Funds Final(exams 1-4)

What must the nurse do first when stuck with a contaminated needle?

Allow some bleeding to drain from the site

The nurse enters the room to find the client sitting up in bed crying. How should the nurse display a critical thinking attitude in this situation?

Ask the client why she's crying

The nurse is caring for a client who is post myocardial infarction. What information should the nurse give the client about resuming exercise?

Avoid exercise when the weather is very hot or very cold

The nurse is caring for a wheelchair-bound client. What is the first action of the nurse prior to transferring the client from bed to wheelchair?

Lock brakes on the bed and wheelchair

The nurse is giving a bed bath to a client who begins to have a seizure. Which action is needed by the nurse to maintain the client's safety?

Loosen any tight clothing around the neck and chest.

The nurse is instructing a client on a ostomy care. What should the nurse included in the teaching?

Secure the faceplate to the drainage pouch so no skin is exposed

The nurse is preparing materials to instruct the parent of a newborn about the proper use of car seats. Which information should the nurse include in the presentation?

the car seat should be secured with a c belt and backwards-facing

The nurse is caring for a client who was just informed they will never be able to walk again. Which client reaction dictates action by the nurse?

" I don't think I can live like this."

A client who has undergone a gastrointestinal surgery is permitted to have a clear liquid diet on the second postoperative day. Which fluid should the nurse order from the diet kitchen for this client?

Chicken broth

The nurse is working on a unit where it's common practice to not clean portable blood pressure machines after existing an isolation room and the nurse is encouraged to do what is done by others to conserve time. Which action by the nurse is needed to provide adequate patient care?

Clean the blood pressure machine after each use

A nursing supervisor is educating new staff on professional and safe working appearance. What should she include in the presentation?

Clean wrinkle free uniform with short fingernails.

The nurse is assisting the nurse tech in bathing a female client with a catheter. Which precautions are needed to prevent the client from developing a UTI?

Cleanse from the pubis to the rectum.

The nurse is determining the client understanding of the surgical procedure prior to surgery. What is the What is included to meet criteria for informed consent?

Client must give consent voluntarily

Nurses identifying goals for a client experiencing diarrhea. What goal should the nurse select for the client?

Client will regain normal stool consistency

The nurse is assessing a client's chest tube insertion site notices a fine crackling sound and feeling upon calculating the area. What action should the nurse take?

Collaborate with the client's provider.

The nurses walking with a client who is confined to a wheelchair when the facility fire alarm system is activated. The client becomes excited from the noise. What is the nurse's priority action?

Comfort the client while quickly moving to a safe place.

The nurse is caring for an elderly homebound client. The client states that she is frequently constipated, passes hard stools, does not like water and had her last bowel movement 3 days before the nurse visit. What is the appropriate nursing diagnosis for this client?

Constipation r/t decreased activity AEB hard stools.

The nurse is providing education to a client having difficulty with urinary elimination. What should the nurse instruct the client to do to promote urinary elimination?

Drink eight to 10 glasses of water daily

the nurse is delegating to an unlicensed assistive Personnel assigned the task of feeding breakfast to a geriatric client with alterations in mobility and orientation. What instruction should the nurse include in the delegation?

Engage the client in conversation during the meal

The nurse is caring for an older client diagnosed with Alzheimer's disease who continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client?

Place a bed safety monitoring device on the bed

A nurse is assessing a client surgical incision for signs of infection. Which finding would be interpreted as normal at the surgical site?

Serious drainage

Which of the following is not a requirement in a medication order?

Signature of pharmacist who prepared prescription

A 36 year old female is admitted for outpatient surgery. Which assessment data is most important for the nurse to report to the anesthesiologist before surgery?

The client's states that she missed her menstrual period last week

The client complains of difficulty breathing. Which assessment findings should the nurse associated with that component?

a. Use of accessory sensory muscles. b. Increased respiratory depth c. Increase respiratory rate d. And decrease respiratory depth.

The nurse is teaching a new employee about proper hand hygiene. Which correct principles should the nurse include when teaching hand hygiene?

a. Using friction and interlacing fingers during hand hygiene is required. b. Covering all surfaces of hands with antiseptic gel/foam. c. Always keep hands and lower than elbows washing.

The nurse is caring for a client who has influenza. Which info should be provided to the client to prevent the spread of the infection?

a. Wash your hands thoroughly w/ soap and water. b. Cover mouth and nose when coughing and sneezing

The nurse is planning care for a client who has limited Mobility. What instruction should be given to the assistive Personnel who will be caring for the client?

a. always use two persons to move the client b. encourage the client to assistant possible c. Place turn sheet on the bed

The nurse is bathing a diabetic client. Which nursing action should be taken if an elevation of the client's ft indicates a new finding of decreased sensation in pain?

notify the client's Health provider

the nurse is preparing to witness the client signing the operative consent form when the client says " I do not really understand what the doctor said". Which action should the nurse perform?

notify the surgeon that the client needs a more complete explanation of the procedure

.The nurse is preparing to assess a client's fecal elimination status. Which will the nurse assess first?

obtain a nursing history

The nurse needs to reposition a 300-pound client. Which of the following strategies is most likely to prevent back injury?

obtain the number of people needed to help meet the client

The nurse is checking the vital signs of a pediatric client who is complaining of pain. The nurse knows that the physiological factors are

of limited value as the sole indicator of pain

A client has been admitted and placed on a fall precaution. Which priority action should be initiated?

place a high risk for Falls armband on the client

The nurse is caring for an unconscious patient. Which will most likely contribute to the development of a decubitus ulcer?

pressure

A client has back pain from a motor vehicle crash that has persisted for eight months. The pain is controllable with sustained release oral opioid medication. How would the nurse describe the client's pain ?

recurrent

The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for Homeland Security?

smallpox

The nurse is assisting a potential injury to a client's wrist,the nurse asks the client to turn the hand and forearm upward. What movement is the client demonstrating?

supination

The nurse is performing an assessment on a client in which a cardiac murmur occurs between S1 and S2. How should the nurse document the murmur?

systolic

The nurse is identifying outcomes for a client with a nursing diagnosis stress urinary incontinence. Which outcome would be related to Spencer incontinence?

the client will perform five Kegel exercises for 10 seconds

The nurse is discussing elimination patterns with their client. The client asks why it is more difficult to use a bedpan for defecating then sitting on the toilet. What is the appropriate response by the nurse?

the sitting position increases the downward pressure on the rectum make it easier to pass stool.

The nurse is teaching a parenting class for parents of toddlers. The discussion centers around helping the toddlers cope positively with stresses of surgery. Which statement should the nurse include in the teaching ?

toddler responses to stress are dependent on their developmental level

The nurse prepares to administer an IM injection to a 4 month year old infant. The nurse selects which best site to administer the injection?

vastus lateralis

The nurse is admitting a client with incontinence. What should the nurse expect to assess in the client?

Leakage of urine occurs when client laughs.

What is the most critical question to ask the client before medication administration?

Can you tell me what your name and date of birth is

The nurse is caring for a client admitted with a possible deep vein thrombosis. Nursing interventions should be implemented to prevent which complication?

Pulmonary embolism

How many grams are in 4000 micrograms?

0.004 g

A nurse is preparing to administer 300 mg of a medication subcutaneously. Available is 1g/2mL of the medication. How many milliliters should the nurse administer?

0.6 mL

A healthcare provider has prescribed Prochlorperazine 4 mg IM for a client who is vomiting. The nurse read the label of the medication vial ( 5mg/mL) and administered how many milliliters to the client? round to the nearest tenth

0.8 mL

A client is to receive 300mcg of a medication subcutaneously. Available is 600mcg/2 mL of the medication. How many ml should the nurse administer?

1 mL

A client is to receive 50mg of a medication subcutaneously. Available is 100 mg/2 mL of the medication. How many ml should the nurse administer?

1 mL

The nurse is caring for a client who has had a stroke. Which intervention is needed to address left sided weakness while assisting the client with their daily hygiene?

Asses what hygiene the client can do on their own

A healthcare provider prescription reads to administer an IV dose of 400,000 units of penicillin G benzathine. The label on the 10 mL impulse sent from the pharmacy read penicillin G benzathine 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Round to the nearest tenth

1.3 mL

A healthcare provider prescription reads levothyroxine, 150 mcg orally daily. The medication label read levothyroxine 0.1 mg tablets. The nurse administers how many tablets to the client?

1.5 tab

A nurse is preparing to administer 60 mg medication po every 12 hours. The amount available is 40 mg tablets. How many tablets should the nurse administer with each dose?

1.5 tab

The healthcare provider prescription reads 150 mcg of a medication orally daily. The medication label read 0.1 mg per tablet. The nurse should administer how many tablets to the client? round to the nearest tenth.

1.5 tab

A HCP prescribes one unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops (gtt)/ 1 mL. The nurse prepares to set the flow rate at how many drops per minute?

10 gtts/min

A nurse is preparing to administer lactated ringers 100 IV to infuse over 60 Minutes. The nurses should set the IV pump to deliver how many mL/ hr ?

100 mL/hr

The nurse is preparing to administer 5% dextrose and 0.45 % sodium chloride 1,000 mL of IV to infuse over 10 hours. The nurse should set the IV pump to deliver how many ml / hour?

100 ml/hr

A nurse is caring for a client on a liquid diet. The client assumes ½ a cup of coffee, 4 oz of gelatin, 4 oz of tea, and 24 oz of ice chips. How many mL should the nurse record as a client's fluid intake?

1080 mL

How many milliliters are in 2.5 tablespoons?

12.5 mL

A healthcare provider prescribes 3000 mL of D5W to be administered over a 24 hour period.The nurse determines that how many mL per hour will be administered to the client?

125 mL

The nurse is preparing to administer 9% sodium chloride 1000 ml IV to infuse over 8 hours. The nurse should set the IV pump to deliver how many mL/ hr?

125 ml/hr

How many pounds is 60kg?

132 lbs

A nurse is preparing to administer 4 mg of a medication subcutaneously. Available is 1 mg / 0.5 mL of the medication. How many milliliters should the nurse administer?

2 mL

A nurse is preparing to administer 0.2 mg of a medication po daily. The amount available is 0.1 mg tablet. How many tablets should the nurse administer with each dose?

2 tabs

A nurse is preparing to administer 0.5g of a medication PO every 8 hours. The amount available is 250 mg tablet. How many table should the nurse administer with each dose?

2 tabs

A nurse is preparing to administer 0.5g of a medication po every 12 hours. The amount available is 250 mg tablet. How many tablets should the nurse administer with each dose?

2 tabs

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which clients should the nurse plan to care for first?

A client with a white blood cell count of 14000 mm3 ( 14.0 x 109/L) and a temp of 101*F ( 38.4*C)

A nurse is caring for a client who has an order for a 3.5 mg / kg / dose of a medication every 12 hours. The client weighs 145 lbs. How many mg should the nurse administer per dose?

231 mg

How many ounces are in 3 cups?

24 oz

How many mL are in 1 cup?

240 mL

Cefuroxime sodium, 1g in 50 mL normal saline, is to be administered over 30 mins. The drop factor is 15 drops (gtt)/ 1mL. The nurse sets the flow rate at how many drops per min?

25 gtts/min

How many mL are in 2.5 liters?

2500 ml

The nurse is admitting and 82 year old client for an elective surgery. Which information should be reported to the anesthesiologist prior to surgery?

Ate toast and bacon two hours ago

The nurse is assigned to care for four clients. I'm planning client rounds, which clients should the nurse assess first?

A client with asthma who requested a breathing treatment during the previous shift.

A nurse is preparing to administer 2,000 mL of an IV fluid with the IV to infuse over 6 hours. The nurses that the IV pump to deliver how many mls HR?

333 mL

The nurse is caring for a postoperative client who is receiving the demand dose Hydromorphone via PCA pump for pain control. The nurse enters the clients room and finds the clients drowsy and records the following Vital sign temperature 97.2 orally, pulse 52 bpm, blood pressure 101/58 mm Hg? Respiratory rate 11 breaths per minute, and O2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

Attempt to arouse the client

How many lbs are in 93 kg?

204.6 lb

A nurse is preparing to administer 1000 ml D5W with 40 meq KCl every 8 hours. The drop factor of the manual IV tubing is 10 g t t / ml. The nurse shirts at the manual IV infusion to deliver how many gtt/min?

21 gtt/min

A healthcare provider prescription reads 1000 mL of normal saline to infuse over 12 hours. The drop factor is 15 drops (gtt)/1mL. The nurse prepares to set the flow rate at how many drops per min?

21 gtts/min

How many cups are in 32oz?

4 cups

a client is to receive 100 mg medication subcutaneously. Available is 125mg / 5 mL of the medication. How many mL should the nurse administer?

4 mL

A nurse is caring for a client who has orders for 0.5 mg / kg / dose of a medication every 4 hours. The client weighs 17 lbs. How many mg should the nurse administer per dose?

4 mg

A nurse is preparing to administer 10 mg of a medication po every 8 hours. The amount available is 2.5 mg tablet. How many tablets should the nurse administer with each dose?

4 tabs

A nurse is preparing to administer 2g of a medication po every 12 hours. The amount available is 500 mg tablet. How many tablets should the nurse administer with each dose?

4 tabs

the 154 lb adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate the client has not yet been successful and should continue?

30 mL per hour

A nurse is preparing to administer a 500ml D5W every 4 hours. The drop factor of the manual IV tubing is 15 gtt / mL. The nurse should say the manual IV infusion to deliver how many gtt/min?

31 gtt/min

A healthcare provider prescribes 1000 mL of normal saline 0.9% to fuse over 8 hours. The drop factor is 15 drops (gtt)/ 1 mL. The nurse sets the flow at how many drops per minute?

31 gtts/min

The nurse is reviewing the care needs for a group of assigned clients. Which clients should the nurse recognize as being most at risk for a nosocomial infection?

An 86 year old female client on steroid therapy

A post-operative client on a surgical unit is confined to bed. The nurse is aware that which intervention will improve venous return?

Applies sequential compression device.

The nurse has admitted a client with malnutrition and Stage 1 pressure ulcer. Which intervention would NOT prevent progression to a stage 2 ulcer?

Avoid use of lifting devices

When performing a surgical dressing change of a clients abdominal dressing, a nurse noted an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse expect in the initial care of this wound?

Apply sterile dressing soap with normal saline.

The nurse is assisting a client with morning care when the client tells the nurse that they do not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do?

Ask the client the usual way bathing occurs at home

A nurse is preparing to administer 150 mg of a medication Subcutaneously. Available is 125 mg / 4 mL of the medication. How many ml should the nurse administer?

4.8 mL

A nurse is preparing to administer an IV fluid bolus of 100 ml over 30 minutes. The drop factor for the manual IV tubing is 15 gtts/mL. The nurse and should set the manual IV infusion to deliver how many gtts/min?

50 gtts/min

A nurse is preparing to administer an IV fluid bolus of 300 mL over 40 minutes. The drop factor of the manual IV tubing is 10 gtt / mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

75 gtt/min

A healthcare provider prescribes 1000 ml D5W to infuse at a rate of 125 mL/ hour. The nurse determines that it will take how many hours for 1 L to infuse?

8 hrs

A nurse is preparing to administer 1000 mL of an IV fluid with the IV to infuse over 12 hours. The nurse should set the IV pump to deliver how many mL/hr?

83 ml/hr

A nurse is caring for a client on a liquid diet. 8 oz of coffee w/ 1 oz of cream, 2 cups of juice, ½ cup of tea, how many mL should the nurse record at the client's fluid intake?

870 ml

The nurse has received report on 4 clients. Which client would the nurse identify as being the greatest risk for developing a pressure ulcer?

A 40 year old male who is comatose after a motor vehicle accident.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs?

Actual for Life threatning concerns

The client reports increasing pain of 10, describing it as "almost unbearable". The RN notes stable vital signs and the client is able to socialize when visitors. Which of the following is an appropriate approach from the nurse?

Admin an ordered opioid and re-evaluate in 30 mins.

A client has stage 3 pressure ulcer on his sacrum. Which nursing action will be included prior to a wet to dry dressing change?

Administer the ordered PRN pain medication 30 mins before the dressing change.

the nurse is assessing a client's urinary elimination. Which factor should the nurse keep in mind as influencing their elimination?

Age

The nurse is performing an admin assessment on a client. The client states "fresh fruit should only be eaten on an empty stomach, as it will cause other foods to ferment in the stomach". The nurse recognize this client centered decisions are based upon what?

Beliefs about food

The nurse is assessing a newly admitted client suspected to have necrosis of the urinary division stoma. What finding would the nurse report to the provider?

Black with sloughing

The nurse is performing passive range of motion exercises on a bed-bound client. The nurse stands at the side of the bed closest to the Joint being exercised. What is the best action to perform this task?

Carries out the movement to the point of resistance

The nurse is assigned to assist the surgeon. Which action will maintain sterile technique during surgery?

Change gloves after touching the back of the surgeons gown

The student nurse administers a client's oral meds at 0930 instead of the ordered time of 1000. What action should the student take?

Chart the medication admin at 0930

The nurse is preparing to administer morning medications to their client. Which of the following is not considered part of the "three label checks" of medication administration?

Check label right after giving medication to the patient.

The nurse notes and abnormal pattern on the client's cardiac monitor. What is the nurses priority action?

Check the client pulse

A client was found in their garage with the door closed and the car running. Which immediate intervention is appropriate when the client has signs and symptoms of carbon monoxide poisoning?

Check the clients airway

The nurse has delegated the administration of tube feeding to a specially trained UAP. What action should be taken by the nurse in regarding to this delegation?

Check the tube for proper placement.

The nurse calls the healthcare provider regarding a new medication prescribed because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the health care provider and the medication is due to be administered. Which action should the nurse take?

Contact the supervisor

The nurse determines that an adult clients feces are normal. What did the nurse assess to come to this conclusion?

Cylindrical in shape

the nurse is caring for a patient with a fluid balance issue. Which of the following measurements can the nurse Implement with without a physician's order?

Daily weight, Vital Signs, and I&O's

The nurse is assessing a newly admitted client for the presence of a impaired Peripheral arterial circulation. Which finding would be significant to this condition?

Decreased hair on the legs

A nurse is getting ready to discharge home a client who has a nursing diagnosis of impaired physical Mobility. Before discontinuing the client's plan of care, what does the nurse need to do?

Evaluate whether the clients goals and outcomes have been met

The nurse is assessing a clients abdomen in the ER. What is the nurses appropriate description for the clients wound?

Evisceration (protrusion of internal organs through an incision typically through abdomen)

The nurse prepares to administer furosemide personality 40 mg, P0, daily, as prescribed. At the bedside, the patient states, " I don't think I want to take that medication today". What is the nurse's first action?

Explore reasons why patient does not want the medication

The nurse is taking the history of a client who reports following the food pyramid to guide their nutritional intake. How should the nurse interpret this information?

Following the appropriate food pyramid is helpful, but there are additional factors to consider in a balanced diet

The nurse is caring for a client who has suffered a stroke and has residual Mobility problems. Which intervention will prevent skin breakdown?

Gentle perineal care and thorough drying of the skin

The nurse is caring for a client in isolation. The nurse is entering the room and understands the proper order of DONNING the personal protective equipment when performing the tasks in what order

Gown, mask, goggles/face shield, gloves

The nurse is caring for a client who has just been given a terminal diagnosis and short life expectancy when the client begins to hyperventilate and complain of being light-headed with tingling of the fingers, toes and mouth. What action should be taken by the nurse?

Have the client concentrate on slowing respirations.

The nurse is caring for a client on strict bed rest following hip surgery. What nursing intervention would support vascular Health?

Have the client engaged in active range of motion exercises

The nurse is caring for a client diagnosed with chronic obstructive lung disease receiving oxygen at 1.5 L per minute via a nasal cannula who is complaining of shortness of breath. What action should the nurse take?

Have the same breathe through pursed lips

A client has been admitted with complaints of shortness of breath x 2 weeks of duration and has received the nursing diagnosis of impaired gas exchange. Which admission laboratory result would support the choice of diagnosis?

Hematocrit

The nurse is caring for a client who has experienced severe shortness of breath but is not cyanotic. What laboratory data should the nurse review to discover the cause of the clients respiratory problems?

Hemoglobin and hemocrit

The nurse is providing medication instructions to a parent which statement by the parent indicates a need for further instruction?

I should mix the medication in the baby food and give it when I feed my child.

A staff nurse is precepting a new grad nurse and the new grad is assigned to care for a client with chronic pain. Which statement, made by the new grad nurse, indicates the need for further teaching regarding pain management?

I will be sure to cue in any indicators that the client may be exaggerating their pain.

A new nurse is working in a fast-paced nursing unit and has been approached to work additional shifts. What is the best strategy to prevent burnout?

Identify their limits and scope of work responsibilities

The nurse is assessing an infant. What criteria should be used to evaluate if the infants regurgitation should be further investigated?

If the infant is gaining weight at accurately

The nurse is caring for a client who states that they ignore the urge to defecate when they are at work. Which response should the nurse make to explain why this practice should be changed?

If you continue to ignore the urge to defecate, the urges ultimately lost

The nurse is caring for a client who exhibits confusion, decreased capillary refill time, low oxygen saturation reading, and decreased renal output. What priority nursing diagnosis should the nurse choose for the client?

Ineffective tissue perfusion

the nurse is providing discharge teaching to a client. Which intervention would the nurse plan to teach the client to prevent further urinary tract infections?

Instruct the client to empty bladder completely.

The nurse is completing discharge teaching for a client who will be discharged with oxygen therapy. Which statement made by the client would indicate a need for further teaching?

It is okay to have a guest who smokes as long as I don't

creating a plan of care for renal patients scheduled for dialysis in the afternoon. Which statement best describes the evaluation step of the nursing process

It is performed to determine if the patient has met the expected outcomes

The nurse is caring for a 90 year old patient with fluid volume deficit. Which intervention is the highest priority?

Keep fluid Within Reach for the patient

The nurse expects that a client's body is attempting to correct an acid-base imbalance. How would this imbalance be corrected?

Kidney regulation is powerfully effective.

The nurse is caring for a bed bound client who has become immobile for 6 weeks. Which assessment would be adaptive when the client reports pain and burning in the right calf?

Measure the calf compared to the opposite calf.

The nurse is performing a history on a client. The client has a history of recurrent Transit ischemia attacks. What should the nurse be concerned about the client developing in the future?

More severe stroke

The nurse is assessing a one-day-old if it discovers the heart rate is 140 and irregular. Which action should the nurse take?

Note this normal finding in the infant's medical records.

The nurse is completing a plan of care for an admission patient. What best describes how nursing diagnosis differs from medical diagnosis?

Nursing diagnosis focuses on clients' response to actual and potential health problems.

The nurse is planning teaching for a client that focuses on healthy people 2020 objective for a cardiovascular health. Which modifiable risk factor should the nurse include in the teaching?

Obesity, smoking, hypertension

The nurse is caring for an older client who told them that showers are not taking because of a previous fall. What can the nurse do to support the client's bathing needs?

Obtain a shower chair and assisted the client in the shower.

The nurse is planning the care for a client who has needs for frequent suctioning. What should the nurse delegate to the UAP

Only Oral suctioning

The nurse is applying restraints to a client. After securing a health care provider's orders, what should the nurse do?

Pad the bony prominences.

A pediatric client has experienced fluid volume deficit and has just been started on an oral rehydration. Which fluid should the nurse choose to offer the client?

Pedialyte

The nurse is preparing to assist a client to a lot of positions to position a bedpan. What action should the nurse take first?

Perform hand hygiene

The nurse is planning morning care for a client who has sequential compression device in place. How should the nurse instruct the UAP who will give the bath?

Put the device on as quickly as possible after the bath

The nurse is preparing to bathe a client on the first postoperative day. Which nursing intervention should be taken priority?

Raise side rails while Gathering supplies

The nurse is caring for a patient with a nursing diagnosis of impaired gas exchange, related to water retention leading to a pulmonary edema, as evidenced by increased respiratory rate. Which of the following is a primary goal of treatment?

Remove fluid without producing abnormal changes in the electrolyte composition.

The nurse is preparing to change the dressing of a client a surgical incision. Which of the following demonstrates a correct sequence for changing the dressing?

Remove old dressing, discard gloves and perform hand hygiene, apply clean gloves, clean wound, blot dry, apply new dressing

The post-anesthesia care nurse (PACU) has received report from the intraoperative RN. What is the priority assessment for this client?

Respiratory adequacy

The nurse is providing preoperative instructions to a patient having abdominal surgery what information is essential to tell the patient?

Splint incision with a pillow and coughing

The nurse is assessing a client in the physician's office. What Vital sign measurement will the nurse report as abnormal?

Temperature of 39*C ( C x 9/5+32= F)

The nurse is assessing a client in the physician's office. Which vital sign measurement would the nurse report as abnormal?

Temperature of 39*C ( C x 9/5+32= F)

The nurse is assessing a client with a body mass index BMI of 18. How should the nurse interpret this finding?

The client is underweight

The nurse is admitting a client to the medical unit. Which assessment data is most important for the nurse to validate?

The client says she feels like her blood pressure is low.

The nurse is caring for a client who is experiencing constipation. Which client Behavior indicates that teaching was effective?

The client walks around the unit several times a day

A nurse hears a client calling out for help, hurries down the hall to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notified the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

The client was found lying on the floor.

Which goal should the nurse identify as appropriate for a client with a nursing diagnosis urinary pattern alteration related to an enlarged prostate?

The client will avoid bladder distention

The nurse is assessing a client with hypertension who is complaining of dizziness for the past three weeks after taking their medication. What is likely contributing to their dizziness?

The client's blood pressure is too low

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

The client's pain rating

he nurse is caring for an immobile client. What is the scientific rationale for placing a live pet under the client?

The pads will help prevent friction shearing when repositioning the client.

A client is placed in isolation. Isolation techniques attempt to Break the Chain of Infection by interfering with what?

The transmission mode

The nurse knows that the tube fed client has shallow breathing and Dusky color. The feeding is running at the prescribed rate. What is the priority action of the nurse?

Turn off the tube feeding

The nurse is caring for a client with dementia. Which strategy should be implemented to manage the clients confusion while performing a bed bath?

Use a supportive, calm approach with the client.

. A new graduate nurse will make the best clinical decision by applying the components of the nursing critical thinking module and which of the following?

Using the nursing process

The nurse is preparing to administer an IM injection and draws up the prescribed amount of 2.5mL of medication. Which location will the nurse select to administer this medication?

Ventrogluteal muscle

When measuring a client's blood pressure, at what point is the diastolic pressure identified?

When Korotkoff sounds can no longer be heard

the nurse is caring for a client who is being placed in an airborne precautions for TB. Which explanation by the nurse would be accurate and appropriate

You must wear a N95 mask any time you want to ambulate out in the hallway.

A client was served a clear liquid diet and consumed 8 oz of broth, 240 mL of tea , and 4 oz of apple juice. What input does the nurse report?

a. 600 mL ( 8 oz = 1 cup = 240 mL)

The nurse is completing an assessment on a medical-surgical client. Which questions would be included in the Skin Integrity assignment?

a. Do you have a sensitivity to heat or cold? b. Can you easily change your position? c. Is movement painful ? d. How often do you need to use the toilet?

the nurse is admitting the patient for surgery. Which of the following is included in the preoperative assessment?

a. Present religious influences b. smoking habits and frequency c. prescription medication history d. use of herbal supplements

the nurse prepares to give a bed bath to a client. Which Step should the nurse perform prior to the bed bath? Select all that apply

a. explain the procedure. b. Provide privacy. c. Hand hygiene. d. Gather all supplies. e. Identify the client

The nurse is admitting a new client. The nurse notices the client has an odor and appears unkempt. When assessing a client, what self-care defense should the nurse consider? Select all that apply.

a. the client may have decreased or lack of motivation. b. The client may have severe anxiety / depression. c. The client may have a cognitive impairment. d. The client may have increased pain and discomfort. e. The client may have environmental barriers

The nurse has a prescription to give 30 ml of an antacid to a client through a feeding tube. What is the priority nursing action?

access tube placement

NANDA international refines and promotes nursing diagnostic terminology for use by all professional nurses. Which diagnosis below is NANDA-I approved?

acute pain

The nursing is assisting a sterile dressing change. Sterile field is broken by the provider performing the dressing change. What priority action is needed by the nurse?

alert the provider to the break and sterile field

A nurse is eating in a restaurant and notices that a customer at the next table begins to clutch their throat while eating a steak. What should the nurse do first?

ask the customer if they are choking

The nurse is completing an admission on a client while interviewing the client they State "I am allergic to latex". Which action will the nurse take first?

ask the patient to describe the type of reaction.

The nurse is caring for a 10 month old child who had a hernia repair. What is the best way to assess pain in the child?

assess face, leg activity, General activity, cry and consolability (Flacc Scale)

The nurse is assisting a client from bed to wheelchair when the client experiences dizziness. Which intervention should the nurse take initially?

assist the client back into a sitting position.

The nurse is caring for a Restless client who has been pulling out their nasotracheal tube. How should the nurse asses if the tube is still in place?

auscultate for bilateral breathing sounds

The nurse is reviewing orders for an immobilized bedridden client. The order States the client is to be placed on a 2-hour turning and positioning program. What type of intervention is the nurse performing?

maintaining skin integrity

The nurse documents the following "client has nausea, vomiting, diarrhea, and fever". Which assessment finding is subjective?

nausea

The nurse is performing a focus paid assessment. The client has had uncontrolled type 2 diabetes for the last 10 years and describes the pain as tingling and shooting down the leg. What type of pain is the client describing?

neuropathic

A client with a Branden Score of 14 is placed on an every two hour repositioning regimen. When the client complains about the requent turing, what is the nurses most appropriate response?

changing position prevents tissue breakdown that could ultimately become infected

The nurse has a prepared 50 mg oral dose of new medication for a client according to the physician orders. The client states, "the physician told me I would be started on a 100 mg of the medication". What is the nurse's best action?

contact the prescriber and clarify the order

as the initial gastric tube is passed into the ortho fairness, the client begins to gag and cough. What is the correct nursing action?

give the client a few sips of water

The nurse is instructing the mother of a toddler about safety in the home. Which finding would alert the nurse to a safety hazard in the home?

handles of Pots turned out on the stove

The nurse is assisting the client with a bath and encourages full range of motion in all the clients joints. Which activity would be the best range of motion in the hand and arm?

have the clan brush their hair and teeth

A client develops a surgical wound infection one week after surgery. What is the most likely cause of the infection?

healthcare-associated infection

The nurse knows what parts are required in a nursing problem statement? Which nursing diagnosis is correctly stated?

impaired skin integrity related to presence of fecal matter on the skin as manifested by reddened, broken skin over coccyx.

The nurse provides a postoperative client with pain medication to alleviate their discomfort. Which best describes the phase of the nursing process?

implementation

the nurse is caring for an elderly client and knows that the client is not eating or drinking. Which assessment finding best indicates the presence of dehydration?

increase drowsiness and concentrated urine

The nurse is instructing the client on ways to manage stress urinary incontinence. What should be included in a client teaching?

limit evening fluid intake b. limit intake of alcohol c. limit intake of caffeine

The nurse is caring for a client who developed a surgical wound infection one week after surgery. What is the most likely cause of this infection?

nosocomial infection