NUR-111 final

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic? A. Precipitating cause B. Quality C. Region D. Severity

Quality Rationale: Asking the client what they were doing when the pain started is using the precipitating cause component of the PQRST mnemonic. Asking the client what the pain feels like is using the quality component of the PQRST mnemonic. The client might describe the pain as sharp, stabbing, dull, crushing, or throbbing. The nurse should use the PQRST mnemonic to obtain more information about the client's pain

A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by the newly licensed nurse indicates an understanding of the teaching? a. bp 148/72 mm hg b. temp 36 degrees C (96.8 F) c. SpO2 95% d. radial pulse regular 68/min

Radial pulse regular 68/min Rationale: The nurse should document the location where the pulse was taken and whether the pulse is regular or irregular

A nurse is preparing to reposition a client. Which of the following actions should the nurse take first A. Place their feet in line with their shoulders B. Pivot their feet in the direction of the move C. Raise the height of the client's bed D. Tighten their abdominal muscles

Raise the height of the client's bed. Rationale: According to evidence-based practice, the first action the nurse should take is to raise the height of the client's bed. This ensures the client is close to the nurse's center of gravity and reduces the risk of injury

A nurse is teaching a client about performing leg exercises to reduce the risk for deep vein thrombosis. Which of the following instructions should the nurse include? A. Perform leg exercises every 4 hr. B. Repeat each leg exercise 2 times per session. C. Point the toes toward the foot of the bed. D. Rotate the feet in a circular motion. E. Point the toes toward the head.

Rationale: Perform leg exercises every 4 hr is incorrect. The client should use perform leg exercises every 1 to 2 hr to reduce the risk for deep vein thrombosis.Repeat each leg exercise 2 times per session is incorrect. The client should repeat each exercise 5 times per session to reduce the risk for deep vein thrombosis.Point the toes toward the foot of the bed is correct.The client should alternate dorsiflexion and plantar flexion of the feet to promote venous return and reduce the risk for deep vein thrombosis.Rotate the feet in a circular motion is correct.The client should rotate the feet in a circular motion to promote venous return and reduce the risk for deep vein thrombosis.Point the toes toward the head is correct. The client should alternate dorsiflexion and plantar flexion of the feet to promote venous return and reduce the risk for deep vein thrombosis.

A nurse is providing preoperative teaching for a client. Which of the following outcomes should the nurse expect? A. Reduced postoperative anxiety B. Increase in postoperative pain C. Increased length of postoperative care in the health care facility D. Reduced postoperative respiratory function

Reduced postoperative anxiety Rationale: Clients who receive preoperative education should have an understanding about what to expect before and after the procedure, which results in a decrease in anxiety.

A nurse is caring for a client who has an oral temperature of 39.5° C (103.1° F). Which of the following actions should the nurse take? a. place a warming blanket over the client b. remove excess clothes from the client c. restrict the client's fluid intake d. increase the temperature in the client's room

Remove excess clothing from the client. Rationale: The nurse should remove blankets and excess clothing to decrease the client's temperature without causing shivering

A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take? A. Remove the protective gown before leaving the client's room B. Shake bed linens before placing them in a linen bag C. Remove protective gown before removing gloves D. Use an electronic thermometer to take the client's temperature

Remove the protective gown before leaving the client's room. Rationale: The nurse should remove the protective gown and gloves before leaving the client's room to reduce the risk of transmission of the infectio

A nurse is teaching a client who reports insomnia. Which of the following statements should the nurse make? A. "Take a 1 hr nap each day." B. "Stop exercising at least 30 minutes before bedtime. C. "Keep your bedroom at a warm temperature." D. "Remove the television from your bedroom."

Remove the television from your bedroom." Rationale: The client should remove the television and work items from the bedroom to promote sleep

A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing? a. researcher b. educator c. nurse manager d. case manager

Researcher Rationale: The nurse is performing the role of a researcher. A nurse researcher gathers evidence-based practice data on a topic such as CAUTI which is supported with scientific research to show its effectiveness. This can assist with the improvement of quality care given to clients.

A nurse is teaching a class about mucous membranes. The nurse should include mucous membranes are found in which of the following locations? A. Respiratory tract B. Dermal layer of skin C. Cuticle area of the nails D. Enamel of the teeth

Respiratory tract Rationale: Mucous membranes provide a protective barrier to pathogens. They are found in the mouth, respiratory tract, gastrointestinal tract, and urinary tract.

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation? A. Right communication B. Right time C. Right documentation D. Right room

Right communication Rationale: Right communication is one of the five rights of delegation. The nurse should be sure to communicate clearly and provide sufficient directions when delegating tasks.

A nurse is preparing a poster presentation about communicating with clients. Which of the following strategies should the nurse include to enhance communication? A. Show respect for a client who is making decisions about treatment. B. Convey empathy for a client who voices painful emotions. C. Exhibit receptive body language when discussing difficult topics. D. Interrupt a client when they are verbalizing feelings of worthlessness. E. Speak to a client using clear and simple words and phrases. F. Cross both arms across the chest when speaking with an angry client.

Show respect for a client who is making decisions about treatment. Convey empathy for a client who voices painful emotions. Exhibit receptive body language when discussing difficult topics. Speak to a client using clear and simple words and phrases. Show respect for a client who is making decisions about treatment is correct. The nurse should include that showing respect for a client is a basic strategy that can enhance communication, regardless of any potential communication barriers.Convey empathy for a client who voices painful emotions is correct. The nurse should include that conveying empathy for a client is a basic strategy that can enhance communication, regardless of any potential communication barriers.Exhibit receptive body language when discussing difficult topics is correct. The nurse should include that exhibiting receptive body language toward a client is a basic strategy that can enhance communication, regardless of any potential communication barriers.Interrupt a client when they are verbalizing feelings of worthlessness is incorrect. The nurse should include that interrupting a client is a nontherapeutic action that can inhibit effective communication. The nurse should avoid interrupting the client and actively listen while they speak.Speak to a client using clear and simple words and phrases is correct. The nurse should include that using simple, clear language with a client is a basic strategy that can enhance communication, regardless of any potential communication barriers.Cross both arms across the chest when speaking with an angry client is incorrect. The nurse should identify that crossing the arms across the chest is a nonverbal action that can inhibit effective communication. The nurse should keep their arms and legs uncrossed and make eye contact with the client.

A nurse is teaching a class about skeletal muscles. Which of the following should the nurse identify as a function of skeletal muscles? A. Skeletal muscles enable the heart to contract with each heartbeat B. Skeletal muscles enable a hand to contract and form a fist C. Skeletal muscles enable the bladder to contract during voiding D. Skeletal muscles enable the bronchioles to dilate in the lungs

Skeletal muscles enable a hand to contract and form a fist. Rationale: The contraction and relaxation of skeletal muscles enable movement in bones and joints, such as forming a fist with the hand.

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a modifiable risk factor for developing a disease? A. Sunbathing B. Age C. Genetics D. Family history

Sunbathing Rationale: The nurse should identify sunbathing as a modifiable risk factor for cancer. Modifiable risk factors are behaviors or a lifestyle that can be changed to improve health

A nurse is preparing to reposition a client towards the head of the bed. In which of the following positions should the nurse place the client before repositioning them to the head of the bed? A. Supine B. High-Fowler C. Lateral D. Prone

Supine Rationale: The nurse should lower the head of the client's bed and place the client in a supine position to reduce the risk of injury to the client or the nurse.

A nurse is preparing an educational session about The Joint Commission (TJC). Which of the following information should the nurse include? a. TJC provides licensure for health care providers b. TJC is a for-profit organization c. TJC is an organization that monitors insurance claims d. TJC provides accreditation to facilities

TJC provides accreditation to facilities

A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect? A. Hypotension B. Weight loss C. Diaphoresis D. Tachycardia

Tachycardia Rationale: manifestations of circulatory overload can include tachycardia, crackles in lungs, cough, pallor, and edema

A nurse is assessing a client for manifestations of pain. Which of the following findings is a subjective indicator of pain? A. The client is grimacing B. The client reports a burning sensation C. The client's pupils are dilated D. The client is restless

The client reports a burning sensation

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication? A. The client has a urine output of 400 mL for the past 8 hr B. The client reports dizziness when ambulating to the bathroom C. The client ate 60% of their breakfast

The client reports dizziness when ambulating to the bathroom. Rationale: The client's report of dizziness can indicate hypotension. The nurse should take a current reading of the client's blood pressure before administering medication that could decrease the blood pressure further. This nursing action indicates the use of clinical judgement.

A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision? A. The client seems to be more comfortable performing self-administration of insulin B. The client's FBD was 95 mg/dl C. The client demonstrated proper technique when drawing up 8 units of insulin D. The client stated, "I struggle to see those little lines on the syringe"

The client seems to be more comfortable performing self-administration of insulin. Rationale: This statement reflects the nurse's opinion and should be revised. The American Nurses Association standards for documentation state that entries into a client's medical record must be factual, accurate, complete, timely and organized.

A nurse is assessing a client who is postoperative.. Which of the following findings should the nurse identify as objective data? A. The client states they are experiencing "extreme pain". B. The client's current blood pressure is below their preoperative reading. C. The client's urine output has been 150 mL over the past 3 hr. D. The client is reporting nausea. E. The client's right calf is swollen and warm to the touch.

The client states they are experiencing "extreme pain" is incorrect. Objective findings are derived from direct observation or measurement by the nurse. They include findings that the nurse can see, hear, smell, or touch. Subjective findings are verbalized by the client and include their descriptions of what they are feeling.The client's current blood pressure is below their preoperative reading is correct. Objective findings are derived from direct observation or measurement by the nurse. They include findings that the nurse can see, hear, smell, or touch. Subjective findings are verbalized by the client and include their descriptions of what they are feeling.The client's urine output has been 150 mL over the past 3 hr is correct. Objective findings are derived from direct observation or measurement by the nurse. They include findings that the nurse can see, hear, smell, or touch. Subjective findings are verbalized by the client and include their descriptions of what they are feeling.The client is reporting nausea is incorrect. Objective findings are derived from direct observation or measurement by the nurse. They include findings that the nurse can see, hear, smell, or touch. Subjective findings are verbalized by the client and include their descriptions of what they are feeling.The client's right calf is red and warm to the touch is correct. Objective findings are derived from direct observation or measurement by the nurse. They include findings that the nurse can see, hear, smell, or touch. Subjective findings are verbalized by the client and include their descriptions of what they are feeling.

A nurse is reviewing the medical history of a client who is scheduled for surgery. Which of the following findings places the client at risk for an incisional hematoma? A. The client takes anticoagulant medications. B. The client has urinary incontinence C. The client has peripheral vascular disease. D. The client is underweight

The client takes anticoagulant medications. Rationale: Anticoagulant medications interfere with blood clotting mechanisms and place the client at risk for a hematoma.

A nurse is teaching a client who has been newly diagnosed with diabetes mellitus. Which of the following information demonstrates health literacy by the client? a. the client understands to take their blood glucose daily b. the client requests to speak with a nutritionist c. the client asks to speak with their provider d. the client requests further information to improve their health

The client understands to take their blood glucose daily. Rationale: The nurse should identify the client is demonstrating health literacy by understanding to take their blood glucose daily. The client is demonstrating health literacy by being knowledgeable about and understanding their health care information and treatments.

A nurse is caring for a client who is 3 hr postoperative following abdominal surgery. Which of the following assessment data should the nurse report to the provider? A. The client's pain level has decreased since the administration of morphine B. Postoperative laboratory results are Hbg 15% and Hct 40% C. The client urine output has been 50 mL since surgery D. Serosanguineous drainage noted on the abdominal dressing.

The client urine output has been 50 mL since surgery. Rationale: The nurse should report to the provider that the client's urine output is 50 mL over 3 hr. This amount is below the expected reference range of at least 30 mL/hr, which can indicate the client requires an increase in fluid intake.

A nurse is teaching a newly licensed nurse about the peripheral nervous system. Which of the following statements should the nurse make? The peripheral nervous system regulates the body's response to external stimulus." B. "The brain is part of the peripheral nervous system." C. "The spinal cord is part of the peripheral nervous system." D. "The peripheral nervous system is responsible for memory."

The peripheral nervous system regulates the body's response to external stimulus." Rationale: The peripheral nervous system is a network of thousands of nerves outside of the brain and spinal cord that regulates the body's response to external stimuli.

A nurse is teaching a class about documenting blood pressure. The nurse should include to document which of the following information? A. The site where the blood pressure was obtained. B. Interventions implemented in response to a client's blood pressure. C. A client's position when the blood pressure was obtained. D. The frequency in which a blood pressure is taken. E. A client's response to interventions implemented.

The site where the blood pressure was obtained is correct. The nurse should document the site where the blood pressure was taken. This information might be needed in evaluation of future blood pressure measurements. Interventions implemented in response to a client's blood pressure is correct. The nurse should document interventions implemented in response to a client's blood pressure, such as changing the client's position. A client's position when the blood pressure was obtained is correct. The nurse should document a client's position when the blood pressure was obtained. This information might be needed in evaluation of future blood pressure measurements. The frequency in which a blood pressure is taken is incorrect. The nurse does not need to document routine client care, such as frequency of vital signs. A client's response to interventions implemented is correct. The nurse should document the client's response to interventions implemented. This information might be needed in evaluation of future blood pressure measurements.

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics? A. They twist their spine when lifting B. They stand close to the object being moved C. They bend at the hip when lifting D. They keep their feet together when lifting an object

They stand close to the object being moved. Rationale: The nurse should stand close to the object being moved to reduce reaching and decrease the risk of injury. This action indicates an understanding of the teaching.

This framework helps clients to establish order in their individual environment." "This framework guides care by recognizing conditions that can worsen rapidly." "This framework follows a specific algorithm for prioritizing care." "This framework recognizes when client conditions have less time to adapt." "This framework will guide your care using a sequential process."

This framework helps clients to establish order in their individual environment." is incorrect. The nurse should instruct the newly licensed nurses that Maslow's Hierarchy of Needs includes safety and security needs, the second level of the hierarchy. Safety needs are met when individuals have order, certainty, and control in their lives."This framework guides care by recognizing conditions that can worsen rapidly." is correct. The nurse should instruct the newly licensed nurses that the acute vs. chronic priority framework prioritizes acute problems, those that are severe, appear suddenly, and can worsen rapidly, over chronic conditions that worsen over a period of time."This framework follows a specific algorithm for prioritizing care." is incorrect. The nurse should instruct the newly licensed nurses that the ABCDE priority framework follows an algorithm for prioritizing care for clients. The ABCDE framework is to recognize and stabilize the most critical issues first."This framework recognizes when client conditions have less time to adapt." is correct. The nurse should instruct the newly licensed nurses that the acute vs. chronic priority framework prioritizes acute problems, those that are severe, appear suddenly, and can worsen rapidly, over chronic conditions that worsen over a period of time."This framework will guide your care using a sequential process." is incorrect. The nurse should instruct the newly licensed nurses that the nursing process is a framework that guides nurses in prioritizing care. The steps are used regularly and continuously in client care.

A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration? A. Toxic B. Trough C. Half-life D. Peak

Trough Rationale: Medication toxicity occurs when a medication accumulates in the blood due to the inability to be effectively metabolized or excreted by the body. Trough blood level is the lowest concentration of a medication in the circulatory system. It is measured before administering the next scheduled dose of a medication

A nurse is planning care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following A. Bladder outlet obstruction B. Urinary tract infection C. Genitourinary system effects D. Neurogenic bladder

Urinary tract infection Rationale: Incomplete emptying of the bladder can cause bacterial growth due to pooling of urine. The nurse should monitor the client for manifestations of a urinary tract infection, such as urgency, frequency, and burning during urination.

A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include? A. Rub your skin firmly when cleaning B. Use a moisturizer on your skin after cleaning C. Wash your skin daily with hot water D. Allow your sin to dry after bathing

Use a moisturizer on your skin after cleaning." Rationale: The client should use gentle moisturizers on the skin to promote hydration and protect the skin from injury that might lead to an infection.

A nurse is preparing to administer an intramuscular injection to a client. Which of the following actions should the nurse plan to take? A. Recap the needle after administration B. Break the needle before disposal C. Use a needle that retracts D. Dispose of the needle in a wastebasket

Use a needle that retracts. Rationale: Preparing the injection with a needle that retracts is a sharps injury prevention measure established by OSHA to minimize needlestick injuries.

A nurse is teaching a newly licensed nurse about reducing the risk for healthcare-associated infections. Which of the following instructions should the nurse include? A. Change a gauze dressing over central vascular access devices every 3 days. B. Use clorhexidine gluconate to clean skin on the clients who are preoperative. C. Provide mouth care every 8 hours for clients who require mechanical ventilation D. Irrigate in dwelling urinary catheters daily.

Use chlorhexidine gluconate to clean skin on clients who are preoperative. Rationale: The nurse should use chlorhexidine gluconate to clean skin on clients who are preoperative to reduce the risk for healthcare-associated infections.

A nurse is reinforcing teaching with a client who has low health literacy. Which of the following actions should the nurse take? A. Use the teach-back method. B. Encourage questions. C. Speak slowly. D. Use medical terminology. E. Provide written materials.

Use the teach-back method is correct.When reinforcing teaching with a client who has low health literacy, the nurse should use the teach-back method to ensure that the client understands the material.Encourage questions is correct.When reinforcing teaching with a client who has low health literacy, the nurse should encourage the client to ask questions to ensure that they understand the material.Speak slowly is correct. When reinforcing teaching with a client who has low health literacy, the nurse should speak slowly to ensure that the client understands the material.Use medical terminology is incorrect. When reinforcing teaching with a client who has low health literacy, the nurse should use simple terms instead of medical terminology to ensure that the client understands the material.Provide written materials is incorrect.When reinforcing teaching with a client who has low health literacy, the nurse should use other methods to ensure that the client understands the material. Written materials can often be difficult for clients to understand.

Use two acceptable client identifiers Verify that the surgical site has been marked. Ask the client to state the surgery being performed. Ask the client to read their identification bracelet. Ask the client to point to the surgical site.

Use two acceptable client identifiers is correct. The nurse should use two acceptable client identifiers to identify a client during time-out. Acceptable identifiers include the client's date of birth and the client's t full name.Verify that the surgical site has been marked is correct. The nurse should verify that the client's surgical site has been marked during time-out to ensure that the correct site is being operated on. The surgeon typically marks the surgical site indicating where the surgery will be performed.Ask the client to state the surgery being performed is correct. The nurse should ask the client to state the procedure scheduled, in their own words, during time-out to ensure that the correct client is present and that the correct procedure is being performed.Ask the client to read their identification bracelet is incorrect. The nurse should ask the client to state their full name while the nurse reads their identification bracelet to verify the client's identity during time-out.Ask the client to point to the surgical site is correct. The nurse should request that the client point to the surgical site during time-out. This verifies the correct site is being operated on.

A nurse is reviewing laboratory values for a client. Which of the following findings indicates the presence of an infection? A. Creatinine kinase 75units/L B. WBC count 22,000/mm3 C. Platelet count 200,000mm3 D. Hgb 15 g/dL

WBC count 22,000/mm3 Rationale: The client's WBC count is greater than the expected reference range of 5,000 to 10,000/mm3. An elevated WBC count is a manifestation of an infection

A nurse is teaching a client about using a PCA device for postoperative pain management. Which of the following statements should the nurse make? A. "A large dose of pain medication is administered with each injection." B. "The pain medication is delivered into your muscle." C. "Your partner can push the PCA button for you if you are asleep." D. "You will have control of administering your own pain medication."

You will have control of administering your own pain medication." Rationale: PCA devices allow the client to control administration of their own pain medication.

a nurse is teaching a class about physical manifestations associated with the fight-or flight response to stress. which of the following manifestations should the nurse include? a. decreased blood pressure b. hypoglycemia c. dilated pupils d. bronchai airway constriction

dilated pupils rationale: dilated pupils are associated with the fight or flight response to stress to increase the visual field.

a nurse is assessing a client who has obstructive sleep apnea. which of the following findings should the nurse expect? a. constipation b. nausea c. headache d. hypotension

headache rationale: obstructive sleep apnea can cause fatigue, irritability, depression, and decreased sex drive.

a nurse is teaching a class about stress. the nurse should include that which of the following is a manifestation of prolonged stress? a. decreased blood pressure b. hypoglycemia c. anemia d. impaired immune function

impaired immune function rationale: impaired immune function can occur in response to prolonged stress, which places the client at risk for infection

a nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect? a. elevated temperature b. anxiety c. lightheadedness d. fluid volume deficit

lightheadedness rationale: bradycardia can cause lightheadedness due to decreased cerebral perfusion

A nurse is teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations? a. pulmonary veins b. pulmonary artery c. left atrium d. left ventricle

pulmonary artery

A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse expect? a. tachypnea b. hypothermia c. bradycardia d. pulse deficit

tachypnea Rationale: A respiratory infection, such as pneumonia, can cause an increase in respiratory rate

A nurse is caring for a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client? A. Justice B. Fidelity C. Autonomy D. Veracity

Autonomy Rationale: Autonomy is an ethical principle that refers to the client's right to make their own decisions. The client has a right to refuse treatment or procedures at any time and the nurse should respect and honor the client's decision.

nurse assessing a client who has vitamin C deficiency. Which of the following findings should the nurse expect? A. Bleeding gums B. Swollen gums C. Impaired vision D. Diarrhea

Bleeding gums Rationale: Vitamin C deficiency can result in scurvy. Manifestations of scurvy can include bleeding gums, muscle loss, bone deformities, and anemia.

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? A. Muscle mass B. Muscle strength C. Bone density D. Joint flexibility

D. Joint flexibility Rationale: Passive range of motion increases joint flexibility and reduces joint stiffness

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take? a. don sterile gloves before inserting the indwelling urinary catheter. b. apply an oil-based lubricant to the indwelling urinary catheter c. use one cotton swab to clean the client's urinary meatus d. test the balloon on the indwelling catheter before insertion

Don sterile gloves before inserting the indwelling urinary catheter. Rationale: The nurse should don sterile gloves before inserting the indwelling urinary catheter to maintain medical asepsis.

A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect? A. Bradycardia B. Decreased respiratory rate C. Hypoglycemia D. Hypertension

Hypoglycemia Rationale: Physiologic response to pain can result in hyperglycemia.

Anurse is using a medical interpreter to communicate with a client. Which of the following actions should the nurse take? A. Make eye contact with the client when speaking. B. Speak to the client in the third position C. Have the interpreter sit in front of the client D. Use long sentences when speaking to the client

Make eye contact with the client when speaking. Rationale: The nurse should make eye contact with the client when using a medical interpreter to promote communication with the client.

A nurse is assessing a client who is experiencing hypervolemia. Which of the following findings should the nurse expect? A. Bradycardia B. Hypotension C. Oliguria D. Peripheral edema

Peripheral edema Rationale: The nurse should expect the client who has hypervolemia to have peripheral edema, crackles in lungs, and increased central venous pressure.

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia? A. Provide the client with oral hygiene B. Elevate the head of the bed to 45 degrees during meals C. Instruct the client to tilt their head back while swallowing D. Turn on the television for the client during meals.

Provide the client with oral hygiene. Rationale: Good oral hygiene decreases bacteria in the mouth that can result in aspiration pneumonia.

A nurse is assessing a client who has a heart rate of 56/min. Which of the following findings should the nurse expect? A. Dizziness B. Hypoglycemia C. Temp of 39C (102.2 F) D. History of cigarette smoking

Report of dizziness Rationale: A heart rate of 56/min is less than the expected reference range of 60 to 100/min. Bradycardia can cause dizziness due to decreased perfusion to the brain.

A nurse is teaching a class about the stages of sleep. The nurse should explain that vivid dreaming occurs during which of the following stages of sleep? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

Stage 4 Rationale: Stage 4 is the dreaming stage. During stage 4 sleep, there is a loss of skeletal muscle tone and vivid, color dreams occur.

A nurse is preparing a client for a procedure. Which of the following is an acceptable identifier to use identify the client A. Telephone number B. Home address C. Room number D. Medical condition

Telephone number

A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take? A. Use soap and water to clean the client's perineum. B. Start at the client's rectum and clean to the client's perineum C. Allow the client's perineum to air dry D. Use the same section of washcloth for each area cleaned

Use soap and water to clean the client's perineum. Rationale: The nurse should use soap and water or perineal wipes to wash the client's perineum to decrease micro-organisms.

A nurse is teaching a client about health promotion strategies. Which of the following statements should the nurse make? a. choose foods containing simple sugars each day b. increase your daily intake of saturated fats c. drink 2 large glasses of water when you wake up each day d. limit intake of sodium to 3000 mg per day

"Drink 2 large glasses of water when you wake up each day." Rationale: The client should drink at least per 2500 mL (84.5 oz) of water per day to promote health and reduce stress

A nurse is providing preoperative teaching for a client about coughing and deep breathing. Which of the following statements should the nurse make? a. "hold your breath" b. "repeat your breathing exercise every 2 hours" c. "inhale through your mouth" d. "exhale through your nose"

"repeat your breathing exercise every 2 hrs" rationale: the client should repeat the breathing exercise every 1 to 2 hours to increase lung expansion and reduce the risk for atelectasis and pneumonia.

A nurse is caring for a client who has a potassium deficiency. Which of the following foods should the nurse recommend as the best source of potassium? A. 1 slice of cheddar cheese B. 1 wedge of cantaloupe C. 1 banana D. 1 slice of wheat bread

1 banana Rationale: The nurse determines that a banana is the best food source to recommend because 1 banana contains 326 mg of potassium.

A nurse is preparing to administer cefotaxime 1,000 mg IM to a client. How many grams (g) should the nurse plan to administer? A. 0.1 g B. 1 g C. 10 g D. 100 g

1 g Rationale: When converting mg to g, the nurse should move the decimal point three places to the left. Therefore, 1,000 mg is equal to 1 g.

A charge nurse is providing an in-service to a group of staff nurses about unexpected events. Which of the following should the nurse include in the teaching as an example of a sentinel event? A. A client had bowel surgery and died from sepsis B. A client fell out of bed and fractured their hip. C. A client was almost given another client's medication D. A client was prescribed a medication they were allergic to, but the prescription was canceled before the medication was given.

A client had bowel surgery and died from sepsis. Rationale: The nurse should include in the in-service that a client who had a bowel surgery and then died from sepsis is a sentinel event. A sentinel event is an unexpected event that caused severe or permanent harm to the client and even death.

A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first? A. A client who has cirrhosis of the liver and bruising on their arms B. A client who has a new onset of atrial fibrillation and a heart rate of 152/min C. A client who reports urinary burning and a temperature of 39.2 C (102.5 F) D. A client who has heart failure and peripheral edema

A client who has a new onset of atrial fibrillation and a heart rate of 152/min. Rationale: Using the urgent vs. nonurgent priority framework, the nurse should determine that the client who has a new onset of atrial fibrillation and a heart rate of 152/min should be seen first. The client is experiencing rapid ventricular response and should be attended to as the heart cannot sustain a rate this high without the client decompensating.

A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first? A. A client who is scheduled for discharge and has a 38.4 (101.1 F) temperature this morning B. A client who has pneumonia and has developed wheezing C. A client who is postoperative and has a urine output of 50 mL for the past 3 hr D. A client who has early dementia and awoke confused to their location this morning

A client who has pneumonia and has developed wheezing. Rationale: Using the ABCDE priority framework, the nurse should first see the client who has pneumonia and has developed wheezing as this can lead to a compromised airway that requires immediate attention. The nurse should check the client to determine if they can talk or if secretions are obstructing the airway, in which case suctioning of the client's airway is required

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? A. A client who alert and responsive and eats 25% of each meal. B. A client who is unresponsive to verbal commands and changes position occasionally C. A client who is receiving enteral feeding and can change position independently D. A client who makes frequent slight changes in position and walks occasionally

A client who is unresponsive to verbal commands and changes position occasionally. Rationale: This client is at greatest risk for a pressure injury because they have a very limited sensory perception. The nurse should monitor the client for a pressure injury.

A nurse is caring for four clients who are all requesting assistance. Which of the following clients should the nurse assist first? A. A client who is postoperative and is reporting nausea B. A client who reports their IV pump is beeping C. A client who is requesting a bedpan D. A client who reports they have fallen while ambulating

A client who reports they have fallen while ambulating. Rationale: Using the urgent vs. nonurgent priority framework, the nurse should first assist the client who has fallen on the floor. The client will need to be assisted back to bed and assessed to determine if they have sustained an injury. Following this, the nurse should obtain vital signs and notify the provider of the incident. An incident report of the event will be required.

A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse. Which of the following should the charge nurse include in the teaching? A. A medical record can be used as evidence in a court of law B. A nurse should ensure the documentation is organized and completed in a timely fashion C. Documentation should include the nurse's interpretation of the client situation D. Data contained in a client's medical record can be shared with all employees within a health care facility E. Information recorded in the client's medical record must be accurate and complete

A medical record can be used as evidence in a court of law is correct. A court of law can examine client medical records to determine if the care provided was consistent with the standards of care outlined by the American Nurses Association.A nurse should ensure the documentation is organized and completed in a timely fashion is correct.The American Nurses Association has published standards for nursing documentation within the medical record. These standards reflect the documentation must be accurate, factual, complete, timely, organized, and compliant with any applicable state and federal agencies. Documentation should include the nurse's interpretation of the client situation is incorrect. Documentation should not contain opinions. As per the American Nurses Association published standards, documentation must be accurate, factual, complete, timely, organized, and compliant with any applicable state and federal agencies.Data contained in a client's medical record can be shared with all employees within a health care facility is incorrect. As per the Health Insurance Portability and Accountability Act (HIPPA), information from a client's medical record can only be viewed by those who are directly involved in the client's care.Information recorded in the client's medical record must be accurate and complete is correct.The American Nurses Association has published standards for nursing documentation within the medical record. These standards require the documentation to be accurate, factual, complete, timely, organized, and compliant with any applicable state and federal agencies.

A nurse is caring for a client who reports frequent headaches. Which of the following statements by the nurse uses holistic nursing? A. Are you feeling stressed before you have a headache?" B. Do any medications relieve your headaches? C. We should check your blood pressure when you have a headache. D. We should check your blood pressure when you have a headache.

A. "Are you feeling stressed before you have a headache?" Rationale: The holistic nurse should consider factors such as stress, diet, and sleep that might trigger the client's headaches. A holistic approach to nursing includes the mind, body, and spirit to relieve pain and promote health.

A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take? A. Choose a finger with a capillary refill less than 2 sec. B. Place the sensor probe on the same extremity as an electronic blood pressure cuff. C. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading. D. Relocate the sensor every 8 hrs.

A. Choose a finger with a capillary refill less than 2 sec. Rationale: The nurse should choose a site with adequate perfusion to obtain an accurate reading.

A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. The client refuses to take the medication. Which of the following actions should the nurse take? A. Report the incident to the provider B. Notify the facility's ethics committee C. Fill out an incident report D. Return the opened medication to the medication cart

A. Report the incident to the provider. Rationale: The client has the right to refuse a medication. The nurse should investigate the reason for the refusal, educate the client about the potential adverse effects of the refusal, and notify the provider.

A nurse is caring for a client who states, "My doctor was just here, but I still do not understand my diagnosis." The nurse contacts the provider to return to speak with the client. Which of the following principles is the nurse demonstrating A. Advocacy B. Accountability C. Confidentially D. Fidelity

Advocacy Rationale: The nurse is demonstrating advocacy. The nurse is advocating for the client by notifying the provider that the client has questions and concerns about their diagnosis. As a client advocate, the nurse should act on behalf of the client to protect their rights, health, and safety.

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take? A. Align the artery indicator on the blood pressure cuff with the client's brachial artery. B. Select a cuff that covers 50% of the client's upper arm C. Place the blood pressure cuff 5 cm above the client's antecubital space. D. Elevate the client's arm above the level of the heart

Align the artery indicator on the blood pressure cuff with the client's brachial artery. Rationale: The nurse should align the artery indicator on the blood pressure cuff with the client's brachial artery to obtain an accurate measurement.

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take? A. Elevate the client's head of the bed to 45° during meals. B. Instruct the client to tilt their head back while swallowing C. Turn off the client's television during meals D. Alternate the client's liquids and solids during meals

Alternate the client's liquids and solids during meals. Rationale: The nurse should alternate liquids and solids so the client can clear their mouth before adding additional food. This action promotes swallowing and decreases the risk of aspiration.

A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take? a. use hot water to clean the client's skin b. use soap to clean the client's skin c. apply a barrier cream to the client's skin d. apply friction when drying the client's skin

Apply a barrier cream to the client's skin. Rationale: The nurse should apply a protective barrier cream to clean, dry skin to reduce the risk for irritation and breakdown.

A nurse is planning to insert a short-peripheral IV device into the arm of a client who has a bleeding disorder. Which of the following actions should the nurse plan to take? a. apply a tourniquet to the client's arm b. elevate the client's arm above the heart. c. apply a warm compress over the selected insertion site. d. apply friction to the selected insertion site.

Apply a warm compress over the selected insertion site. Rationale: The nurse should apply a warm compress over the selected insertion site to promote vascular distention.

A nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include? A. Offering approval or disapproval B. Asking for explanations C. Offering sympathy D. Asking open-ended questions

Asking open-ended questions Rationale: Asking open-ended questions is a therapeutic communication technique. Open-ended questions allow the client to lead the conversation and encourages further dialogue

A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take? a. ask the client to perform the Valsalva maneuver b. check the clients heart rate for 30 seconds c. auscultate the clients apical pulse d. palpate the client's pulse at the third intercostal space

Auscultate the client's apical pulse. Rationale: The nurse should auscultate the client's apical pulse for 1 min to obtain an accurate heart rate.

A nurse is teaching a client who has diabetic neuropathy about foot care. Which of the following instructions should the nurse include? A. Wear open-toed shoes. B. Avoid walking barefoot C. Wash feet in hot water D. Apply lotion between the toes.

Avoid walking barefoot. Rationale: The client should avoid walking barefoot to reduce the risk of injury to the feet.

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increase the client's risk of a pressure injury? A. BMI of 20 B. Peripheral neuropathy C. Immobility D. Hypoperfusion E. Prealbumin level of 16 mg/dL

BMI of 20 is incorrect. Obesity can increase the risk of pressure injury due to decreased blood and lymphatic flow.Peripheral neuropathy is correct. Peripheral neuropathy increases the client's risk for pressure injury due to a decrease in pain related to pressure sensation. Immobility is correct. Immobility increases the client's risk for a pressure injury due to a decreased ability to reposition off bony prominences.Hypoperfusion is correct. Hypoperfusion increases the client's risk for a pressure injury due to decreased circulation in tissuesPrealbumin level of 16 mg/dL is incorrect. A prealbumin level that is lower than the expected reference range of 15 to 36 mg/dL indicates malnutrition, which places the client at risk for a pressure injury.

A nurse is teaching a class about complementary and integrative health. The nurse should include nutritional supplements are a component of which of the following therapies? A. Biological B. Manual C. Mind-body D. Bioenergetic

Biological Rationale: Biological therapies include herbal and nutritional supplements, vitamins, and minerals.

A nurse is assessing a client who is a professional athlete. Which of the following findings should the nurse expect? A. Hypertension B. Decreased oxygen saturation C. Bradycardia D. Hypothermia

Bradycardia Rationale: Long-term exercise can result in a heart that pumps blood efficiently. Therefore, it can pump fewer times per min to provide adequate perfusion.

A charge nurse is providing an in-service to a group of nurses about self-care. Which of the following information should the nurse include in the teaching? a. bring healthy meals to work b. get at least 5 hrs of sleep every night c. restrict daily water intake d. exercise at least once a week

Bring healthy meals to work Rationale: The nurse should include in the in-service to prepare and bring healthy meals and snacks to work to increase energy and promote self-care.

A nurse is assessing a client who has peripheral neuropathy. Which of the following findings should the nurse expect? A. Hyperreflexia B. Increased ability to detect temperature C. Burning sensation in feet D. Loss of sensation to pressure

Burning sensation in feet Rationale: Manifestations of peripheral neuropathy can include burning, numbness, or tingling sensation which can occur in hands or feet.

A nurse is admitting a client to the post-anesthesia care unit. Which of the following actions should the nurse take first? A. Check the client's airway. B. Check the clients blood pressure C. Check the clients level of consciousness D. Check the client's level of pain

Check the client's airway. Rationale: The first action the nurse should take using the airway, breathing, circulation approach to client care is to check the client's airway. Anesthesia places the client at risk for hypoxia. The nurse should check the client's airway, reposition the airway if needed, and apply supplemental oxygen

A nurse is caring for a client who is postoperative, has a peripheral IV, and is requesting ice chips. Which of the following actions should the nurse take? A. Remove the client's peripheral IV. B. Check the client for bladder distention. C. Lower the head of the clients bed D. Check the client's gag reflex..

Check the client's gag reflex. Rationale: The nurse should check the client's gag reflex before administering ice chips to reduce the risk of aspiration.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take? A. Use hot water to clean the client's skin. B. Clean the client's skin with a pH-balanced cleanser C. Apply cornstarch to the client's skin D. Allow the client's skin to air-dry after cleaning

Clean the client's skin with a pH-balanced cleanser. Rationale: The nurse should clean the client's skin with a pH-balanced cleanser to decrease the risk of skin breakdown

A. Client reports dull, aching pain in lower right calf. B. Client's oral temperature is 38.4° C (101.2° F). C. Client has a vesicular rash on their upper back. D. Client reports nausea following administration of pain medication. E. Client reports the rash on their back is itchy.

Client reports dull, aching pain in lower right calf is correct. The nurse should identify that the client's self-report of pain is subjective data.Client's oral temperature is 38.4° C (101.2° F) is incorrect. The nurse should identify that data that is measurable, such as a temperature reading, is objective data.Client has a raised, red rash on their upper back is incorrect. The nurse should identify that data that is visible, such as a rash, is objective data.Client reports nausea following administration of pain medication is correct.The nurse should identify that the client's self-report of nausea is subjective data.Client reports the rash on their back is itchy is correct. The nurse should identify that the client's self-report report of itching is subjective data.

A nurse is teaching a class about vulnerable populations that are at risk for health disparities. The nurse should include that which of the following populations are at risk for health disparities? A. Clients who have a college education B. Clients experiencing poverty C. Clients who have an employer-provided health insurance D. Clients who are fluent in the primary language of their health care team

Clients experiencing poverty Rationale: Clients experiencing poverty are at risk for health care disparities. These clients are often unable to afford to pay for health care, avoid seeking treatment for existing conditions, and obtaining preventative health care.

Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision? A. Critical thinking B. Clinical judgement C. Critical reasoning D. Concept mapping

Clinical judgement Rationale: The clinical judgement model is designed to be used by nurses to think critically and make decisions based on evidence-based practice.

A nurse sees smoke coming from the central supply room. Which of the following actions should the nurse take first? A. Close all the doors B. Wrap clients in blankets C. Stay close to the ground D. Walk to a safe area

Close all the doors. Rationale: The greatest risk to clients is injury from smoke inhalation or burns; therefore, the first action the nurse should take is to close all the doors to contain the smoke or fire.

A nurse is teaching a class about National Patient Safety Goals (NPSGs). Which of the following goals should the nurse include? A. Correctly identify clients prior to administering medications. B. Educate clients about health promotion and prevention. C. Improve communication among staff members. D. Prevent catheter-associated urinary tract infections in clients. E. Increase job satisfaction for staff members.

Correctly identify clients prior to administering medications is correct. The primary focus of NPSGs is to reduce medical and surgical errors and increase client safety. Using at least two client identifiers prior to administering medications reduces the risk for errors.Educate clients about health promotion and prevention is incorrect. The primary focus of NPSGs is to reduce medical and surgical errors and increase client safety. Educating clients about health promotion and prevention is not part of NPSGs.Improve communication among staff members is correct. The primary focus of NPSGs is to reduce medical and surgical errors and promote client safety. Improving effectiveness of communication among staff members facilitates continuity of care and increases client safety.Prevent catheter-associated urinary tract infections in clients is correct. The primary focus of NPSGs is to reduce medical and surgical errors and promote client safety. Preventing catheter-associated urinary tract infections in clients is providing safe, quality client care.Increase job satisfaction for staff members is incorrect. The primary focus of NPSGs is to reduce medical and surgical errors and increase client safety. Increasing job satisfaction for staff members is not part of NPSGs.

A nurse is applying knowledge to analyze a clinical situation. Which of the following roles is the nurse taking? A. Mentor B. Critical thinker C. Educator D. Advocate

Critical thinker Rationale: A critical thinker applies knowledge and experience to analyze, and problem solve a clinical situation.

A nurse is caring for a client who has a wound that requires negative pressure wound therapy. Which of the following actions should the nurse take? A. Cover the client's wound with an alginate dressing. B. Expect the inner dressing to expand after the vacuum pump is initiated. C. Shave hair on the client's skin surrounding the wound D. Cut a round hole in the center of the outer dressing

Cut a round hole in the center of the outer dressing. Rationale: The nurse should cut a 2.5 cm (1 in) round hole in the center of the outer dressing to allow for insertion of the drainage tube.

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take? A. Cut the client's food into small pieces. B. Turn on the television when the client is eating. C. Place the head of the client's bed flat after meals. D. Instruct the client to tip their head back when eating.

Cut the client's food into small pieces. Rationale: The nurse should cut the client's food into small pieces and instruct the client to chew food completely before swallowing to reduce the risk of aspiration.

A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect? a. urine osmolality of 200 mosm/kg b. cloudy urine c. urine specific gravity of 1.015 d. dark colored urine

Dark-colored urine Rationale: Dark-colored urine indicates concentrated urine and is a manifestation of dehydration

A nurse is teaching a class about physiological changes that occur during sleep. The nurse should include that which of the following changes occur during non-rapid eye movement sleep? A. Constriction of peripheral blood vessels B. Decrease in body temperature C. Reduced secretion of growth hormones D. Increase in basal metabolic rate

Decrease in body temperature Rationale: Body temperature, heart rate, blood pressure, and respiratory rate decrease during non-rapid eye movement sleep.

A nurse is caring for a client who has hypoglycemia. The nurse should monitor the client for which of the following adverse effects of hypoglycemia? A. Decreased blood pressure B. Fever C. Increased urination D. Metabolic acidosis

Decreased blood pressure Rationale: A client who has hypoglycemia is at risk for hypotension. The nurse should monitor the client for hypotension.

A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting? A. Dehydration B. Diarrhea C. Urinary frequency D. Peripheral edema

Dehydration Rationale: The client is at risk for dehydration and electrolyte imbalance. Therefore, the nurse should monitor the client for hypotension, tachycardia, and reduced urine output.

A nurse is planning care for a client who has urinary incontinence. The nurse should plan to monitor the client for which of the following findings? A. Dermatitis B. Hypoglycemia C. Fluid volume overload D. Kidney stones

Dermatitis Rationale: A client who has urinary incontinence is at risk for incontinence-associated dermatitis and impaired tissue integrity.

A nurse is preparing a teaching plan for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? A. Determine the client's readiness to learn B. Identify short-term goals for the client C. Provide written educational material for the client D. Ask the client to demonstrate checking their blood sugar

Determine the client's readiness to learn. Rationale: The first action the nurse should take using the nursing process is to gather data regarding the client's learning needs, readiness to learn, health literacy, and learning preferences.

A nurse is teaching a client about the sleep-wake cycle. The nurse should include that which of the following factors can interfere with the sleep-wake cycle? A. Drinking caffeinated beverages in the evening B. Emotional stress C. A bright light D. A 20 min nap during the day E. A regular bedtime schedule

Drinking caffeinated beverages in the evening is correct. Caffeine is a stimulant that can interfere with the sleep-wake cycle. The client should limit caffeine intake to the morning. Emotional stress is correct. Stress can cause excessive worry that can interfere with the sleep-wake cycle. The client should try to perform relaxation activities to reduce stress and increase sleep.A bright light is correct.Darkness causes release of melatonin, which promotes sleep. A 20 min nap during the day is incorrect.Naps should be limited to 20 min or less to avoid interfering with the sleep-wake cycle.A regular bedtime schedule is incorrect. A regular bedtime and wake-up schedule promotes sleep.

A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain? A. Elevated blood pressure B. Decreased heart rate C. Constricted pupils D. Reduced respiratory rate

Elevated blood pressure Rationale: Nonverbal manifestations of acute pain can include hypertension, diaphoresis, grimacing, and guarding.

A nurse is teaching a newly licensed nurse about client education. The nurse should include that which of the following is the role of the nurse in client education? A. Prescribe medications B. Diagnose client illnesses C. Describe the steps of a surgical procedure D. Encourage clients to advocate for themselves.

Encourage clients to advocate for themselves. Rationale: Client education should provide the client with feelings of empowerment and assist clients in taking control of managing their own care.

A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take? a. encourage the client to take deep breaths b. ask the client to cough every 4 hours c. decrease the head of the bed d. request a prescription for an opioid analgesic

Encourage the client to take deep breaths. Rationale: The nurse should encourage the client to cough and breathe deeply at least every 2 hr to increase lung expansion and clear secretions. The client might require supplemental oxygen toincrease oxygen saturation.

19.A nurse is caring for a client who reports chronic pain . Which of the following actions by the nurse uses holistic nursing ? A. Request a prescription for an analgesic for the client B. Encourage the client to take slow, deep breaths C. Check the client's oxygen saturation level D. Obtain blood work from the client .

Encourage the client to take slow, deep breaths. Rationale: Holistic approach to nursing empowers clients to employ therapeutic techniques to relieve pain and promote health. Encouraging the client to take deep breaths utilizes holistic nursing to promote relaxation and reduce pain.

A nurse is teaching a newly licensed nurse about reducing the risk of needlestick injuries. Which of the following instructions should the nurse include? A. Engage the safety device immediately after using a needle B. Bend needles without safety devices before disposing of them C. Dispose of large-bore needles into waterproof wastebaskets D. Use sharps containers until the are completely full

Engage the safety device immediately after using a needle. Rationale: The nurse should instruct the newly licensed nurse to engage the safety device immediately after using the needle and to dispose of the needle into a puncture-proof container to reduce the risk of a needlestick injury.

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non-modifiable risk factor for disease? A. Genetics B. Smoking C. Unhealthy diet D. Sunbathing

Genetics Rationale: The nurse should identify that genetics is a non-modifiable risk factor. Non-modifiable risk factors are findings that cannot be changed and place the client at risk for disease. Other non-modifiable risk factors include age, gender, race, and family history

A nurse is teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching? A. Raw vegetables B. High-fiber cereals C. Fruit with the skin D. Ground beef

Ground beef Rationale: A soft diet includes foods that are soft and easy to digest, such as tender cuts of beef.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I? A. Check the client's visual acuity using a Snellen chart. B. Observe for facial symmetry while the client smiles C. Have the client identify specific smells D. Whisper in one of the client's ears while occluding the other

Have the client identify specific smells. Rationale: The nurse should have the client identify specific smells, such as coffee or peppermint, testing each nostril separately, when checking cranial nerve I, the olfactory nerve.

A nurse is instructing a client who has heart disease about ways to improve their health such as eating a hearthealthy diet. Which of the following concepts is the nurse demonstrating to the client? a. health promotion b. primary prevention c. holistic health d. health education

Health promotion Rationale: The nurse is demonstrating the concept of health promotion by instructing the client on ways to improve their health such as eating a heart healthy diet. Other forms of health promotion caninclude exercise, weight loss, limiting alcohol consumption, and smoking cessation.

A nurse is assessing a client who has an oral temperature of 39° C (102.2° F). Which of the following findings should the nurse expect? A. Respiratory rate 10/min B. Dilated pupils C. Heart rate 108/min D. Decreased peripheral pulses

Heart rate 108/min

a nurse is teaching a class about oxygen transport in the cardiopulmonary system. which of the following transports oxygen in the blood? a. neutrophils b. platelets c. lymphocytes d. hemoglobin

Hemoglobin Rationale: Hemoglobin is part of the red blood cell and transports oxygen in the blood throughout the body

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Holds their hands below the elbows while rinsing off soap B. Uses hot water to wash their hands C. Turns off faucet with their hands D. Washes their hands for 10 seconds

Holds their hands below the elbows while rinsing off soap Rationale: The nurse should keep their hands below the elbows while rinsing off soap so water flows from the least contaminated to the most contaminated area

A nurse is discharge teaching with a client about medications. Which of the following client statements indicate an understanding? A. "I will store narcotic medications in the original package". B. "I will store over-the-counter medications in an unlocked cabinet under a sink" C. "I will discard unused narcotic medications in a trash container." D. "I will obtain my prescribed medications from different pharmacies".

I will store narcotic medications in the original package." Rationale: The client should store narcotic medications in the original package to reduce the risk of mixing up the medications and causing injury.

A nurse is teaching a class about expected changes to the skin in older adults. Which of the following information should the nurse include? A. Increase in skin thinning B. Increase in skin elasticity C. Decrease in subcutaneous tissue D. Increase in blood supply to skin E. Decrease in skin hydration

Increase in skin thinning is correct. Expected changes to the skin that occur with aging can include thinning of the skin. Therefore, older adults are at an increased risk of injury to the skin.Increase in skin elasticity is incorrect. Expected changes to the skin that occur with aging can include a decrease in elasticity. Therefore, older adults are at an increased risk of injury to the skin.Decrease in subcutaneous tissue is correct. Expected changes to the skin that occur with aging can include a decrease in subcutaneous tissue. Therefore, older adults are at an increased risk of injury to the skin.Increase in blood supply to skin is incorrect. Expected changes to the skin that occur with aging can include a decrease in blood supply to skin. Therefore, older adults are at an increased risk of injury to the skin.Decrease in skin hydration is correct. Expected changes to the skin that occur with aging can include a decrease in skin hydration. Therefore, older adults are at an increased risk of injury to the skin.

A nurse is planning care for a client who has dehydration and hypotension. Which of the following actions shouldthe nurse plan to take? a. elevate the head of the bed b. encourage the client to use guided imagery to relax c. increase the client's fluid intake d. instruct the client to perform the valsalva maneuver

Increase the client's fluid intake. Rationale: The nurse should increase the client's fluid intake to increase circulatory blood volume and blood pressure

A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection? A. Airborne B. Vector C. Indirect contact D. Droplet

Indirect contact- Rationale: Indirect contact occurs when an infectious agent is transmitted to an individual through an inanimate object, such as a towel.

A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications? A. Phlebitis B. Infiltration C. Infection D. Circulatory overload

Infiltration Rationale: Pain, swelling, cool temperature, taut skin, and leaking of IV fluid are manifestations of IV infiltration. The nurse should stop the IV infusion, elevate the affected extremity, and report the incident to the provider.

A nurse is teaching a client how to use an incentive spirometer. Which of the following statements should the nurse make? A. "Inhale through the incentive spirometer 10 times with each use." B. "Use the incentive spirometer once every 4 hours." C. "Hold your breath for 7 seconds when using the incentive spirometer." D. "Sit up at a 30-degree angle when using the incentive spirometer."

Inhale through the incentive spirometer 10 times with each use." Rationale: The client should use the incentive spirometer 10 times with each use to promote lung expansion and reduce the risk for atelectasis.

A nurse is teaching a client about reducing the risk for falls. Which of the following statements should the nurse make? A. "Install handrails in your bathroom." B. "Wear backless shoes." C. "Cover extension cords with a throw rug." D. "Use a standard height toilet seat."

Install handrails in your bathroom." Rationale: The client should install handrails in their bathroom to reduce the risk for falls.

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect? A. Partial-thickness skin loss with red tissue in wound bed B. Intact skin with localized erythema C. Full thickness skin loss with visible adipose tissue D. Full thickness skin loss with visible bone

Intact skin with localized erythema Rationale: Intact skin with localized erythema is a stage 1 pressure injury.

A nurse is preparing to teach a client who has impaired cognition. Which of the following actions should the nurse include in the plan? A. Involve the client's family in the educational session B. Avoid making eye contact with the client during the educational session C. Speak quickly to the client D. Provide long educational sessions

Involve the client's family in the educational session. Rationale: The nurse should involve the client's family in the educational session to promote learning

A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make? A. "Hold the cane on the side of your affected leg when walking B. "Keep the cane at the same level as the affected leg when climbing stairs." C. "Move your unaffected leg before your affected leg when walking." D. "Advance the cane 12 inches forward when walking."

Keep the cane at the same level as the affected leg when climbing stairs." Rationale: The client should keep the cane at the same level as the affected leg when climbing stairs to ensure balance and optimal support.

A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make? A. Keep your knees straight B. Keep your back straight C. Tilt your head toward your chest D. Loosen your abdominal muscles

Keep your back straight." Rationale: The nurse should keep their back straight to support the spine and reduce the risk of injury.

A nurse is caring for a client who has a new diagnosis of diabetes mellitus. The client states they will never be able to follow the prescribed diet. Which of the following statements should the nurse make? A. "You will feel better once you start the new diet." B. "Your old diet probably caused your diabetes" C. "Most people get used to the new diet quickly". D. "Let's see what foods you like that we can include in your new diet"

Let's see what foods you like that we can include in your new diet." Rationale: This statement demonstrates comfort by allowing the client an opportunity to make informed choices regarding their care. The nurse is showing respect to the client.

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues. A. 3+ palpable pedal pulses below the affected injury site. B. Sanguineous drainage at site of injury C. Full range of motion at the site of injury D. Localized warmth at the site of injury

Localized warmth at the site of injury Rationale: Manifestations of localized inflammation can include redness, pain, warmth, and decreased function

A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair." Which of the following information should the nurse clarify? a. position of the client b. unit of measurement c. location of blood pressure cuff d. systolic bp

Location of blood pressure cuff Rationale: The location of the blood pressure cuff requires clarification to ensure accurate documentation.

A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool? A. Medical condition B. Vital signs C. List of medications D. Treatment

Medical condition Rationale: The nurse should include the client's medical condition or diagnosis in the situation component of the ISBARR communication tool. Other findings that can be included in this component are the client's age, chief complaint, and urgent needs.

A nurse is performing a medication reconciliation while admitting an older adult client transferred from a long-term care facility. Which of the following should the nurse identify as part of the medication reconciliation process? A. Medications from another facility B. Medications for another pharmacy C. Discontinuation of medications D. Recommendation for prescribed medications

Medications from another facility Rationale: The nurse should identify medications from another facility when being admitted is part of the medication reconciliation process. Medication reconciliation verifies the complete list of medications the client is currently taking and to ensure the prescribed medications are.

A nurse is teaching a class about nonpharmacological therapies to decrease stress. The nurse should include which of the following therapies? A. Meditation B. Electromagnetic therapy C. Yoga D. Acupuncture E. Biofeedback

Meditation is correct. Meditation can promote relaxation and decrease stress. Electromagnetic therapy is incorrect. Electromagnetic therapy might reduce musculoskeletal pain. Yoga is correct. Yoga combines deep breathing, meditation, and physical movements to decrease anxiety, reduce stress, and promote sleep. Acupuncture is incorrect. Acupuncture uses needles inserted into specific anatomic points in the body to decrease pain and improve function. Biofeedback is correct. Biofeedback is a mind-body practice in which a client uses an electronic device to regulate physiological functions. It is used to reduce stress, relieve headaches, and decrease pain.

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk? A. Multiple sclerosis B. Hyperthyroidism C. Hyperlipidemia D. Inguinal hernia

Multiple sclerosis Rationale: The nurse should identify that multiple sclerosis is a physical disorder that can place the client at risk for falls due to problems with mobility. Other physical disorders that can contribute to falls are visual impairment, recent surgery, and stroke.

A nurse is teaching a class about massage therapy. The nurse should include that which of the following is a possible adverse effect of massage therapy. A. Nerve injury B. Headaches C. Depression D. Arthritis

Nerve injury Rationale: Massage therapy can cause blood clots, nerve injury, and bone fractures in older adult clien

A nurse is teaching a class on ethical principles. The nurse should include that protecting a client's safety by not causing harm refers to which of the following ethical principles? A. Nonmaleficence B. Justice C. Fidelity D. Beneficence

Nonmaleficence Rationale: Nonmaleficence refers to protecting a client's safety and avoiding harm. The nurse should weigh the risks and benefits while providing safe, effective care.

A nurse enters a client's room and finds the client on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take? A. Notify the client's provider about the occurrence B. Document the completion of an occurrence report in the client's medical record C. Contact risk management about the occurrence D. Request another nurse to complete the occurrence report

Notify the client's provider about the occurrence. Rationale: Once the client has been assessed and is safe, the nurse should notify the client's provider about the occurrence and determine if further treatment is needed.

A nurse is completing a SOAP note in a client's chart. In which of the following sections should the client's vital signs be documented? A. Objective B. Subjective C. Assessment D. Plan

Objective

A nurse is reviewing the medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication? A. Obstructive sleep apnea B. Fractured ankle C. BMI 24 D. Glucose level 75 mg/dL

Obstructive sleep apnea Rationale: Obstructive sleep apnea places the client at risk for postoperative airway obstruction

A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should they expect A. Bradycardia B. Hypertension C. Oliguria D. Peripheral edema

Oliguria Rationale: The nurse should expect the client who has hypovolemia to have decreased urine output, decreased capillary refill, and confusion.

A nurse is teaching a class about medication interactions. The nurse should include that iron preparations should be administered with which of the following? A. Milk B. Cheese C. Anti acids containing magnesium D. Orange juice

Orange juice Rationale: Orange juice, or foods containing vitamin C, can promote absorption of iron preparations

A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include? A. Orthostatic hypotension increases a client's risk of a fall B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg C. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg. D. Orthostatic hypotension increases a client's risk of a pulmonary emboli.

Orthostatic hypotension increases a client's risk of a fall. Rationale: Orthostatic hypotension is a decrease in blood pressure when a client changes from lying down to sitting or standing. The drop in blood pressure can cause the client to become dizzy and increases the risk for fall

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective? a. respiratory rate 28/min b. heart rate 110 /min c. pink mucous membrane d. restlessness

Pink mucous membranes Rationale: Pink mucous membranes, capillary refill less than 2 sec, intact mental status, and increased oxygen saturation indicate the intervention was effective.

A nurse is caring for a client who is placed on droplet precautions. Which of the following actions should the nurse take? A. Move the client to a positive airflow room B. Place a surgical mask on the client when they leave their room C. Wear a surgical mask when within 0.6 m (2ft) of the client D. Remove fresh flowers from the client's room.

Place a surgical mask on the client when they leave their room. Rationale: The nurse should place a surgical mask on the client when they leave their room to reduce the risk of transmission of the infection.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? A. Place a towel under the client's head B. Hold the client's arms and legs still. C. Leave the client to get help D. Place the client in the prone position.

Place a towel under the client's head. Rationale: The nurse should place a folded towel or pillow under the client's head to help protect the client from injury.

A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications? A. Diarrhea B. Pneumonia C. Pulmonary embolism D. Pressure injury

Pneumonia Rationale: Clients who have dysphagia are at risk for aspiration pneumonia. The nurse should monitor the client for fever and adventitious breath sounds.

A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications? A. Postoperative cognitive dysfunction B. Alzheimer's disease C. Postoperative delirium D. Dementia

Postoperative delirium Rationale: Postoperative delirium is a temporary condition in which clients become disoriented and confused following anesthesia. This condition can last up to a few weeks.

A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider? A. Potassium level 3 mEq/L B. Sodium 135 mEq/L C. BUN 9.5 mg/dL D. Creatinine 0.4 mg/ dL

Potassium level 3 mEq/L Rationale: Using the urgent vs. nonurgent priority framework, the nurse should report the client's potassium level to the provider. A level of 3 mEq/L is below the expected reference range of 3.5 to 5 mEq/L and is at the critical level of < 3. This potassium level can lead to life-threatening dysrhythmias for the client.

A nurse is teaching an older adult client about a new medication. Which of the following actions should the nurse take? A. Provide reading material using blue-colored ink B. Dim the lights in the client's room C. Present the information in small segments D. Avoid repeating information to the client

Present the information in small segments. Rationale: The nurse should provide short educational sessions, with regular breaks, to promote learning

A nurse is preparing to teach a client about a new medication. Which of the following actions should the nurse take? A. Turn on the television in the client's room. B. Use technical language in the educational session C. Provide educational material written at a 6th grade reading level. D. Begin with the least important information

Provide educational material written at a 6th grade reading level. Rationale: The nurse should provide educational material written at a 5th- to 6th-grade reading level to promote learning.

A nurse is caring for a client who has a new diagnosis of bladder cancer. Which of the following interventions should the nurse take to promote comfort? A. Avoid eye contact with the client during care. B. Avoid giving the client choices regarding their care C. Provide limited explanations of procedures needed for the client D. Provide honest answers to the client's questions.

Provide honest answers to the client's questions. Rationale: The nurse should present information and answer questions honestly to show respect, promote a caring relationship, and provide comfort to the client.

A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority? A. Blood pressure B. Pulse ox C. Level of sedation D. Pain level

Pulse oximetry Rationale: Using the airway, breathing, circulation framework, the nurse should identify that pulse oximetry is the priority. The client is at risk for opioid-induced ventilatory impairment or respiratory depression following an opioid narcotic.