Practice Assessment A

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Auscultate the lungs (priority assessment)

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water * Each medication should be dissolved in at least 30 mL of warm sterile water * Medications should be drawn up separately * If the nurse encounters resistance when adm. meds, he should stop and contact the provider

Nurse should report: A client who has an IV infusion pump receives an additional 250 ml of IV fluid.

Nurse should report if IV pump malfunctions.

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Remove the stockings at least once per shift. (This allows the nurse to check the client's circulation and skin integrity) - nurse should ensure there are no creases or wrinkles in the socks - apply socks in morning when the patient gets out of bed because the legs are less edematous at this time

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

Skin Blanching along with edema and coolness at the IV site indicates infiltrations - purulent exudate indicates infection - warmth indicates phlebitis - bleeding can be mechanical or from anticoagulation

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of the body. Proceeding with Ambulation: 1. the patient stands with weight evenly distributed between the feet and the cane 2. The cane is held on the patients stronger side and is advanced 6-12in (15-30cm) 3. Supporting weight on the stronger leg, advance the weaker leg forward, parallel with the cane 4. Supporting weight on the weaker leg, advance the stronger leg forward, ahead of the cane 5. The weaker leg is moved forward with advancement of the cane. This helps to divide weight between strong and weak leg.

C diff

must wash hands with soap and water, phenol solution does not get rid of c diff pathogens, must wear gown and gloves, private room necessary but does not need negative pressure

Mechanically soft diet

pancakes, tomato juice, sliced bananas, poached or scrambled eggs are acceptable but NOT FRIED EGGS

A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

walking briskly is a weight bearing activity that is essential for maintaining bone mass, preventing osteoporosis. - riding a bike and preforming isometric exercises have no weight bearing advantages so they do not help osteoporosis - high-impact aerobics can injure bones that have decreased density and INCREASE RISK OF INJURY

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output. - open irrigation requires 30 - 50 ml of fluid - should use a 30 - 50ml syringe

A nurse is administering an otic medication to an older adult. Which of the following actions should the nurse take to ensure the medication reaches the inner ear?

Press gently on the tragus.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen.(selecting a suction catheter 1/2 size prevents hypoxemia and trauma to the mucosa) -100% O2 should be used - the nurse should lubricate with sterile water or 0.9% sodium irrigation to decrease trauma to the mucosa - 120 mm Hg, no higher than 150 mm hg should be used to prevent hypoxemia and trauma to the mucosa

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach" (patient using their own words) -"I'm having mild pain" (describes the severity of the pain. The nurse should use a pain scale to make this more accurate) -"I notice the pain gets worse after I eat" (this is a factor that aggravates the pain) -"The pain makes me feel nauseous" (manifestation of the pain)

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year."-avg risk starts at age 50 - blood-contrast barium enema every 5yrs - Colorectal cancer screenings begin at age 50. - flexible sigmoidoscopy Q5yrs

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

- Place the client in a room with negative-pressure due to airborne precautions. - Wear gloves when assisting the client with oral care to meet standard precautions - The nurse does not need to limit the client's visitors. Nurse should limit client's presence outside the room and have him wear a surgical mask when he does leave the room. - Wear an N95 respirator during client care to meet the requirements of airborne precautions. - Use antimicrobial sanitizer for hand hygiene is correct. The nurse should also wash her hands with soap and water when her hands have visible soiling.

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling = swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility -bladder distention can cause urinary retention, bladder distention, can be a complication of bed rest due to a loss of muscle tone in bladder and detrusor muscles -A pt on bed rest can develop postural hypotension manifested by a drop in BP when the client moves from lying to sitting. The nurse should also assess for a increase in pulse rate and dizziness -diminished bowel sounds reflect slowed peristalsis and constipation

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward to prevent introduction of microorganisms from skin. - irrigation should be body temp - have nurse wear clean gloves not sterile when changing dressing - use 30 - 60 ml syringe (35 ml used to irrigate wound)

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen (hearing bruits on the audiotape indicates that blood flowing through the occluded or narrowed arteries - distended jugular veins don't make sounds - impaired ventricular contraction produces extra heart sounds at s3 or s4 - asynchronous closure of aortic and pulmonic valves is known as "splitting" and produced 2 dubs Heart Sounds: https://www.youtube.com/watch?v=6YY3OOPmUDA