ATI 1 Flashcards
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? Dyspnea on exertion Tracheal deviation Pericardial rub Weight loss
Dyspnea on exertion
Notes: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.
The nurse should identify that tracheal deviation is an expected manifestation of a tension pneumothorax
The nurse should identify that a pericardial rub is an expected manifestation of pericarditis.
The nurse should identify that weight gain is an expected manifestation of dilated cardiomyopathy. Weight gain is due to ventricular compromise and fluid retention.
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.)
Use a wheeled infant walker.
Place soft pillows around the edge of the infant’s crib.
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? Terbutaline Nifedipine Magnesium sulfate Methylergonovine
Methylergonovine
Notes: administer magnesium sulfate to a client who has preeclampsia to lower blood pressure and minimize the risk of seizures.
administer nifedipine, a smooth muscle relaxant, to a client who is experiencing preterm labor.
administer terbutaline, a smooth muscle relaxant, to a client who is experiencing preterm labor.
A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? Rooting Moro Tonic neck Babinski
Tonic neck
Notes: rooting reflex, the nurse should touch the newborn’s lip, cheek, or corner of the mouth
Moro reflex, the nurse should hold the newborn in a semi-sitting position and allow the trunk and head to fall backward about 2.5 cm (1 in). The newborn should abduct and extend his arms symmetrically, and the fingers should fan out and form a “C” with the thumb and forefinger
Babinski reflex, the nurse should stroke the bottom of the newborn’s foot upward along the lateral edge, then along the ball of the foot with a finger
A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.) Magnesium sulfate infusion Distended bladder Oxytocin infusion Prolonged labor Small for gestational age newbornA nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.) Magnesium sulfate infusion Distended bladder Oxytocin infusion Prolonged labor Small for gestational age newborn
Magnesium sulfate infusion
Distended bladder
Prolonged labor
A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?
Collect the specimen upon arising in the morning.
Force fluids during the day and collect the specimen in the evening.
Collect the specimen after antibiotics have been started.
Collect 2 mL of sputum before sending the specimen to the laboratory.
Collect the specimen upon arising in the morning.
Notes: encourage the client to force fluids, especially clear liquids, to help to thin respiratory secretions. However, evening hours are not the preferred time for obtaining a deep sputum specimen, collect the sputum specimen ordered for culture and sensitivity before the client receives antibiotic therapy, collect 4 to 10 mL of sputum before sending the specimen to the laboratory
A nurse is caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? Establishing a sense of achievement Contributing to society Creating meaningful social relationships Enhancing self-confidence
Creating meaningful social relationships
A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? To the left To the right Away from the body Toward the body
Away from the body
A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills?
Living wills require a written prescription from the provider to be legal.
Living wills allow the client to designate a health care proxy.
Living wills ensure hospitals provide emergency care regardless of health coverage.
Living wills detail treatment wishes of the client in the event of terminal illnes
Living wills detail treatment wishes of the client in the event of terminal illness.
Notes: A written prescription from the provider is required for a do-not-resuscitate (DNR) order
The durable power of attorney for health care allows the client to designate a health care proxy, not the living will.
The Emergency Medical Treatment and Active Labor Act ensures that hospitals provide emergency care regardless of health coverage, not the living will.
The living will detail treatment wishes of the client in the event of terminal illness or persistent vegetative state.
A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teaching?
“I’ll make sure that the medication container is kept tightly sealed.”
“I’m lucky I have a prescription plan that allows me to buy pills in bulk quantities.”
“I’ll keep my pills in the medicine cabinet when I’m home.”
“I’ll go to the emergency room if my chest pain doesn’t go away.”
“I’m lucky I have a prescription plan that allows me to buy pills in bulk quantities.”
Notes: The client should keep the nitroglycerin tablets in a dark, dry place, and in a dark-colored glass bottle with a tight lid. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened.
Keep the medication in a dark, dry place because exposure to air, heat, and moisture cause loss of potency.
The client should call 911 or go to the nearest emergency department if anginal pain is not relieved within 5 min. Typically, the client can take up to 2 additional nitroglycerin tablets at 5-min intervals while awaiting emergency care.
A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor?
Faxing laboratory results to a client’s provider
Discussing changes in a client’s plan of care with his friend who is a nurse on another unit
Describing a client’s level of independence to the case manager arranging home health services
Remaining in the room with the client while he reviews his own medical records
Discussing changes in a client’s plan of care with his friend who is a nurse on another unit
A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? Urinary retention Rapid respirations Dilated pupils Diarrhea
Urinary retention
Notes: morphine can cause urinary hesitancy, urinary retention, and urinary urgency. Respiratory depression is an adverse effect of morphine.
Morphine can cause pupils to constrict, known as miosis
Constipation is an adverse effect of morphine.
A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter? Dorsal recumbent Orthopneic Side-lying Supine
Supine
A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion?
Determining the client’s respiratory rate
Measuring the client’s chest diameter
Obtaining the client’s level of oxygen saturation
Checking the client’s depth of respirations
Obtaining the client’s level of oxygen saturation
A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider?
Silver-colored striae
Unilateral nipple inversion present since menarche
Dimpling of the tissue in the upper outer quadrant
Visible symmetrical venous patterns
Dimpling of the tissue in the upper outer quadrant
Notes: silver-colored striae of the breast tissue is the result of stretch marks caused by rapid growth of the breast tissue
New onset nipple inversion should be reported as it can indicate underlying disease
Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor
Visible symmetrical venous patterns is often noted in thin, pregnant, or light-skinned women. However, venous patterns that are unilateral, or hypervascular areas caused by an increased blood flow, should be reported to the provider.
A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, “I don’t think I’m going to have the surgery. Everybody has to die sometime.” Which of the following responses by the nurse is appropriate?
“Clients having this surgery are always scared.”
“Why have you changed your mind about the surgery?”
“You shouldn’t worry, everything will be fine.”
“Tell me more about your concerns.”
“Tell me more about your concerns.”
While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take?
Reposition the client every 4 hr.
Cover the area with a transparent wound barrier.
Massage areas surrounding the redness.
Wash the area with hot water every 8 hr.
Cover the area with a transparent wound barrier.
Notes: repositioned every 2 hr instead of every 4 hr to prevent further damage to the tissues
A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction
Massaging area surrounding the reddened area can result in trauma to the deep tissues
Washing the area with hot water should be avoided because it can cause further irritation and increase skin dryness
A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? Spongy gums that are receding Fissures at eyelid corners Easily plucked hair Deep reddish-colored tongue
Deep reddish-colored tongue
Notes: Gums should be pink to red in color, without swelling, bleeding, or receding from the gum line
The eyes should be clear and shiny, without sores or fissures at the corner of membranes or eyelids
Hair should be shiny and firm, unable to be easily plucked.
The tongue should be a healthy pink to a deep, reddish color with surface papillae present, without swelling or lesions.
A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching? mcg q.d. mL PO
q.d.
A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? Hypomagnesemia Hyperglycemia Hyponatremia Hyperkalemia
Hyperglycemia
Notes: Adverse effects of dexamethasone include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing’s syndrome
A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? Cyanosis Jaundice Erythema Pallor
pallor
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? Isopropyl alcohol Chlorhexidine gluconate (Hibiclens) Chlorine (bleach) Iodophor
Chlorine (bleach)
A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? Twisting at the waist and shoulders Standing with feet in a wide stance Positioning self-close to the client Using arms and legs to lift
Twisting at the waist and shoulders
A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? Chill formula prior to administration. Verify feeding tube placement. Reduce the rate of the feedings. Place the client supine during feedings.
Reduce the rate of the feedings.
Note: Chilled formula can cause abdominal cramping, nausea, and vomiting; therefore, formula should be administered at room temperature.
displaced tube will not cause diarrhea. Findings associated with tube displacement include coughing, vomiting, and pulmonary aspiration.
The head of the bed should be elevated to at least 30° during the administration of enteral tube feedings to prevent aspiration.
A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program?
Watch a video discussing healthy meal preparation.
Prepare a healthy meal to serve at the end of class.
Read pamphlets about preparing a healthy meal.
Discuss healthy meal preparation as a class.
Prepare a healthy meal to serve at the end of class.
Notes: Visual learners learn best from strategies that involve sight
Tactile learners learn best by touching and doing
Auditory learners learn best from strategies that involve hearing
A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication? Speech pathologist Occupational therapist Social worker Respiratory therapist
Speech pathologist
Notes: A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy.
An occupational therapist works with clients who have limited functional abilities to develop skills that are necessary to complete activities of daily living.
A social worker offers education and counseling to clients and families to provide links to community resources, plan for discharge, or resolve conflict.
A respiratory therapist provides specialized therapy to clients who have respiratory difficulties, such as oxygen therapy, inhalation therapy, administering pulmonary function tests, collection of sputum specimens, and collection of arterial and venous blood specimens.
A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, “I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain.” Upon review of scientific evidence, the nurse should inform the client of which of the following?
Celecoxib is contraindicated in clients taking valproic acid.
Celecoxib is contraindicated in older adults.
Celecoxib is contraindicated in clients with a seizure disorder.
Celecoxib is contraindicated in clients with an allergy to sulfonamide.
Celecoxib is contraindicated in clients with an allergy to sulfonamide.
Notes: Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults
A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule?
Use a filter needle to administer the promethazine.
Expel air bubbles back into the ampule.
Set the ampule on a flat surface to withdraw the promethazine.
Break the ampule toward the body.
Set the ampule on a flat surface to withdraw the promethazine.
Notes: A filter needle should be used to withdraw the medication from the ampule
Expelling air bubbles back into the ampule creates pressure in the ampule, which forces the medication out, wasting it. Air bubbles should be expelled by removing the needle from the ampule and tapping the side of the syringe, then pulling back on the plunger, and finally pushing the plunger up gently to remove the air.
To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle
The ampule should be broken away from the body to prevent injury from the shattering glass.
A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles? Justice Autonomy Veracity Fidelity
Autonomy Notes: Justice is the use of fairness Autonomy is respecting the client's right to make personal health care decisions Veracity is the act of truth-telling. Fidelity is the act of keeping promises.
A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client?
Mammogram every year to detect breast cancer
Colonoscopy every 10 years to detect colon cancer
Dermatologist evaluation every 3 years to detect skin cancer
Complete eye examination every year to detect eye disorders
Dermatologist evaluation every 3 years to detect skin cancer
Notes: Women ages 40 or older should have annual mammograms.
Men and women ages 50 and older should have a colonoscopy every 10 years.
Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations.
Clients between the ages of 40 and 64 should have a complete eye examination every 2 years, and clients older than 65 should have a complete eye examination annually.
A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions? Lithotomy Dorsal recumbent Prone Lateral recumbent
Lithotomy
Notes: lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia
dorsal recumbent position can be used as an alternative to the supine position when assessing the head and neck, lungs, breasts, axillae, heart, and abdomen
prone position is used to assess hip joint extension, skin, and buttocks.
lateral recumbent position is used to detect heart murmurs when assessing the heart.
A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client?
Acupuncture is loosely regulated by the federal government.
Acupuncture has been discredited by scientific research.
Acupuncture is thought to be effective only as a placebo.
Acupuncture has been proven to reduce pain and increase function.
Acupuncture has been proven to reduce pain and increase function.
A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality?
Placement of computer systems in restricted areas
Installation of firewall software on each computer
Ability of staff to access electronic health records of clients throughout the facility
Occurrence of an automatic log-off after a period of inactivity
Ability of staff to access electronic health records of clients throughout the facility
A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse’s priority goal?
Support the client’s relationship with his caregivers.
Encourage the client to express his feelings.
Determine who is responsible for the abuse.
Protect the client from further abuse.
Protect the client from further abuse.
A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention? Painful swallowing Hoarse voice Difficulty breathing Blood-tinged sputum
Difficulty breathing
Notes: Painful swallowing is an expected finding following a bronchoscopy. The swallowing reflex is usually blocked for about 6 hr after the procedure
A hoarse voice is an expected finding following a bronchoscopy. The client may complain of hoarseness after the bronchoscopy because of the trauma to tissue of the larynx and the trachea
The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication.
Blood-tinged mucous and sputum is an expected finding following the procedure because of trauma of the tissue of the larynx, trachea, or bronchi when the bronchoscope is inserted
A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate?
“I know this must be frightening, but you are going to be fine.”
“Let’s talk for a minute about your concerns.”
“You were transferred because it is in your best interest.”
“Why do you feel a family member should be with you?”
”Let’s talk for a minute about your concerns.”
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene?
Including in a client’s nurses’ note that an incident report was completed after a medication error
Drawing horizontal lines through blank spaces left in the nurses’ notes followed by a signature
Refusing to chart the vital signs taken by another nurse on a client’s graphic flow sheet
Documenting the provider was contacted to clarify a questionable prescription
Including in a client’s nurses’ note that an incident report was completed after a medication error
A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? Loss of color discrimination Nausea and vomiting Red-orange discoloration to body fluids Edema of feet and hands
Loss of color discrimination
A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective?
Self-reporting the ability to perform the procedure
Answering appropriately when questioned orally
Responding accurately on a written examination
Demonstrating independent performance of the procedure
Demonstrating independent performance of the procedure
A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action? Inform the nurse manager. Determine the client's condition Notify the provider. Complete an incident report.
Determine the client’s condition.
A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective?
“I should leave the patch on for 16 to 20 hours each day.”
“I will apply a new patch in the same location each day.”
“The patch should be effective within an hour of being applied.”
“The medication is not absorbed as well when placed on the abdomen.”
“The patch should be effective within an hour of being applied.”
Notes: The client should only wear the patch for 12 to 14 hr each day for the medication to remain effective and prevent the development of tolerance.
The patch should be applied to a new location each day to prevent development of local irritation.
Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.
Adequate results are attained when the patch is applied to the chest, back, abdomen, or anterior thigh.
A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? Blood glucose 150 mg/dL Potassium 2.5 mEq/L Total protein 5.2 g/dL Urine specific gravity 1.040
Potassium 2.5 mEq/L
A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client?
Raising her voice level when speaking to the client
Asking the client open-ended questions
Clarifying client statements with the family as needed
Having the client use eye blinks to indicate yes or no
Having the client use eye blinks to indicate yes or no
A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include?
Medications will eliminate HIV in most clients.
Adolescents are at a lower risk for developing HIV.
Initial HIV symptoms are often similar to the flu.
Using condoms ensures the prevention of HIV during sexual intercourse.
Initial HIV symptoms are often similar to the flu.
A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching?
States that pain is an 8 on a scale of 0 to 10
States that her partner should be given the information
Expresses concern about the exercises causing pain when performed after surgery
Expresses uncertainty about the benefits of the exercises
States that pain is an 8 on a scale of 0 to 10
A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse? Malaise Anorexia Headache Diarrhea
Diarrhea
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
A client who has peripheral vascular disease and reports numbness in the toes
A client who has depression and is easily distracted
A client who has Alzheimer’s disease and is unable to complete activities of daily living
A client who had abdominal surgery 10 days ago and reports feeling his incision pop
A client who had abdominal surgery 10 days ago and reports feeling his incision pop
A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse?
Administer medications with meals when possible.
Ensure client understanding of medication’s effects.
Determine the client’s ability to self-administer medications.
Have the client position the head with the chin down while swallowing.
Have the client position the head with the chin down while swallowing.
A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? Lithium carbonate 0.8 mEq/L Digoxin 3.0 ng/mL Peak serum gentamicin 6 mcg/mL Magnesium sulfate 4 mEq/L
Digoxin 3.0 ng/mL
A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?
Ensure all four side rails are up.
Administer a prescribed sedative.
Place the client in soft wrist restraints.
Move the client to a room near the nurses’ station.
Move the client to a room near the nurses’ station.
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?
Place the infant in a supine position when sleeping.
Place the infant on a firm mattress when sleeping.
Avoid covering the infant with loose bedding while sleeping.
Avoid leaving stuffed animals in the crib with the sleeping infant.
Place the infant in a supine position when sleeping.
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? Obtain an ECG. Administer oral potassium. Encourage potassium-rich foods. Monitor I & O.
Obtain an ECG.
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
Place O2 at 2 L per nasal canula on the client.
Place the client in the orthopneic position.
Perform chest percussion.
Perform nasotracheal suctioning.
Place the client in the orthopneic position.
A nurse is collecting data on four clients. Which of the following findings is the most urgent? Bladder distension and urgency Pedal edema Warmth and pain in the calf Hypoactive bowel sounds
Warmth and pain in the calf
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? Initiate oxygen therapy. Encourage an increase in oral fluids. Provide room humidification. Assist client to cough effectively.
Assist client to cough effectively.
A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?
Provide assistance with ambulation when indicated.
Determine the mobility status of each client.
Maintain the side rails of each bed in the raised position.
Plan a fall prevention program for clients at risk.
Determine the mobility status of each client.
A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention? Cholesterol 220 mg/dL Platelets 95,000 mm3 BUN 20 mg/dL Potassium 3.5 mEq/L
Platelets 95,000 mm3
A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? Check on the client. Unlock the crash cart. Begin cardiopulmonary resuscitation. Announce a code.
Check on the client.
A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action? Providing pain control Preventing hemorrhage Maintaining a patent airway Ensuring adequate fluid intake
Maintaining a patent airway
A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster? Immediate Delayed Minimal Expectant
Immediate
A nurse in a provider’s office has collected data on four clients. Which of the following clients should be the nurse’s priority concern?
A client who has a history of heart failure
A client who has type 1 diabetes mellitus
A client who is reporting pain associated with osteoarthritis of the knees
A client who is having a nosebleed associated with hypertension
A client who is having a nosebleed associated with hypertension
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit? Obtain an arterial pH level. Check the heart rate and blood pressure. Insert an indwelling catheter. Collect a serum BUN and creatinine
Check the heart rate and blood pressure.
A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take?
Administer an anticoagulant.
Check the leg for warmth and edema.
Apply elastic stockings.
Promote bed rest and extremity elevation.
Check the leg for warmth and edema.
A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? Homelessness Lack of family support Hypoxic Under nourished
Hypoxic
A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer? Partial thickness skin loss Visible subcutaneous fat Non-blanchable redness Exposed muscle
Partial thickness skin loss
Notes: A stage I pressure ulcer involves intact skin with a localized area of non- blanching redness.
A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.
A stage III pressure ulcer involves full-thickness skin loss and can have visible subcutaneous fat.
A stage IV pressure ulcer involves full-thickness tissue loss and exposed bone, tendon, or muscle. Slough or eschar can also be present.
A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading?
Wrapping the cuff loosely around the arm
Using a cuff that is too wide
Leaving client’s arm unsupported
Taking client’s blood pressure immediately after client sits down
Using a cuff that is too wide
A nurse is caring for a client who is receiving vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor? Respiratory depression Hearing loss Hypertension Bradycardia
Hearing loss (Ototoxicity)
Notes:
nephrotoxicity
A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client? Lithotomy Dorsal recumbent Prone Sims'
Sims’
A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (Select all that apply) Cooked oatmeal Grape juice Applesauce Ice cream Smooth peanut butter
Grape juice
Ice cream
A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following? Mood Immunity Memory Vitality
Mood
Note: Immunity, Echinacea
Memory, Ginkgo biloba
Vitality, Ginseng
A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion? Dullness Hyper-resonance Resonance Tympany
Dullness
Notes: Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness
Percussion over emphysematous lungs produces a booming sound, which is described as hyper-resonance.
Percussion over healthy lung tissue produces a hollow sound, which is described as resonance.
Percussion over an air-filled stomach produces a drum-like sound, which is described as tympany.
A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective? "I am wide awake now." "My mouth is very dry." "I feel very relaxed." "My heart is racing."
“I feel very relaxed.”
A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle? 1/2 inch 5/8 inch 1 inch 1 1/2 inch
1 1/2 inch
Notes: A 1/2 inch needle is used for subcutaneous injections in adults
A 5/8 inch needle is used for subcutaneous injections in adults
A 1 inch needle is used for IM injections in adults who have a low BMI
A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching? 1/2 cup of white rice 1 slice of wheat bread 1 cup of 2% milk 3/4 cup of canned tomato juice
3/4 cup of canned tomato juice
A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief? Anger Acceptance Bargaining Denial
Bargaining
A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.
The first action the client should be taught when using a 3-point crutch gait to go up stairs is to stand and bear weight on the unaffected leg.
The second action the client should be taught when using a 3-point crutch gait to go up stairs is to transfer body weight to the crutches.
The third action the client should be taught when using a 3-point crutch gait to go up stairs is to advance the unaffected leg between the crutches.
The fourth action the client should be taught when using a 3-point crutch gait to go up stairs is to shift weight from the crutches to the unaffected leg.
The fifth action the client should be taught when using a 3-point crutch gait to go up stairs is to align crutches on the stair.
A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first? Percussion Palpation Auscultation Inspection
Inspection
A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury? Lock knees. Stand close to the client. Keep feet close together. Move client by twisting at the waist.
Stand close to the client.
A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include that the disease is transmitted in which of the following ways? Vector Airborne Vehicle Bloodborne
Vector
A nurse is preparing to auscultate a client’s heart. Which of the following positions is best for detecting a low-pitched diastolic murmur?
lateral recumbent position
A charge nurse is assembling a list of clients who can be safely discharged home to accommodate incoming casualties following an earthquake. The nurse should recognize that it is unsafe to discharge which of the following clients?
A client who has osteomyelitis and will require 6 weeks of IV antibiotic therapy
A client who has Crohn’s disease and is 1 day preoperative for an ileostomy
A client who has Alzheimer’s disease and is awaiting placement in a long-term care facility
A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace
A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace
A home health nurse is performing an assessment of an older adult client’s home. Which of the following findings should the nurse recognize as a potential hazard?
Hot water temperature set at 46° C (115° F)
A night light in each room of the house
A secured, large area rug in the living room
Wires to the television tunneled under the carpet
Wires to the television tunneled under the carpet
A nurse is responding to a community-wide request for health care providers to come to the scene of an explosion. When using the North Atlantic Treaty Organization triage system, the nurse should put which of the following tags on a client who is unresponsive and has third-degree burns over 75% of her body? Red Yellow Green Black
Black
A nurse manager at a clinic for clients who are homeless notes that many of the clients have a history of mental illness and substance use disorder. While compiling figures for a regulatory agency about the clients who visit the clinic, the nurse should classify these clients as having which of the following conditions? Codependency Bipolar disorder Comorbidity Somatization disorder
Comorbidity
Notes:
Codependency is a set of maladaptive, compulsive behaviors learned by family members to survive in an emotionally painful and stressful environment.
bipolar disorder is a mood disorder characterized by the occurrence of mania alternating with episodes of depression.
Comorbidity is the presence of more than one disease or health condition in an individual at a given time.
Somatization disorder is a psychiatric condition manifesting as a physical complaint. Internal psychological conflicts are unconsciously expressed as physical manifestations.
A public health nurse is caring for an older adult client who has chronic airflow limitation disease and is a former cigarette smoker. The client’s medications include ipratropium bromide and albuterol inhalers, and she has a new prescription for home oxygen to use as needed. The nurse should recognize that this client’s primary prevention needs include which of the following?
Periodic pulmonary function tests
Review of appropriate use of oxygen in the home
Yearly mammography examinations
Annual influenza immunizations
Annual influenza immunizations
A home health nurse is caring for a client who is living in a mental health group home. During a visit, the nurse discovers that the client has been hoarding psychotropic medications. Which of the following actions should the nurse take first?
Have the client transported to an acute care facility.
Determine the reason for the client’s hoarding behavior.
Alert the staff that has been administering the client’s medications.
Require the client to return any hoarded medications.
Determine the reason for the client’s hoarding behavior.
A nurse is providing teaching to a client who has a prescription for ciprofloxacin following exposure to anthrax. Which of the following statements by the client indicates that further teaching is required?
“I will limit my intake of coffee, tea, or cola beverages.”
“I will wear a large-brim hat and long sleeves if I am out in the sun.”
“I will take the ciprofloxacin with an antacid if I get an upset stomach.”
“I will avoid taking ciprofloxacin along with dairy products.”
“I will take the ciprofloxacin with an antacid if I get an upset stomach.”
Notes: avoid caffeine while taking ciprofloxacin because it can trigger adverse effects of the nervous system, including irritability, anxiety, and restlessness.
A common adverse effect of ciprofloxacin is extreme photosensitivity, so clients taking ciprofloxacin must avoid sun exposure to prevent sunburns and blistering.
Taking ciprofloxacin with antacids can impair the absorption of the medication, reducing its effectiveness.
Taking ciprofloxacin with dairy products can impair the absorption of the medication, reducing its effectiveness,
A community health nurse is preparing a disaster preparedness plan about smallpox. Which of the following groups of people should the nurse include in the plan to inoculate? Newborns Mortuary workers Immunosuppressed clients Clients who have eczema
Mortuary workers
A charge nurse in an emergency department is notified by the county’s emergency medical services that there has been a multiple-casualty crash involving a truck carrying radioactive waste. Which of the following actions should the nurse take first?
Designate a decontamination area to accommodate clients who are irradiated.
Notify the admissions office to clear as many critical care beds as possible.
Clear the department of all nonurgent clients and move those awaiting admission to a holding area.
Determine the number of casualties the emergency department can accommodate.
Clear the department of all nonurgent clients and move those awaiting admission to a holding area.
A nurse is teaching a community group about smallpox. When discussing the possible means of transmission, which of the following statements by a member of the group indicates that further teaching is required?
“Smallpox can be transmitted through bodily fluids, such as blood or vomit.”
“Smallpox can be transmitted through contaminated objects, such as bedding and clothing.”
“Smallpox can be transmitted through bites from insects, such as mosquitoes.”
“Smallpox can be transmitted through inhalation of droplets, such as from coughing.”
“Smallpox can be transmitted through bites from insects, such as mosquitoes.”
A nurse is working in the triage area of an emergency department. Which of the following activities is unlikely to be the nurse’s responsibility in this setting?
Fostering positive public relations for the facility
Performing a comprehensive client assessment
Preventing cross contamination of infectious clients
Educating a client and his family
Educating a client and his family
A nurse is caring for several clients who have become ill after a company picnic. After extensive interviews and a review of the food handling practices, the nurse determines that the most likely cause of the illnesses was a poultry dish that had been allowed to cool for several hours before being served. The nurse is performing which of the following steps in the epidemiological process? Planning Assessing Implementing Evaluating
Assessing
An industrial health nurse is caring for a client who states, “I have been under a lot of stress lately.” When the nurse suggests stress management techniques, the client calmly states that he has a pistol in his car and intends to take his life in the parking lot after work that day. Which of the following actions should the nurse take?
Have the industrial facility’s security officers search the client’s car and remove the pistol.
Call emergency medical services to transport the client to a proper treatment facility.
Contact the client’s family member to pick him up from work and take him for treatment.
Explore with the client the reasons he feels that he has no options except suicide.
Call emergency medical services to transport the client to a proper treatment facility.
A nurse is providing psychological counseling at a community center for families whose loved ones died in a fire. After learning that both of their children died in the fire, two parents express disbelief at the loss of their children. One parent states, “How will I make it through this?” Which of the following is an appropriate response by the nurse?
“Are you feeling overwhelmed right now?”
“Don’t worry. You will have plenty of help.”
“Can I call someone to be here with you?”
“Anyone who has experienced a loss like this would feel that way.”
“Are you feeling overwhelmed right now?”
A triage nurse is in an emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. The nurse should determine that which of the following clients requires immediate treatment?
A client who has neck pain and was transported to the facility on a backboard
A client who has epigastric and left-arm pain and is diaphoretic
A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min
A client who has abdominal pain and is 2 months pregnant
A client who has epigastric and left-arm pain and is diaphoretic
A nurse is performing a community assessment in a rural setting. Which of the following types of health care should the nurse recognize is most likely to be absent in this setting? Tertiary care Primary prevention Chronic care Secondary prevention
Tertiary care
A charge nurse in an emergency department is informed that a tornado touched down in a nearby town and mass casualties are en route. Which of the following actions should the nurse take first?
Follow facility policy to activate the disaster plan.
Prepare the triage rooms.
Obtain additional supplies.
Call in off-duty staff.
Follow facility policy to activate the disaster plan.
A nurse is planning to participate in a public education program about prevention of West Nile virus. Which of the following instructions should the nurse include in her presentation?
“Eliminate sources of standing water.”
“Make sure your immunizations are up to date.”
“Keep all of your pets indoors.”
“Spray insect nests with a repellant that contains DEET.”
“Eliminate sources of standing water.”
A nurse is providing teaching to a community group who lives near a nuclear power plant about safety related to radiation exposure. A client asks, "Isn't there something we should have on hand in case of a nuclear disaster?" The nurse should recognize that the client is referring to which of the following substances? Potassium iodide Potassium cyanide Ciprofloxacin Atropine
Potassium iodide
Notes:Potassium iodide, if taken in time and at the appropriate dosage, blocks the thyroid gland’s uptake of radioactive iodine
Potassium cyanide is one of the most lethal poisons known and can cause death within minutes
Ciprofloxacin is an antibiotic used to treat certain infections caused by bacteria, such as pneumonia, gonorrhea, infectious diarrhea, typhoid fever, and inhalation anthrax (after exposure), as well as bone, joint, skin, and urinary tract infections.
Atropine is an anticholinergic agent used to reverse the effects of nerve gas exposure caused by gases such as sarin, tabun, and soman.
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
“I should expect my heart rate to take longer to return to normal after exercise as I get older.”
“Urinary incontinence is something I will have to live with as I grow older.”
“I can expect to have less ear wax as I get older.”
“My stomach will empty more quickly after meals as I grow older.”
“I should expect my heart rate to take longer to return to normal after exercise as I get older.”
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
Frequent bowel sounds with flatus
Absent bowel sounds with distention
Hyperactive bowel sounds with diarrhea
Normal bowel sounds with increased peristalsis
Absent bowel sounds with distention
Note: Paralytic Ileus is an immobile bowel
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2° C (102.6° F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? Heart rate 105/min Soft, nontender abdomen Temperature Overdue menses
Temperature
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Encourage the child to cough frequently to clear congestion from anesthesia.
Place a heating pad at the child’s neck for comfort.
Administer analgesics to the child on a routine schedule throughout the day and night.
Provide the child with ice cream when oral intake is initiated.
Administer analgesics to the child on a routine schedule throughout the day and night.
Notes: discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding.
offer an ice collar
Milk products, such as ice cream and pudding, are avoided because they coat the mouth and throat, causing the child to clear the throat. Ice chips and ice pops are usually the first items offered following a tonsillectomy.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub
Pericardial friction rub
Notes:
audible clicking sound occurs in clients who have prosthetic valve replacement surgery.
heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts
third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole.
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
“There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands.”
“I will use cold water when I wash my hands to protect my skin from becoming too dry.”
“I will apply friction for at least 10 seconds while washing my hands.”
“After washing my hands I will dry them from the elbows down.”
“There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands.”
Notes: washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.
Hand hygiene should be performed with warm water
friction should be applied for at least 15 to 20 seconds.
Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms)
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
Turn on the machine every 15 min to measure the client’s blood pressure.
Record only blood pressure readings needed for the 15-min intervals.
Obtain manual and automatic readings and compare them.
Disconnect the machine, and measure the blood pressure manually every 15 min.
Disconnect the machine, and measure the blood pressure manually every 15 min.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client’s ability to learn new dietary habits?
The involvement of the client in planning the change
The emphasis the provider places on the dietary changes
The learning theory the nurse uses to teach the dietary changes
The extent of the dietary changes planned for the client
The involvement of the client in planning the change
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Rectal Tympanic Oral Temporal
Temporal
Notes:
The oral route is not appropriate for use with children under the age of 3.
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
The client fully understands the provider’s explanation of the procedure.
The client has been informed about the risks and benefits of the procedure.
The nurse witnessed the provider’s explanation of the procedure.
The signature on the preoperative consent form is the client’s.
The signature on the preoperative consent form is the client’s.
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress
Assessment
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
The nurse washes each part of her hands with 5 strokes.
The nurse washes from the elbows down to the hands.
The nurse washes with her hands held higher than her elbows.
The nurse uses minimal friction when washing her hands.
The nurse washes with her hands held higher than her elbows.
Notes: Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes.
scrub the hands first, then work toward the elbows.
hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.
The use of mechanical friction is necessary to decontaminate the skin effectively.
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
Measure the pulse using a Doppler ultrasound stethoscope.
Check the client’s pedal pulses.
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
Take the pulse at each peripheral site and count the rate for 30 seconds.
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Fifth intercostal space just medial to the midclavicular line
Second intercostal space to the left of the sternum
Fifth intercostal space to the left of the sternum
Second intercostal space to the right of the sternum
Second intercostal space to the right of the sternum
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make?
“It’s for your safety. Dentures can slip and block your airway during surgery.”
“You wouldn’t want your teeth to be lost or broken during surgery, would you?”
“The anesthesiologist requires everyone to remove their dentures.”
“What worries you about being without your teeth?”
“What worries you about being without your teeth?”
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. Which of the following actions should the nurse take?
Change the topic because the client is trying to divert attention from the illness to the nurse.
Encourage the client to express his thoughts about death and dying.
Tell the client that religious beliefs are a personal matter.
Offer to contact the client’s minister or the facility’s chaplain.
Encourage the client to express his thoughts about death and dying.
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
“Tell me what I can do to help you overcome your fear of giving yourself injections.”
“I am sure your provider will not be pleased that you refuse to give yourself insulin injections.”
“It’s okay. I’m sure your partner will be able to learn how to give you the insulin injections.”
“You won’t be able to go home unless you learn to give yourself insulin injections.”
“Tell me what I can do to help you overcome your fear of giving yourself injections.”
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Call for assistance. Begin chest compressions. Confirm unresponsiveness. Give rescue breaths
Confirm unresponsiveness.
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
Holding a community clinic to administer influenza immunizations.
Screening groups of older adults in nursing care facilities for early influenza manifestations.
Educating parents of young children about dangers of influenza.
Finding rehabilitation programs for older adults who have complications from influenza.
Screening groups of older adults in nursing care facilities for early influenza manifestations.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Open all sterile supplies and solutions. Stabilize the tracheostomy tube. Don sterile gloves. Perform hand hygiene.
Perform hand hygiene.
A nurse is obtaining the blood pressure in a client’s lower extremity. Which of the following actions should the nurse take?
Auscultate for the blood pressure at the dorsalis pedis artery.
Measure the blood pressure with the client sitting on the side of the bed.
Place the cuff 7.6 cm (3 in) above the popliteal artery.
Place the bladder of the cuff over the posterior aspect of the thigh.
Place the bladder of the cuff over the posterior aspect of the thigh.
Notes: auscultate for the blood pressure at the popliteal artery.
measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed.
position the cuff 2.5 cm (1 in) above the popliteal artery.
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
Explain the x-ray procedure to the client.
Help the client into a wheelchair before the transporter arrives.
Ask if the client has any questions.
Identify the client using two identifiers.
Identify the client using two identifiers.
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client’s skin turgor?
Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink.
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.
Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression.
Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
“Drink a minimum of 1,000 milliliters of fluid daily.”
“Increase your intake of refined-fiber foods.”
“Sit on the toilet 30 minutes after eating a meal.”
“Take a laxative every day to maintain regularity.”
“Sit on the toilet 30 minutes after eating a meal.”
Notes: consume a minimum of 1,500 mL of fluid
increase consumption of coarse-fiber and whole grain
“Take a laxative every day to maintain regularity.”
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Identify goals for client care. Obtain client information. Document nursing care needs. Evaluate the effectiveness of care.
Obtain client information.
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?
Stand toward the client’s stronger side.
Instruct the client to lean backward from the hips.
Place the wheelchair at a 45° angle to the bed.
Assume a narrow stance with feet 15 cm (6 in) apart.
Place the wheelchair at a 45° angle to the bed.
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients’ commitment to a long-term goal of weight loss?
Attempt to increase the clients’ self-motivation.
Keep detailed records of each client’s progress.
Test client learning after each teaching session.
Avoid discussing areas that might cause client anxiety.
Attempt to increase the clients’ self-motivation.
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
Tie the restraints to the side rails.
Perform range-of-motion exercises to the wrists every 3 hr.
Remove the restraints one at a time.
Obtain a PRN prescription for the restaints.
Remove the restraints one at a time.
Notes: range-of-motion exercises are performed every 2 hr.
Restraint prescriptions can only be written for a 24-hr period and cannot be a PRN prescription.
should not tie the restraints to the side rails because this can injure the client if the rails are lowered.
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
Contact the family and ask them to stay with the client.
Offer to call the client’s minister.
Sit and hold the client’s hand.
Leave the room and allow the client to cry privately.
Sit and hold the client’s hand.
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
“My parents are retired, and they have come to help out with our children.”
“I am going to ask my husband to go to counseling with me.”
“I keep having nightmares about my upcoming surgery.”
“My girlfriends bought me a nice wig.”
“I keep having nightmares about my upcoming surgery.”
perform the abdominal assessment
inspect, auscultate, percuss, and then palpate
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Obtaining hydrogen peroxide for the tracheostomy care
Obtaining cotton balls for the tracheostomy care
Obtaining sterile gloves for the tracheostomy care
Obtaining a sterile brush for the tracheostomy care
Obtaining cotton balls for the tracheostomy care
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses. Obtain a medical history. Measure vital signs. Assess for leg pain.
Evaluate pedal pulses.
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
Tell the client it is too late for her to change her mind because the surgery is already scheduled.
Telephone the operating room and cancel the surgery.
Inform the client’s family about the situation.
Notify the provider about the client’s decision.
Notify the provider about the client’s decision.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?
“Ask your provider to prescribe epoetin before the surgery.”
“You should ask your provider about taking iron supplements prior to the surgery.”
“Request a family member to donate blood for you.”
“Donate autologous blood before the surgery.”
“Donate autologous blood before the surgery.”
Note: Epoetin is a hematopoietic growth factor used for the treatment of anemia. While taking epoetin prior to surgery can boost the client’s hematocrit levels
While taking an iron supplement prior to surgery can boost the client’s hemoglobin levels
A blood donation from a family member does not eliminate the risk of acquiring an infection.
Autologous blood is the safest form of blood transfusion because exclusive use of a client’s own blood eliminates exposure to transfusion-transmitted infection.
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
The client asks the nurse to repeat the instructions before attempting the exercises.
The client reports severe pain.
The client asks the nurse how often deep breathing should be done after surgery.
The client tells the nurse that this exercise will probably be painful after surgery.
The client reports severe pain.
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
Wash the gloved hands and then throw the gloves away.
Prepare an incident report to document the event.
Carefully remove the gloves and follow with hand hygiene.
Ask the provider to order a blood culture to determine the risk of infection.
Carefully remove the gloves and follow with hand hygiene.
A nurse observes assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
“The reading will be inaudible if the cuff is too small for the client.”
“The width of the cuff bladder should be 75% of the circumference of the client’s arm.”
“As long as the cuff will circle the arm the reading will be accurate.”
“Using a cuff that is too small will result in an inaccurately high reading.”
“Using a cuff that is too small will result in an inaccurately high reading.”
Notes:
blood pressure reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading.
width of the cuff bladder should be 40% of the circumference of the client’s arm.
cuff that is an incorrect size for the client will not yield an accurate reading.
Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement.
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?
Lock the wheels on the bed and stretcher.
Instruct the client to raise his arms above his head.
Elevate the stretcher 2.5 cm (1 in) above the height of the bed.
Log roll the client.
Lock the wheels on the bed and stretcher.
Notes: cross his arms across his chest to prevent injuring the arms during the transfer.
should be no more than 1.3 cm (0.5 in) above the height of the bed.
Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
Place the client supine.
Keep both side rails up.
Raise the level of the bed.
Inspect the client’s mouth using a finger sweep.
Raise the level of the bed.
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?
Irrigate the tubing with sterile normal water once each shift.
Cleanse the opening with soap and water after emptying.
Maintain the tubing above the level of the surgical incision.
Collapse the device of air after emptying.
Collapse the device of air after emptying.
Notes: collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device, maintain the drainage tubing below the level of the incision to enhance drainage, cleanse the drain opening with an alcohol wipe after opening it to decrease entry of microorganisms, keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage.
A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? Calibrate the scales weekly. Use a different scale each time. Weigh the client on arising. Weigh the client without clothing.
Weigh the client on arising. (After voiding and before breakfast), weigh the client using the same scale each time, calibrate the scales to 0 each day or before each use to provide accurate information, have the client’s weight taken wearing the same type of clothing
A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask
A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula
A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar
A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?
Place an oxygen mask on the client.
Check the client’s pulse.
Determine whether the client is able to breathe.
Wrap arms around the client from behind.
Determine whether the client is able to breathe.
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing.
Loosen the dressing by pulling the tape away from the wound.
Remove the entire old dressing at once.
Open sterile supplies after applying sterile gloves.
Don clean gloves to remove the old dressing.
Notes: remove the tape by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges, remove the old dressing one layer at a time to prevent the removal of drains, open the sterile supplies after the removal of the old dressings, after washing her hands, and before applying sterile gloves
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Hold the irrigator 1.25 cm (0.5 in) above the eye.
Direct the irrigation solution upward toward the upper eyelid.
Exert pressure on the bony prominences when holding the eyelids open.
Direct the irrigation from the outer canthus to the inner canthus of the eye.
Exert pressure on the bony prominences when holding the eyelids open.
Notes: hold the irrigator 2.5 cm (1 in) above the eye, direct the irrigation solution onto the lower conjunctiva sac, should hold the upper lid against the eyebrow and the lower lid against the cheekbone, direct the irrigation solution from the inner canthus to the outer canthus of the eye
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?
Maintain suction while removing the NG tube.
Instill 100 mL of air into the NG tube before removal.
Pinch the NG tube while removing the tube.
Instruct the client to breathe in and out during the removal of the NG tube.
Pinch the NG tube while removing the tube.
Notes: disconnect the NG tube from the suction apparatus before removal,
instill 50 mL of air into the tube to clear the contents of gastric drainage,
pinch the NG tube while removing the tube, instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
Applies sterile gloves to open catheter package
Wipes the labia minora in an anteroposterior direction
Spreads the labia with the dominant hand
Uses one cotton ball to wipe the right and left labia majora
Wipes the labia minora in an anteroposterior direction
Notes: apply sterile gloves after opening the catheter package, wipe anteroposterior both the right and left labia minora, use the nondominant hand to spread the labia, use a separate cotton ball to wipe the right and left labia majora
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
Speak directly into the client’s impaired ear.
Exaggerate lip movements.
Speak loudly.
Face the client when speaking.
Face the client when speaking.
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?
Exhale slowly to reach goal volume.
Hold breath for 5 seconds after goal volume is reached.
Continue to deep breathe between each cycle.
Limit repeat pattern of breathing to 5 breaths.
Hold breath for 5 seconds after goal volume is reached.
Notes: instruct the client to inhale slowly to reach goal volume, instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume, instruct the client to breathe normally for short periods of time between each cycle of breaths,
instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake
A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?
Roll the stocking partially down if too long.
Remove the stocking once per day.
Bunch and pull the stocking halfway up the calf.
Turn the stocking inside out up to the heel before applying.
Turn the stocking inside out up to the heel before applying.
Notes: remove the stockings once every shift to inspect the skin and check circulation, apply another size stocking if the stocking is too long, slide the top of the stocking up over the client’s calf
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? Apply a fecal collection system. Apply a barrier cream. Cleanse and dry the area. Check the client's perineum.
Check the client’s perineum.
A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?
Remove the sleeve of the gown from the arm without the IV line.
Slow the infusion using the roller clamp.
Disconnect the IV line from the pump.
Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.
Remove the sleeve of the gown from the arm without the IV line.
nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? Flushing of the skin Inability of the toddler to cry or speak Presence of nausea and mild emesis Capillary refill time 1.5 sec
Inability of the toddler to cry or speak
Notes: cyanosis
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? Vitamin C and zinc Vitamin D Vitamin K and iron Calcium
Vitamin C and zinc
Notes: Vitamin D is important when used with calcium to prevent osteoporosis, Vitamin K is important for normal clotting of blood and for impaired intestinal synthesis caused from antibiotics, Calcium is administered to prevent osteoporosis when used with vitamin D
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube.
Position the client on his right side.
Insert the tip of the tubing 8 cm (3.1 in).
Hold the enema container 61 cm (24 in) above the rectum.
Insert the tip of the tubing 8 cm (3.1 in).
Notes: lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube, position the client on the left side in the Sims’ position, insert the tip of the tubing 7 to 10 cm (3 to 4 in), hold the enema container a maximum of 45 cm (18 in) above the rectum
A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?
Check to determine if the catheter tubing is kinked.
Palpate the bladder.
Obtain a prescription to irrigate the catheter with 0.9% sodium chloride.
Encourage the client to drink more fluids.
Check to determine if the catheter tubing is kinked.
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
Instruct the client to defecate into the toilet bowl.
Transfer the specimen to a sterile container.
Refrigerate the collected specimen.
Place the stool specimen collection container in a biohazard bag.
Place the stool specimen collection container in a biohazard bag.
Notes: client defecate into a bedpan or a container for stool collection, place the stool specimen a clean container using a tongue depressor, send the collected stool specimen immediately to the laboratory after labeling the specimen properly, place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?
“Does the medication you’re taking relieve the pain?”
“Can you point to where the pain is the worst?”
“What do you think caused the onset of your pain?”
“Changing positions makes your pain worse, right?”
“What do you think caused the onset of your pain?”
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?
Drop the eye medication into the lower conjunctival sac.
Apply gentle pressure in the outer opening of the eye for 2 min.
Hold the eye dropper 0.5 cm (0.2 in) from the cornea.
Instruct the client to close eyes tightly after administration.
Drop the eye medication into the lower conjunctival sac.
Notes: apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds,
hold the eye dropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac,
should instruct the client to close eyes gently when applying ointment or liquid to distribute the medication
A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?
Use a gait belt during ambulation.
Ensure the client is wearing socks before ambulating.
Instruct the client to sit on the edge of the bed for 15 seconds before ambulating.
Walk 2 feet behind the client during ambulation.
Use a gait belt during ambulation.
Notes: ensure the client is wearing nonskid shoes or slippers, encourage the client to dangle her legs on the edge of the bed for 60 seconds before attempting to ambulate, walk beside the client to provide physical support
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
Provide the client with a glass of water.
Assist the client to a sitting position.
Explain the procedure to the client.
Measure the length of tubing to be inserted.
Explain the procedure to the client.
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?
“Lunch trays should be here within the hour.”
“I am going to listen to your abdomen.”
“I’ll get you some water to drink.”
“I would wait a bit, or you could feel sick.”
“I am going to listen to your abdomen.”
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?
Start chest compressions.
Provide breaths with a manual resuscitation bag.
Administer oxygen.
Establish an airway.
Start chest compressions.
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?
Withdraw the specimen from the drainage bag.
Cleanse the collection port with soap and water.
Place the specimen in a clean specimen cup.
Clamp the tubing below the collection port.
Clamp the tubing below the collection port.
Notes: use a fresh urine specimen obtained near the indwelling urinary catheter, cleanse the collection port with an antimicrobial swab, place the specimen in a sterile specimen cup, clamp the tubing below the collection port to allow fresh uncontaminated urine
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? Sanguineous exudate Serous exudate Serosanguineous exudate Purulent exudate
Purulent exudate
Notes: Purulent exudate drainage on the client’s dressings is thick yellow, green and brown drainage; Serosanguineous exudate drainage on the client’s dressings indicates plasma mixed with light bloody drainage, Serous exudate drainage on the client’s dressings indicates plasma from the blood and appears clear to light yellow, and is watery, Sanguineous exudate drainage on the client’s dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings.
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh
Lower abdomen
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?
Pull suction catheter back 1 cm (0.5 in) if the client starts coughing.
Allow 30 seconds between suctioning passes.
Hyperventilate the client with 50% oxygen for 30 seconds.
Perform a maximum of 4 passes with the suction catheter.
Pull suction catheter back 1 cm (0.5 in) if the client starts coughing.
Notes: allow at least 1 min between suctioning passes to prevent hypoxia, hyperventilate the client with 100 % oxygen for at least 2 min before suctioning, maximum of 3 passes with the suction catheter
A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?
Redness at the IV catheter entry site
A palpable cord is felt along the vein used for the infusion
Taut skin around the IV catheter site that is cool to the touch
Bleeding at the IV insertion site
Taut skin around the IV catheter site that is cool to the touch
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?
Renew the prescription for the use of restrains within 24 hr.
Secure the restraint with the buckle side next to the client’s skin.
Ensure 4 fingers can be inserted under the secured restraint.
Remove the restraint every 3 hr.
Renew the prescription for the use of restrains within 24 hr.
Notes: secure the client’s restraints with the softer side next to the client’s skin, with the buckle or velco closure on the outside, ensure 2 fingers can be inserted under the restraints, restraint at least every 2 hr
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Auscultate for bowel sounds after each feeding.
Ensure the formula is cold before administering.
Elevate the client’s head of bed 45° before the feeding.
Flush the tubing with 15 mL of water after the enteral feeding.
Elevate the client’s head of bed 45° before the feeding.
Notes: auscultate for bowel sounds before each feeding to ensure the client has peristalsis, ensure the formula is at room temperature before administering, client’s head of bed between 30° to 45° to prevent aspiration, flush the tubing with at least 30 mL of water after the enteral feeding to maintain patency of the feeding tube
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?
The wound edges are well-approximated.
The wound is closed at a later date.
A skin graft is placed over the wound bed.
Granulation tissue fills the wound during healing.
Granulation tissue fills the wound during healing.
Notes: Primary intention occurs when the closing of the wound using sutures or staples, Tertiary intention includes using sutures to close an open wound, Tertiary intention can include the provider placing grafted skin over the client’s wound bed after a wound is left open to drain and start healing
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? Abdominal binder Montgomery straps Hypoallergenic tape Plastic tape
Montgomery straps
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?
Place the soiled linens on the chair while making the bed.
Hold the linens away from the body and clothing.
Place the linens on the floor until able to place it in a linen bag.
Shake the clean linens to unfold.
Hold the linens away from the body and clothing.
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?
Encourage the client to drink fluids before swallowing food.
Offer the client tart or sour foods first.
Tilt the client’s head backward when swallowing.
Turn on the television.
Offer the client tart or sour foods first.
Notes: consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?
The lower, medial quadrant of the buttock near the coccyx
The side hip between the iliac crest and anterior iliac spine
The tissue of the posterior upper arm
The lower, inner thigh 4 finger widths above the patella
The side hip between the iliac crest and anterior iliac spine
A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?
Change the colostomy bag following breakfast.
Cleanse the skin around the stoma with warm water.
Change the pouch every day.
Place an aspirin in the ostomy pouch to decrease odor.
Cleanse the skin around the stoma with warm water.
Notes: instruct the client to change the colostomy bag before a meal because drainage from the ostomy is least likely to occur, change the pouch every 3 to 7 days to avoid skin breakdown around the stoma, not to place an aspirin in the ostomy pouch to decrease odor, because it can cause stoma bleeding.
A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?
Use the pain scale to determine the client’s pain level.
Discuss the adverse effects of pain medication with the client.
Obtain the client’s vital signs.
Check the client’s allergies.
Use the pain scale to determine the client’s pain level.
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client’s surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
Tenderness when touched
Pink, shiny tissue with a granular appearance
Serosanguineous drainage
A halo of erythema on the surrounding skin
A halo of erythema on the surrounding skin
A nurse is admitting an older adult client who fell at home 3 days ago. The client has a fractured hip, malnutrition, and dehydration. Which of the following laboratory values, noted on admission, should indicate to the nurse prolonged malnutrition? Increased sodium Decreased albumin Increased BUN Decreased blood glucose
Decreased albumin
Notes: Increased sodium is indicative of dehydration, Increased BUN is indicative of renal failure, or dehydration, Decreased blood glucose is indicative of inadequate intake of glucose
A nurse is teaching a group of healthy older adult clients about health screenings after age 50 years. Which of the following health screenings should the nurse recommend that the clients complete annually? Cholesterol Colonoscopy Diabetes mellitus Visual acuity
Visual acuity
Notes: diabetes mellitus screening performed every 3 years, colonoscopy is every 5 to 10 years beginning at the age of 50 years, cholesterol screening every 3 to 5 years until age 75 years.
A nurse is teaching a group of older adult female clients who are postmenopausal about dietary requirements. Which of the following statements about the role of folic acid should the nurse make?
“Clients who are postmenopausal need to limit their intake of folic acid to reduce their risk of stroke.”
“Dietary folic acid is not of significant importance after the childbearing years.”
“Healthy clients who are postmenopausal require a daily folic acid supplement.”
“Adequate folic acid intake is associated with a reduced risk for heart disease.”
Adequate folic acid intake is associated with a reduced risk for heart disease.”
Notes: increasing daily intake of foods such as orange juice, beans, legumes, and green leafy vegetables, as well as foods enriched with folic acid, such as breads and pastas.
A nurse is planning care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client?
The client’s skin will remain intact during hospitalization.
The client will verbalize one new word each week.
The client will begin to help turn himself in bed, indicating improved mobility.
The client’s airway will remain clear, as evidenced by clear breath sounds.
The client’s airway will remain clear, as evidenced by clear breath sounds.
A nurse in a long-term care facility is promoting reminiscence among older adult clients. Which of the following actions should the nurse take?
Establish a weekly pet therapy visitation program.
Place a calendar and clock in each resident’s room.
Institute a daily storytelling hour.
Encourage all clients to eat their meals in the dining room.
Institute a daily storytelling hour.
Notes: Pet therapy visitation programs can be beneficial in promoting socialization and social skills, Placing a calendar and clock in each client’s room will promote the client’s level of orientation to date and time, Having clients eat their meals in a group dining room is beneficial to promoting socialization
A nurse is caring for an older adult client who has dementia. The client becomes agitated and confused at night and wanders into the hallway. Which of the following actions should the nurse take?
Place the client’s mattress on the floor.
Restrain the client during the nighttime hours.
Provide continuous orientation to the client.
Turn out the lights in the client’s room at night.
Place the client’s mattress on the floor.
A nurse is planning to administer diphenhydramine hydrochloride to an older adult client. Which of the following actions should the nurse plan to take prior to administration?
Review the medical record for a client history of glaucoma.
Plan to administer the medication 30 min prior to a meal.
Explain to the client he will need to restrict his fluid intake once he takes the medication.
Remind the client that his appetite might increase when starting the medication.
Review the medical record for a client history of glaucoma.
Notes: should administer diphenhydramine with food or milk to decrease gastrointestinal adverse effects, inform the client to increase fluid intake, remind the client that anorexia, nausea, and vomiting are gastrointestinal adverse effects of the medication
A nurse is providing teaching to an older adult client who has osteoarthritis of the right hip and lower lumbar vertebrae. Which of the following statements by the client indicates an understanding of the teaching?
“I should avoid the use of a heating pad on my back.”
“To relieve the pressure on my hip, I can use a cane while ambulating.”
“I will have steroid injections to my joints as the first medication of choice to treat my pain.”
“I will exercise even when it causes pain.”
“To relieve the pressure on my hip, I can use a cane while ambulating.”
A nurse is participating on a committee that is developing age-appropriate care standards for older adult clients. Which of the following of Erikson's developmental tasks should the nurse recommend as the focus? Intimacy Identity Integrity Initiative
Integrity
Notes: Intimacy vs. isolation is the conflict that clients must resolve during young adulthood
Identity vs. role confusion is the conflict that clients must resolve during adolescence
Integrity vs. despair is the conflict that older adult client must resolve when they reflect on their lives and their roles.
Initiative vs. guilt is the conflict that clients must resolve during early childhood
A nurse is caring for a client who has Alzheimer’s disease and refuses to take her morning antihypertensive medication. The client is oriented to name and place and is able to perform ADLs with minimal supervision. Which of the following actions should the nurse take?
Crush the pills and feed them to the client in applesauce.
Insist the client comply by informing her of the possible implications of missing a dose.
Notify the provider of the need for further evaluation of the client’s level of competence.
Ask the client to express her reasons for refusing the medication and document the event.
Ask the client to express her reasons for refusing the medication and document the event.
A nurse at an assisted living center is conducting an orientation session for a group of newly hired assistive personnel (AP). Which of the following instructions should the nurse include regarding clients who are hearing impaired?
Maintain eye contact with the clients.
Stand to one side of the clients and speak into their good ears.
Speak loudly with exaggerated enunciation.
Ask only questions with yes or no answers.
Maintain eye contact with the clients.
A nurse is developing a plan of care for a client who had a recent stroke and has a history of gastroesophageal reflux disease (GERD). For which of the following disorders should the nurse plan to monitor this client? Duodenal ulcer disease Aspiration pneumonia Viral pneumonia Esophageal varices
Aspiration pneumonia
A nurse is assessing an older adult client for signs of dehydration. Which of the following findings should the nurse consider an expected part of the aging process? Elevation of urine specific gravity Decreased creatinine clearance Dry oral mucous membranes Poor skin turgor over the sternum
Decreased creatinine clearance
A nurse is planning care for an older adult client following abdominal surgery for a bowel obstruction. Which of the following information about pain management should the nurse consider when planning care?
Older adult clients have a diminished capacity to perceive pain.
Older adult clients should not take narcotics for pain control.
Older adult clients have increased pain as a normal part of aging.
Older adult clients are sensitive to the analgesic effect of opiates.
Older adult clients are sensitive to the analgesic effect of opiates.
