Practice B

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 stairs, I will first shift my weight to my right leg."

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 that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year."

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.

1) inject 10 units of air into the bottle of NPH insulin 2) inject 5 units of air into the bottle of regular insulin 3) withdraw the correct dose of regular insulin from the bottle 4) withdraw the correct dose of NPH insulin from the bottle

A nurse is preparing a heparin infusion for a client who was admitted to the facility with DVT. The prescription reads; 25,000 units of heparin in 0.9% sodium chloride 250mL to infuse at 800 units per hour. At what rate should the nurse set the infusion pump?

8 mL/hr

A nurse is caring for a group of clients on a medical surgical unit. Which situation does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer and the nurse responds affirmatively.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which finding should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance.

A nurse is providing discharge teaching to a client about self administering heparin. Which instructions should the nurse include in the teaching?

Administer the medication into the abdomen

A nurse is caring for a client who has decreased mobility. Which action should the nurse take to decrease the clients risk of developing plantar flexion contractures?

Apply an ankle-foot orthotic device to the clients feet

A nurse is caring for a client who has a respiratory infection. Which technique should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when with drawling the catheter

A nurse is preparing to insert an IV catheter into a clients arm prior to initiating IV fluid therapy. Which intervention should the nurse implement to prevent infection?

Apply transparent dressing over the Iv insertion site and securement device.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1mL of the medication from a 2mL vial. Which action should the nurse take?

Ask another nurse to observe the medication wastage

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 action should the nurse take next.

Assess the client for orthostatic hypotension

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as priority?

Auscultate lung sounds

A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the clients diet?

Avocado

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which instructions should the nurse provide to the client and their family?

Check the cord routinely for frays or tearing, consider purchasing a generator for power backup, and observe for signs of hypoxia.

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

A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which of the following actions should the nurse take first?

Determine the client's learning style.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which action is the nurses priority?

Determine the reasons why the client is refusing to use the incentive spirometer.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. Which finding should the nurse intervene on.

Erythema on pressure points

A nurse is performing a Romberg test during the physical assessment of a client. Which technique should the nurse use?

Have the client stand with their arms at their sides and their feet together.

A nurse is caring for a client who requires an Ng tube for stomach decompression. Which action should the nurse take when inserting the ng tube.

Have the client take sips of water to promote insertion of the Ng tube into the esophagus.

A nurse is caring for a client who has recently started using a behind the ear hearing aid. What statement indicates that the client understands the use.

I will be sure to remove my hearing aid before taking a shower

A nurse is providing discharge instructions to a client who will be using a walker. What statement by the client indicates the teaching has been effective?

I will hire someone to trim the tree that overhangs the front porch stairs.

A nurse is providing teaching to a client who is on protective isolation precautions. Which client statement indicates an understanding of the teaching?

I will wear a face mask when leaving my hospital room

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which action should the nurse take?

Make sure two fingers can fit under the sleeves

A nurse is reviewing a client's prescription that reads "digoxin 0.25 by mouth everyday." Which components of the prescription should the nurse verify with the provider?

Medication dose

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy, which method should the nurse use as a psychomotor approach to learning?

Practice sessions

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

Press gently on the tragus of the client's ear.

A nurse is assessing an older clients risk for falls. Which assessments should the nurse use to identify the clients safety needs?

Pupil clarity, visual fields and visual acuity

A nurse is reviewing evidence based practice principles about administering oxygen therapy with a newly licensed nurse. Which action should the nurse include.

Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min

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.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which finding at the Iv site should the nurse identify as indicating infiltration?

Skin blanching....as well as edema and coolness.

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 her body.

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.

A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment, the nurse should record which statement by the client?

The pain is like a dull ache in my stomach.

A nurse is caring for a client who asks about the purpose of advance directives. Which statement should the nurse make?

They indicate the form of treatment a client is willing to accept in the event of a serious illness

A nurse is caring for a client who has dementia. Which intervention should the nurse take to minimize the risk for injury to the clients?

Use a bed exit alarm system

A nurse is teaching a client and their family how to care for the clients tracheostomy at home. Which instruction should the nurse include in the teaching.

Use tracheostomy covers when outdoors

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

Walking briskly

The nurse is placing a client on isolation precautions. What interventions should the nurse include?

Wear an N95 mask when caring for the client, place a container for soiled linen in the clients room, place the client in a negative airflow room, remove mask after exiting the clients room.

A nurse is caring for a client with terminal liver cancer. Which statement should the nurse identify as an indication that the client is experiencing spiritual distress?

What could I have done to deserve this illness

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

place a client who has tuberculosis in a room with negative-pressure airflow.