Practice B

A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

"I flushed what I urinated at 7 a.m. and have saved all urine since." Rationale: For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm hg. Which of the following images displays the appropriate mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

122 BP: inflate cuff +30 mm Hg Rationale: To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz ice chips Rationale: The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

[PARTIALLY INCORRECT] A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client and his family?

A. Check the cord routinely for frays and tearing C. Consider purchasing a generator for power backup D. Monitor for signs of hypoxia

nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds (ABC's) Airway, breathing, circulation approach to client care the nurse should determine that the priority information to provide is the current status of the clients breath sounds.

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? A) client has Hx of abuse B) client has pacemaker C) client who has ulcerative colitis D) client who has asthma

Client who has asthma Rationale: Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?A. Assign the client to a room with a negative air-flow systemB. Use alcohol-based hand sanitizer when leaving he client's room.C. Clean contaminated surfaces in the client's room with a phenol solution.D. Have family members wear gown and gloves when visiting.

D. Have family members wear gown and gloves when visiting. Rationale: Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

A nurse is preparing the administer multiple meds to a pt who has an enteral feeding tube. Which nurse plan to take?

Flush the tube with 15 mL of sterile water. Rationale: MY ANSWER The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication. The nurse should flush the feeding tube with ____to____ml of sterile water before administration and between each medication, when giving multiple meds

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with arms at side and feet together Rationale: (balance test) The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

Practice assessment Rationale: it requires psychomotor skills when learning.

[INCORRECT] A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect?

Rapid heart rate Rationale: Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

[INCCORECT] A nurse is reviewing protocol in prep for suctioning secretions from a client who has a new tracheostomy. What action should the nurse plan to take?

Select a suction catheter that is half the size of the lumen. Rationale: The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

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 an indication of infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding

Skin blanching Rationale: Skin blanching, edema, and coolness at the IV site indicate infiltration.

[INCORRECT] A nurse is teaching an older adult 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 Rationale: Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. - No: Riding a bike or isometric exercises: has no weight-bearing advantages; therefore, it does not help prevent osteoporosis.

[INCORRECT] 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 a routine screening. what does this involve?" which of the following responses should the nurse make?

You should have a fecal occult blood test every year. Rationale: Colorectal cancer screening for: > age 50. One option for screening is a fecal occult blood test annually. - colonoscopy every 10 years - sigmoidoscopy every 5 years. - double-contrast barium enema every 5 years.

nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

bladder scan shows 525 ml Rationale: A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include

current medications Rationale: The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider?

medication dose

[INCORRECT] A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending the stairs, I will first shift my weight to the stronger leg/arm.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne: varicella, tuberculosis, and measles. Contact: Staphylococcus aureus, and scabies

* [PARTIALLY CORRECT] A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines? A) A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse. B) A nurse asks a nurse from another unit to assist with her documentation. C) A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care. D) A nurse discusses a client's status with the physical therapies that is caring for the client's bedside.

A nurse asks a nurse from another unit to assist with her documentation. Rationale: Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

[INCORRECT] a nurse is preparing to delegate client care tasks to an assistive personnel (AP) Which of the following tasks should the nurse delegate?

Ambulating a client who is postop. Rationale: This is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching. - Inserting an indwelling urinary catheter for a client (Indwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This task is outside the range of function of an AP.) - Demonstrating the use of an incentive spirometer to a client (Client education requires advanced nursing knowledge and is outside the range of function of an AP.) D. Confirming that a client's pain has decreased after receiving an analgesic. (Evaluating a client's pain level requires advanced nursing judgment and is outside the range of function of an AP.)

A nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

Apply an ankle-foot orthotic device to the client's feet. Rationale: The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A precaution for Behind-the-ear-hearing aid

Remove before shower

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people." Rationale: According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people. NOT: "Maybe you should consider why you are feeling useless." - Clients might interpret "why" questions as accusatory, and they can elicit feelings of mistrust and resentment. With this response, the nurse is asking for an explanation instead of acknowledging the client's feelings.

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

1) Place the client in a negative pressure room 2) Wear gloves when assisting the client with oral care 3) Use antimicrobial sanitizer for hand hygiene Rationale: Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. Wear a surgical mask when providing client care is incorrect. The nurse should 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 use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

[INCORRECT] (don't know) Anurse is caring for a group of medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Rationale: Following the ethical principle of veracity: the nurse must tell the truth at all times and never deceive others.

[INCORRECT] A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement?

An x-ray showing the end of the tube above the pylorus. Rationale: use an xray - must be above the pylorus (definition) Pylorus: the opening from the stomach into the duodenum (small intestine).

a nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on pt's plate. Rationale: (promote self-care) Allow pt to feed themselves. Assigning someone else feed pt impedes in pt's ability to perform self-care.

[INCORRECT] A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension. Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

[INCORRECT] A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Wear sterile gloves when removing the old dressing. B. Warm the irrigation solution to 40.5 C C. Cleanse the wound from the center outward. D. Use a 20 mL syringe to irrigate the wound

Cleanse the wound from the center outward. Rationale: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

* [INCORRECT]A nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins Rationale: s/s - Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

[INCORRECT] A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take?

Gently shake the container of medication prior to administration Rationale: The nurse should gently shake the liquid medication to ensure that the medication is mixed. - do not transfer meds into a medicine cup (The nurse should not transfer prepackaged liquid medication to a medicine cup to reduce the risk of altering the premeasured dose.) - use HIGH-Fowler's position (not semi-fowler's position)

[INCORRECT] A nurse is caring for a client who is receiving pain medication through patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? A. Instruct the family to refrain from pushing the button for a client while she is asleep. B. Inform the client that because she is on a PCA, vital signs will be taken every 8 hours. C. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10. D. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high

Instruct the family to refrain from pushing the button for a client while she is asleep. Rationale: The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain. PCA pump: - The nurse should monitor a client who is using a PCA pump every 1 to 2 hr during the first 12 hr. - The client is at risk for respiratory depression as a result of opioid medication administration.

A nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client?

N-95 respirator Rationale: The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

A nurse is preforming a peripheral vascular assessment for a client. When placing the stethoscope on the client's neck she hears the following sound. This indicated which of the following? (blowing or forcing the blood through the arteries

Narrowed arterial lumen Rationale: Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit. Distended jugular veins : Blood flowing through distended jugular veins does not produce a sound. Impaired ventricular contraction : Impaired ventricular function produces extra heart sounds, either S3 or S4. These sounds are best heard over the aortic area of the heart. Asynchronous closure of the aortic and pulmonic valves: Asynchronous closure of the aortic and pulmonic valves is known as "splitting" of S2, so the nurse should hear two "dub" sounds during auscultation. This sound is best heard over the aortic area of the heart.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30º. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A) Ask the client to consider a direct donation B) Withhold the blood transfusion C) Request a consultation with the ethics committee D) Ask the client's family to intervene

Withhold the blood Rationale: The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? A) Describe the procedure to the client. B) Witness the client's signature on the consent form. C) Inform the client of alternatives to the procedure. D) Tell the client which team member will assist with the procedure.

Witness the client's signature on the consent form. Rationale: The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure. Provider is responsible for: - telling pt of procedure.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

edication compare prescriptions w/ meds the pt received while at the facility. Rationale: When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge. (definition) medication reconciliation: The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. Rationale: (no bottle caps on sterile field.) Remember: - 1 inch (2.5 cm) border - below waist level is nonsterile.

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

wrap blankets around all 4 sides of bed. Rationale: The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.