Fundamentals Dynamic Quizzing (Easy)
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection? A. WBC 15,000 mm^3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063
A
A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client B. Lowering the footplates of the wheelchair before the transfer C. Placing the wheelchair perpendicular to the bed D. Placing the wheelchair on the client's weaker side prior to the transfer
A
A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take." C. "I will come back in 30 minutes to check that you took the medication so I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time."
A
A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? A. Sit beside the client during the interview B. Make sure the device is functioning C. Make sure lighting in the room is soft D. Provide a lengthy interview process to allow adequate time to answer questions
A
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? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. On the day prior to discharge
A
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? A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme
A
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "Your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections."
A
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? A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL
A
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis
A
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 indicates adequate protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium
A
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice
B
A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take? A. Place a padded tongue blade in the client's mouth B. Lower the client to the floor and place a pad under the client's head C. Seek the help of a coworker and lift the client back into bed D. Use an oropharyngeal airway to keep the upper airway passages open
B
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 discharge planning? A. One week prior to the client's discharge B. Upon the client's admission to the care facility C. Once the discharge date is identified D. When the client addresses the topic with the nurse
B
A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? A. Explain that it is against policy to share access codes and refer the resident to his supervisor. B. Access the clients' online data and monitor the resident as he reads them. C. Access the online system and allow the resident to locate clients' data. D. Ask each client to give permission for the resident to access medical records.
A
A nurse in a 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? A. Planning B. Evaluation C. Assessment D. Implementation
A
A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? A. Crackles in the lung fields B. Flat neck veins C. Postural hypotension D. Dark yellow urine
A
A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown. B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest.
A
A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A. Whole milk B. Chicken C. Oranges D. Dried peas
A
A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? A. Hold the sterile drape above the waist and away from the body B. Drop sterile objects toward the edges of the sterile field C. Hold packaged supplies 7.6 cm (3 in) above the sterile field D. Hold sterile objects over the field before setting them down on the field
A
A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? A. Stat prescription B. PRN prescription C. Standing prescription D. Single prescription
A
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? A. Measure the client's apical pulse B. Administer the allopurinol to the client C. Inform the nurse manager D. Complete an incident report
A
A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? A. Lactose B. Sucrose C. Maltose D. Fructose
A
A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist
A
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's record first? A. Assessment B. Plan of care C. Nursing interventions performed D. Evaluation of progress
A
After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities? A. Bounding B. Full C. Variable D. Weak
A
After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2 mm B. 4 mm C. 6 mm D. 8 mm
A
During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information? A. Areas with no public access B. Outside the door of a client's room C. In the cafeteria during break D. In the hallway near the nurses' station
A
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain
B
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia
B
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? (Fill in the blank with the numeric value only and round to the nearest whole number.) A. 7 B. 8 C. 9 D. 10
B
A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations C. Prepare to administer oxygen D. Give the client a back rub to promote relaxation
B
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? A. Complete an incident report B. Check the client for injuries C. Make sure the client has skid-free footwear D. Remind the client to ask for help when getting out of bed
B
A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? A. "I'm afraid this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family."
B
A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching? A. Ovo-vegetarian diets exclude eggs. B. Kosher diets have restrictions regarding how the food must be prepared. C. Macrobiotic diets are plant-based and exclude all animals and seafood. D. Flexitarian diets exclude the consumption of dairy products.
B
A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? A. Give the client a bronchodilator immediately after the procedure B. Position the client for drainage of secretions by gravity C. Schedule postural drainage following meals D. Instruct the client regarding the importance of fluid restrictions
B
A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor
B
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. D. Log-roll the client.
B
A nurse is teaching 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? A. "If I do this often, I won't experience muscle wasting." B. "If I do this often, I won't get pneumonia." C. "If I do this often, I won't get constipation." D. "If I do this often, I won't have a fast heartbeat."
B
A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable.) A. 1 B. 2 C. 3 D. 4
B
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance. B. Begin chest compressions. C. Confirm unresponsiveness. D. Give rescue breaths.
C
A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a medication error report. B. Notify the prescribing provider. C. Assess the client. D. Notify the charge nurse.
C
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carefully remove the gloves and proceed with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection.
C
A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec
C
A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. Palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia
C
A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing a face mask when standing 0.5 m (1.6 ft) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility
C
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? A. Ask the client if he wants to self-administer his insulin B. Have the client list the steps of the procedure C. Have the client demonstrates the procedure D. Ask the client if he understands the purpose of insulin
C
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? A. Close the door to the client's room. B. Evacuate the client from the room. C. Sound the fire alarm. D. Activate the fire extinguisher.
C
A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? A. Pain level B. Hydration status C. Airway D. Urinary output
C
A provider is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine? A. Once during the client's lifetime B. Every 10 years C. Every 5 years D. Annually in the fall
D
A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take? A. Recap the needle on the syringe. B. Schedule a nurse to administer future injections for this client. C. Explain to the client that the syringe should be disposed of in the bathroom trash can. D. Place the syringe in a puncture-proof disposal container.
D
A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? A. Judgment B. Short-term memory C. Attention span D. Abstract reasoning
D
A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed
D
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate
D
A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? A. Close the fire doors on the unit B. Use a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit
D
A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. 2-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test
D
A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test
D
During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? A. "Did you report the chest pain episodes to your physician?" B. "Is there a history of heart disease in your family?" C. "Have you had this pain before?" D. "Can you tell me what the pain felt like and show me exactly where it was?"
D
During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidone-iodine and continue the catheter insertion. B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion. C. Continue with the catheter insertion. D. Obtain a new catheter and reattempt insertion.
D
A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. Increased blood pressure B. Decreased blood glucose level C. Decreased oxygen use D. Increased gastrointestinal motility
A
A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation
A
A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data? A. Secondary-source data B. Experiential data C. Primary-source data D. Quantitative data
A
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea
A
A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting
A
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? A. Sodium B. Calcium C. Potassium D. Magnesium
A
A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A. Eggs B. Cereal C. Peanut butter D. Pasta
A
A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client
A
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves
A
A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis
A
A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to place a towel between the heating pad and my skin." B. "I'll need to turn up the temperature if I can't feel the heat." C. "I'll sleep on top of the heating pad to increase the heat penetration." D. "Keeping the heat continuously on my back will help it heal."
A
A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates that the teaching has been effective? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older."
A
A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur? A. Decreased estrogen and testosterone production B. Increased tone of the large intestines C. Increased percentage of the body's muscle mass D. Decreased incidence of chronic illnesses
A
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down."
A
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis
B
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? A. "I take a warm shower when getting ready for bed." B. "I often have a cup of coffee with my dessert before going to bed." C. "I usually read a chapter in a book before I go to bed." D. "I make sure I do my exercises in the morning."
B
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers
B
A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact
B
A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take? A. Discourage the use of unregulated medications and supplements B. Verify the herbal supplements do not interact with medications the provider has prescribed C. Tell the client to limit the number of herbal supplements to no more than 2 D. Describe the dangers of taking plant-derived medications and supplements
B
A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A. Supine B. Lateral C. Fowler's D. Trendelenburg
C
A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. Insist that the AP attend an in-service training about standard precautions C. Talk with the AP about the technique used D. Observe the AP a second time and intervene if the technique remains the same
C
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? A. Contact the family and ask someone to stay with the client B. Offer to call the client's minister C. Sit and hold the client's hand D. Leave the room and allow the client to cry privately
C
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
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? A. "Life has its ups and downs." B. "I believe that I control my own destiny." C. "God is punishing me for something." D. "I like to keep my rosary beads in bed with me."
C
A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy B. Lateral C. Supine D. Sims'
C
A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? A. Trauma B. Severe infection C. Iron-deficiency anemia D. Chronic hypoxemia
D
A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric ulcers C. Respiratory depression D. Liver damage
D
A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing
D
A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible click B. Murmur C. Third heart sound D. Pericardial friction rub
D
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? A. "You look just fine to me." B. "Nobody expects you to look beautiful in the hospital." C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?"
D
A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial
D
A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's
D
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves. D. Perform hand hygiene.
D
While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document
D
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 interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television for 30 min in bed to relax prior to falling asleep D. Advise the client to take several naps during the day
A
A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Provide oral care to a client who cannot take oral fluids B. Check a client's IV insertion site for manifestations of infiltration C. Assess a client's ability to ambulate D. Demonstrate the use of a glucometer to a client who has diabetes mellitus
A
A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids
A
A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound
A
A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber
A
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? A. Inspection B. Auscultation C. Percussion D. Palpation
A
A nurse is providing discharge teaching to 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. "A nurse will show me how to care for my wound." B. "A nurse will stay with me at home during the day." C. "I will call the nurse to change my bed linens." D. "I will call the nurse to help me bathe in the morning."
A
A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? A. The client holds the hand with the palm up. B. The client holds the hand with the palm down. C. The client points the fingers toward the floor. D. The client points the fingers toward the ceiling.
A
A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation
A
A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every 1 hr D. Provide ice chips as per provider prescription
B
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. A client who has multiple sclerosis and uses a wheelchair B. A client who has end-stage cirrhosis C. A client who has hemiplegia due to a stroke D. A client who has cancer and receives weekly radiation therapy
B
A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time of 1.5 sec
B
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 perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30° or 45° C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding
B
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the soiled linens on the chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold
B
A nurse is collecting health history data from 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 take when working with the interpreter? A. Face away from the client to avoid distraction. B. Pace speech to allow time for the interpreter to convey the words. C. Make eye contact with the interpreter when explaining the procedure. D. Stand in the background while the interpreter translates the message.
B
A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication? A. The motivation for communication is evident. B. Feedback is provided. C. A message is communicated to the group of clients. D. Multiple channels are used by the sender.
B
A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group? A. "I am in no hurry to get married. I think I'll enjoy single life for a while." B. "I go home on the weekends to be with my family because I do not have any good friends here on campus." C. "I am interested in politics and may consider becoming an elected official." D. "I am looking forward to finishing school and going to work for my family's business."
B
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? A. Illness is not influenced by culture. B. The meaning of disease can vary widely across cultures. C. Assigning clients to specific cultural categories facilitates communication. D. Predetermined criteria should generate client care activities.
B
A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization
B
A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep the room temperature warm D. Offer the client a cup of hot chocolate before bedtime
B
nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed." D. "I will secure any wires in my home under rugs."
B
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. "My parents are retired, and they have come to help with our children." B. "I am going to ask my husband to go to counseling with me." C. "I keep having nightmares about my upcoming surgery." D. "My girlfriends bought me a nice wig."
C
A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? A. Decreased respiratory rate B. Pinpoint pupils C. Increased blood pressure D. Bronchiolar construction
C
A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A. Popliteal B. Posterior tibial C. Dorsalis pedis D. Femoral
C
A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind
C
A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints
C
A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside? A. Vest restraint B. Tongue blade C. Oxygen equipment D. Neck brace
C
A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing
C
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6 in) B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm (36 in) above the client's rectum
C
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? A. Check the client's name and medical record number on the MAR against the room and bed number B. Call the client by name and check the name on her identification band against the MAR C. Compare the medical record number and name on the MAR with the client's identification band D. Ask the client's visitor to identify the client by name and to state the client's birth date
C
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted
C
A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? A. "The home health dietitian will visit and help you learn to cook all over again." B. "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control." C. "The dietitian will help you choose foods you are used to that also meet your health needs." D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian."
C
A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? A. Ask the client's neighbor to call a family member to interpret. B. Ask the client's neighbor to translate the information. C. Obtain the services of an interpreter. D. Document the inability to provide discharge instructions.
C
A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream
C
A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include? A. "Include at least 3 g of sodium in your daily diet." B. "Limit wine consumption to 230 mL daily." C. "Include 2.5 cups of vegetables in your daily diet." D. "Limit water intake to 1.5 L each day."
C
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire. B. Squeeze the handle of the extinguisher. C. Remove the safety pin from the extinguisher. D. Sweep the hose from side to side to dispense material.
C
An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? A. "Don't worry; teenagers often have friends who give bad advice." B. "I think you should stop seeing those friends since they discourage you from following your treatment plan." C. "Tell me more about how your friends discourage you." D. "Where did you meet these friends?"
C
An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures there are no kinks in the drainage tubing.
C
A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? A. Limit the client's fluid intake B. Assist the client into a supine position C. Administer oxygen at 2 L/min D. Encourage the client to cough
D
A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage. B. Give the medication in a safe dosage. C. Give the dose the provider prescribed. D. Call the provider to clarify the dosage.
D
A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client? (Fill in the blank with the numeric value only.) A. 45 B. 46 C. 47 D. 48
D
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? A. Speak directly into the client's impaired ear B. Exaggerate lip movements C. Speak loudly D. Face the client when speaking
D
A nurse is caring for a client who is 48 hr 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
A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? A. From the middle of the thigh toward the wound B. From the left lower abdominal quadrant toward the wound C. From the left hip toward the wound D. From the wound toward the surrounding skin
D
A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? A. "In time you'll know the right thing to do." B. "I am sorry. Would you like me to call someone for you?" C. "There are multiple treatment options for you to consider." D. "Can you explain the concerns you're having right now?"
D
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500 mg/day of vitamin E C. Limit fluid intake to 20 mL/kg of body weight per day D. Provide a protein intake of 1.5 g/kg of body weight per day
D
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? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider of the client's decision.
D
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? A. Document the administration of the medication B. Count the amount of available medication on hand and sign for it C. Measure the client's respiratory rate D. Check the medication dose and the client's identification
D
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently
D
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes
D
A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? A. Stand 3 feet from the client when assisting with lifting. B. Lock your knees when standing for long periods. C. Lift up to 22.6 kg (50 lb) without the use of assistive devices. D. When lifting an object, spread your feet apart to provide a wide base of support.
D
A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? A. Pulse rate 90/min B. Rectal temperature 38°C (100.4°F) C. Pulse oximetry 95% D. BP 145/90 mmHg
D
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? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."
D
While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide? A. "Everyone dies sometimes; some die sooner than others." B. "Who do you think deserves to die more than you?" C. "It does seem unfair, doesn't it?" D. "Tell me more about how you feel about dying."
D
