the nurse instruct the parent to give the child?

2 tablespoons

a client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse?

8

a nurse is collecting baseline data about a client's chest as part of a physical examination. which of the following actions should the nurse take first?

inspect the thorax

a nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. which of the following findings should the nurse expect?

absent bowel sounds with distension

a nurse is reinforcing teaching with a cliet who has hypertension and is starting medication therapy for treatment. the provider has recommended that, because of these new medications, the client should increase her intake of potassium. Which of the following foods should the nurse remind the client to include in her diet?

bananas

a nurse is caring for a client who requires a protective environment. Which of the following precaution should the nurse implement for this client?

make sure the client wears a mask when outside his room

a nurse is beginning her shift and reviewing the medication administration records(MAR) for her clients. She notes a medication dosage above the safe range and sees that another nurse administered that dosage during the precious shift. Which of the following actions should the nurse take?

call the provider to clarify the dosage

a nurse in a provider's office is collecting data form a 3-year-old client during a routine physical examination. Which of the following findings should the nurse report to the provider

can not walk up stairs independently

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

coa tthe tip of the tube with a water-soluble lubricant, ask the client to swallow water while the tube enters her throat, tell the client to tilt her head back ward as insertions begins

a nurse is explaining Piaget's theory of cognitive development to a group of day care 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?

collecting and trading game cards

during a physical examination of a client, the nurse suspects strabismus. which of the following tests should the nurse use to collect additional data?

corneal light reflex

a nurse is collecting data form a client who has fluid- volume excess. which of the following findings should the nurse expect?

crackles in the lung fields

a nurse is collecting data during a neurological examination of a client. When asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

cranial nerve XII

a nurse is provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

data collection

a nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client't record first?

data collection for the client

a nurse is collecting data form a client whose potassium level is 2.8 mEq/L. Which of the following findings should the nurse expect?

decreased bowel sounds

a nurse is caring for a client who is immobile. the nurse should recognize that immobility places the client at risk for which of the following health alterations?

decreased cardiac output

a nurse is reinforcing teaching with a middle adult client about health promotion and disease prevention. The nurse should remind the client that which of the following changes could occur?

decreased estrogen and testosterone production

a nurse is caring for the client who is producing large amounts of urine. The nurse should document this as which of the following?

diuresis

a nurse is preparing to administer eye drops to a client following surgery. which of the following actions should the nurse take when instilling the eye drops?

drop the eye medication into the lower conjunctiva sac

a nurse is admitting a client who is experiencing an exacerbation of heart failure. at which of the following times should the nurse initiate discharge planning?

during the admission process

a nurse is caring for an adult client who communicates an unmet spiritual need. which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress?

god is punishing me for something

a nurse is preparing to change the bed lines 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?

gown, and gloves

a nurse is preparing to administer medication to a client who has gout. the nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?

measure the client's apical pulse

a nurse is measuring a client's vital signs. The clients resting radial pulse rate is 55/min. which of the following actions should the nurse take next?

measure the client's apical pulse rate

a nurse is collecting data form a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear?

moro

a nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

notify the provider about the client's decision

a nurse is reinforcing teaching with a client who has heart failure about reducing his daily intake of sodium. Which of the following factors is the most important is determining the clients ability to learn new dietary habits?

the involvement of the client in planning the change

as a nurse is preparing to administer liquid medication from a bottle to a client. which of the following actions should the nurse take?

hold the mediation bottle with the label against the palm of the hand when pouring

a nurse is collecting data form a client who requires hygiene care. Which of the following pieces of information is the nurse's priority to determine before preparing to bathe the client?

how much the client can assist with bathing

a nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

hyperglycemia

a nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

weigh the client on arising in the morning

a nurse is obtaining a capillary blood sample to determine a client's blood glucose level. the nurse prepare and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. which of the following actions should the nurse take

wrap the clients finger in a warm wash cloth

a nurse is evaluating the development of a group of clients. the nurse should understand that, according to Erickson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?

young adulthood

a nurse is reviewing the use of side rails with an assistive personnel (AP). which of the following statements by the AP indicates that further instruction is required?

if the client seems confused i'll raise all 4 side rails to prevent injury

a nurse is caring for a client who has a temperature of 38.7 C (101.7 F) which of the following actions should the nurse take?

keep the client's bed lines dry

a nurse in rehabilitation facility is observing an assistive personnel (AP) help a client transfer form the bed to a wheelchair. Which of the following actions indicates that the AP understands how to perform this task?

locking the brakes one the bed and the wheelchair before moving the client

a nurse in a long-term care facility is in dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take?

observe the client closely

a nurse is caring for an older client who has dysphagia following a cerebrovascular accident. which of the following actions should the nurse take when assisting the client at meal time?

offer the client tart or sour foods first

a nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel. the nurse later observes the AP emptying the bag without wearing gloves. which of the following actions should the nurse take?

talk with a AP about the technique used

a nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors places the client at risk of developing complicated grief?

the death was sudden

a nurse is helping a client perform range of motion exercises of the neck. for evaluating neck flexion, which of the following motion should the nurse instruct the client to perform?

touch his chin to his chest

a nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin assisting with discharge planning?

upon admission to the care facility

a nurse is preparing to assist an older adult client with ambulation; the client has been on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

use a gait belt during ambulation

a nurse is teaching a group of unit nurses about a client who has a surgical wound that is healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching?

granulation tissue fills the wound during healing

a nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?

grimacing

a nurse on a same-day procedure unit is caring for a several clients undergoing different types of procedures. a client who has which of the following devices can safely undergo magnetic resonance imaging(MRI)?

hearing aids

a nurse is reinforcing teaching about crutch use with a client who has had knee surgery. Which of the following instructions should the nurse include?

hold both crutches with a hand when you sit down in a chair

a nurse is collecting health history data form a client who is deaf and uses american sign language (ASL) to communicate. the nurse will be working with an ASL interpreter. which of the following actions should the nurse perform when working with the interpreter?

pace speech to allow time for the interpreter to convey the words

a nurse is performing a physical examination of a client. to evaluate the client's skin moisture, the nurse should use which of the following techniques?

palpation

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?

pinch the NG tube while removing the tube

a nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

place the bladder of the cuff over the posterior aspect of the thigh

a nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up" the nurse finds that the incision separated and intestinal tissue is protruding. after calling for help, which of the following actions should the nurse take?

position the client supine with knees in flexion

a nurse is monitoring a client's laboratory results. which of the following results should the nurse report to the provider?

potassium 3.0 mEq/L

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?

pull the NG tube back slightly

a nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?

reduced level of consciousness

a nurse is reviewing a client's laboratory report. the client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24mEq/L. the nurse should determine that eh client has which of the following acid-base imbalances?

respiratory alkalosis

a nurse is collecting data from a client as part of a neurological examination. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests?

romberg

a nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

sit and hold the client's hand

a nurse is caring for an adult client in the terminal stages of lung cancer who refused any further treatment. the nurse should provide care that facilitates which of the following outcomes?

supports self-determination

a nurse is measuring a client's vital signs. the clietns heart rate is 105/min. the nurse should document the findings as which of the following alterations?

tachycardia