ATI study set- fundamentals

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? a. A client who has a history of physical abuse
b. A client who has a permanent pacemaker
c. A client who has ulcerative colitis
d. A client who has asthma
d
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client’s room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
a. “I will return shortly after I document this in your record.”
b. “Most men live a long time with prostate cancer.”
c. “I am available to talk if you should change your mind.”
d. “I will make a referral to a cancer support group for you.”
c
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client’s pain?
a. “Is your pain constant or intermittent?”
b. “What would you rate your pain on a scale of 0 to 10?”
c. “Does the pain radiate?”
d. “Is your pain sharp or dull?”
d
A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?

a. Insert the IV catheter into the back of the client’s hand.
b. Massage the area of the venipuncture site vigorously.
c. Insert the IV catheter without using a tourniquet.
d. Apply traction to the skin proximal to the insertion site to stabilize the vein.

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

a. The tube aspirate has a pH of 7.
b. An x-ray shows the end of the tube above the pylorus.
c. Bowel sounds are present on auscultation.
d. The client reports relief of nausea.

b
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

a. Activate the emergency fire alarm.
b. Extinguish the fire.
c. Evacuate the client.
d. Confine the fire.

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

a. Carry a client’s soiled linens out of the room in a mesh linen bag.
b. Place a client who has tuberculosis in a room with negative-pressure airflow.
c. Provide disposable plates and utensils for a client who is HIV-positive.
d. Dispose of a client’s blood-saturated dressing in a trash bag inside a second trash bag.

b
A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals’ signatures may the nurse legally witness? (Select all that apply.)

a. A teacher who brings in a 7-year-old student
b. A 16-year-old client who is married
c. A 27-year-old client who has schizophrenia
d. An adoptive parent who brings in his 8-year-old son
e. A 17-year-old mother who brings in her toddler

bcde
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client’s vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next?

a. Document the provider’s statement in the medical record.
b. Notify the nursing manager.
c. Consult the facility’s risk manager.
d. Complete an incident report.

b.
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

a. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
b. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client’s wishes.
c. A client with a do-not-resuscitate (DNR) status has a cardiac arrest, and the nurse does not perform CPR despite requests from the client’s family.
d. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she would give her.

a
A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet?

a. Beef liver
b. Shellfish
c. Egg yolks
d. Avocados

d
A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

a. the client is receiving formula at room temp
b. the feedings infuse at a slow, continuous drip over 8 hours each night
c. the family member flushes the tubing with warm water before and after giving medications
d. the family member washes out the feeding bag with warm water once every 24 hours

d
A nurse is caring for a client who has a terminal illness and is approaching death. The client’s respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?
a. turn the client every 4 hours
b. elevate the head of the client’s bed
c. hold oral care
d. increase the rooms temp
b
A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
a. oat cereal
b. re fried beans
c. peanut butter
d. cheddar cheese
d
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device?

a. “This type of hearing aid does not allow for fine tuning of volume.”
b. “I shouldn’t have trouble keeping the hearing aid in place during exercise.”
c. “I expect to hear a whistling sound when I first insert the hearing aid.”
d. “I will be sure to remove my hearing aid before taking a shower.”

d
A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?

a. Talk directly to the client, instead of the interpreter, when speaking.
b. Use a family member as the client’s interpreter.
c. Make sure that the interpreter has a college degree.
d. Avoid asking the client personal questions through the interpreter.

a
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

a. Administer the medication with the needle at a 45° angle.
b. Administer the medication into the client’s nondominant arm.
c. Pull the client’s skin laterally or downward prior to administration.
d. Massage the injection site after administration

a
A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?

a. Second intercostal space at the left sternal border
b. Fourth intercostal space at the right sternal border
c. Fourth intercostal space at the left sternal border
d. Second intercostal space at the right sternal border

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

a. “When descending stairs, I will first shift my weight to my right leg.”
b. “I should place my crutches 12 inches in front and to the side of each foot.”
c. “As I sit down, I will hold one crutch in each hand.”
d. “I will make sure the shoulder rests are snug against my armpits.

a
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

a. Numbness of the extremities
b. Bradycardia
c. Positive Chvostek’s sign
d. Abdominal cramping

D
a pt with hyponatremia (low sodium level) will have what?abdominal cramping, weakness, headache and nausea
Where should a nurse listen for a pt with a heart murmursecond intercostal space at the left sternal border and apex
A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?

a. “We will determine who the durable power of attorney for health care form has designated.”
b. “We will apply oxygen through a tube in your nose.”
c. “We will ask if you have changed your mind.”
d. “We will insert a breathing tube while we evaluate your condition.”

b
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

a. Increase in hematocrit
b. Increase in respiratory rate
c. Decrease in heart rate
d. Decrease in capillary refill time

c
A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

a. The nurse opens the sterile field on a wet surface.
b. The nurse opens the first fold away from his body.
c. The nurse holds sterile objects above the waist..
d. The outer edge of the sterile field is touching a bottle.

a
A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

a. Uniform pigmentation
b. A regular border
c. An uneven shape
d. A diameter smaller than 6 mm

c
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client’s care, when should the nurse initiate discharge planning?

a. During the admission process
b. As soon as the client’s condition is stable
c. During the initial team conference
d. After consulting with the client’s family

a
A nurse is preparing to insert an IV catheter into a client’s arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

a. Thread the IV catheter so that the hub rests at the insertion site.
b. Shaving excess hair from around the insertion site
c. Cleanse the site with hydrogen peroxide before IV catheter insertion.
d. Palpate the site carefully just before inserting the IV catheter.

a
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

a. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
b. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
c. Make sure the reservoir bag of a partial rebreathing mask remains deflated..
d. Use petroleum jelly to lubricate the client’s nares, face, and lips.

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

a. “Most people are happy when their children grow up and leave home.”
b. “You should be proud that your children are becoming independent.”
c. “Maybe you should consider why you are feeling useless.”
d. “People in middle adulthood often find satisfaction in nurturing and guiding young people.”

d
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

a. Make sure the client’s room has at least 6 air exchanges per hour.
b. Make sure the client wears a mask when outside her room if there is construction in the area.
c. Place the client in a private room with negative-pressure airflow.
d. Wear an N95 respirator when giving the client direct care.

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

a. Role play
b. Group discussions
c. Question-answer meetings
d. Practice sessions

d
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)

a. Assist the client with a partial bed bath.
b. Measure the client’s BP after the nurse administers an antihypertensive medication.
c. Test the client’s swallowing ability by providing thickened liquids.
d. Use a communication board to ask what the client wants for lunch.
e. Irrigate the client’s indwelling urinary catheter.

a b d
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

a. Pad the client’s wrist before applying the restraints.
b. Evaluate the client’s circulation once per shift after application.
c. Remove the restraints every 4 hr to evaluate the client’s status.
d. Secure the restraint ties to the client’s bed side rails.

a
A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

a. Clean sutures along the incision site..
b.Grasp at the knot of the sutures with forceps.
c. Cut the sutures close to the skin on one side.
d. Pull out the sutures with forceps in one piece.

a
A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

a. Examine personal values about the issue.
b. Tell the parents that this is a necessary procedure.
c. Inform the parents that the staff does not require their consent.
d. Contact a spiritual support person to explain the importance of the procedure.

A
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

a. “I think I should take my pain medication more often, since it is not controlling my pain.”
b. “Breathing faster will help me keep my mind off of the pain.”
c. “It might help me to listen to music while I’m lying in bed.”
d . “I don’t want to walk today because I have some pain.”

c
A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?

a. Loss of skin turgor on the back of the hands
b. Varicosities on the lower extremities
c. Thick, discolored nails with ridges
d. Bruises on the arms in various stages of healing

d
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Contact
Droplet
Airborne
Protective

b
_________ precautions are a requirement for clients who have infections that spread via direct ________ with clients or from environmental ________. Examples are vancomycin-resistant enterococci and herpes simplex infections.contact
___________ precautions are a requirement for clients who have infections that spread via _________ nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 ft) of the client who has a disorder requiring this precaution.Droplet
precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.Airborne
Clients who have an immune system compromise, such as those who have had an allogeneic stem cell transplant, require a _____________ environment. It keeps them from acquiring infections from others.protective
A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter?

a. Small air bubbles are in the IV tubing.
b. IV flow stops when the client bends her arm.
c. Swelling and coolness are observed at the IV site.
d. Blood is visible in the IV catheter and tubing.

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

a. 2 cups of soup
b. 1 quart of water
c. 8 oz of ice chips
d. 6 oz of tea.

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

a. Insert the suction catheter while the client is swallowing.
b. Apply intermittent suction when withdrawing the catheter.
c. Place the catheter in a location that is clean and dry for later use.
d. Hold the suction catheter with her clean, nondominant hand.

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

a. Urine has an unusual odor.
b. Urine specific gravity is 1.035.
c. Bladder scan shows 525 mL of urine.
d. Urine is positive for ketones.

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

a. Admitting diagnosis
b. Breath sounds
c. Body temperature
d. Diagnostic test results

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

a. Rock the client up to a standing position.
b. Pivot on the foot that is the farthest from the chair.
c. Assess the client for orthostatic hypotension.
d. Apply a gait belt to the client

c
A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.)

a. Check the cord routinely for frays or tearing.
b. Keep the unit at least 4 feet away from a gas stove.
c. Consider purchasing a generator for power backup.
d. Observe for signs of hypoxia.
Select synthetic clothing and bedding.

a c d
A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

a. Reduce dietary sodium.
b. Administer a loop diuretic.
c. Evaluate electrolytes.
d. Restrict intake of oral fluids.

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

a. Press gently on the tragus of the client’s ear.
b. Pack a small piece of cotton deep into the client’s ear canal.
c. Move the client’s auricle down and back toward her head.
d. Tilt the client’s head backward for 5 min.

a
A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

a. A nurse tied a client’s restraint straps to the moveable part of the bed frame.
b. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology.
c. A nurse administers a medication to a client 30 min before the dose is due.
d. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

d
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

a. Discuss the risk factors for colon cancer.
b. Focus teaching on what the client will need to do in the future to manage his illness.
c. Provide the client with written information about the phases of loss and grief.
d. Reassure the client that this is an expected response to grief.

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

a. Dissolve each medication in 5 mL of sterile water.
b. Draw up medications together in the syringe.
c. Push the syringe plunger gently when feeling resistance.
d. Flush the tube with 15 mL of sterile water.

d
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

a. Bend at the waist.
b. Keep his feet close together.
c. Use his back muscles for lifting.
d. Stand close to the cabinet when lifting it.

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

a. “I’m having mild pain.”
b. “The pain is like a dull ache in my stomach.”
c. “I notice that the pain gets worse after I eat.”
d. “The pain makes me feel nauseous.”

b
A nurse is reviewing a client’s fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

a. BUN 15 mg/dL
b. Creatinine 0.8 mg/dL
c. Sodium 143 mEq/L
d. Potassium 5.4 mEq/L

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

a. The top of the cane is parallel to the client’s waist.
b. When walking, the client moves the cane 46 cm (18 in) forward.
c. The client holds the cane on the stronger side of her body.
d. The client moves her stronger limb forward with the cane.

c
A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

a. Assign the client to a room with a negative air-flow system.
b. Use alcohol-based hand sanitizer when leaving the client’s room.
c. Clean contaminated surfaces in the client’s room with a phenol solution.
d. Have family members wear a gown and gloves when visiting.

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

a. Ask another nurse to observe the medication wastage.
b. Notify the pharmacy when wasting the medication.
c. Lock the remaining medication in the controlled substances cabinet.
d. Dispose of the vial with the remaining medication in a sharps container.

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

a. Place the client in a side-lying position.
b. Instill 15 mL of irrigation fluid into the catheter with each flush.
c. Subtract the amount of irrigant used from the client’s urine output.
d. Perform the irrigation using a 20-mL syringe.

c
A nurse is assessing an older adult client’s risk for falls. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select all that apply.)

a. Lacrimal apparatus
b. Pupil clarity
c. Appearance of bulbar conjunctivae
d. Visual fields
e. Visual acuity

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

a. Purulent exudate
b. Warmth
c. Skin blanching
d. Bleeding

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

a. Gently shake the container of medication prior to administration.
b. Transfer the medication to a medicine cup.
c. Place the client in a semi-Fowler’s position prior to medication administration.
d. Verify the dosage by measuring the liquid before administering it.

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

a. Auscultate lung sounds.
b. Measure urine output.
c. Monitor blood pressure readings.
d. Monitor serum electrolyte levels.

a
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?

a. Tell the client which food she should eat first.
b. Provide small-handle utensils for the client.
c. Thicken liquids on the client’s tray.
d. Use a clock pattern to describe food on the client’s plate.

d
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?

a. Erythema on pressure points
b. Lower-extremity pulse strength of 2+
c. Fluid intake of 3,000 mL per day
d. A bowel movement every other day

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

a. Use a resuscitation bag with 80% oxygen prior to the procedure.
b. Select a suction catheter that is half the size of the lumen.
c. Place the end of the suction catheter in water-soluble lubricant.
d. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

b
A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?

a. Airborne
b. Droplet
c. Contact
d. Protective environment

a
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

a. Drink a cup of hot cocoa before bedtime.
b. Exercise 1 hr before going to bed.
c. Use progressive relaxation techniques at bedtime.
d. Reflect on the day’s activities before going to bed.

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

a. Check the client for injuries.
b. Move hazardous objects away from the client.
c. Notify the provider.
d. Ask the client to describe how she felt prior to the fall.

a
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse’s priority before beginning this procedure?

a. “When do you usually bathe, in the morning or in the evening?”
b. “Do you prefer a bath or a shower?”
c. “At what temperature do you prefer your bath water?”
d. “Are you able to help with your hygiene care?”

d
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

a. “I’ll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank.”
b. “I’ll use a woolen blanket if I get chilly while I’m using my oxygen.”
c. “I’ll check the wires and cables on my TV to make sure they are in good working order.”
d. “I’ll lay my oxygen tank down on the floor when the grandchildren visit so they don’t knock it over.”

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

a. Rinse the feeding bag with water between feedings.
b. Tell the client to keep the head of the bed elevated at least 30°.
c. Make sure the enteral formula is at room temperature.
d. Wipe the top of the formula can with alcohol.

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

a. Touch the face with a cotton ball.
b. Apply a vibrating tuning fork to the client’s forehead.
c. Have the client stand with her arms at her side and her feet together.
d. Perform direct percussion over the area of the kidneys.

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

a. “I’ll get a blood sample from you and send it for a screening test.”
b. “Beginning at age 60, you should have a colonoscopy.”
c. “You should have a fecal occult blood test every year.”
d. “The recommendation is to have a sigmoidoscopy every 10 years.”

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

a. Bladder distention
b. Decreased blood pressure
c. Calf swelling
d. Diminished bowel sounds

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

a. Neck vein distention
b. Urine specific gravity 1.010
c. Rapid heart rate
d. Blood pressure 144/82 mm Hg

c
A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

a. Allow extra time for the client to respond to questions.
b. Expect the client to have difficulty understanding the information.
c. Avoid references to the client’s past experiences.
d. Keep the learning session private and one-on-one.

a
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

a. Protective environment
b. Airborne precautions
c. Droplet precautions
d. Contact precautions

d
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?

a. A nurse who is caring for a client reviews the client’s medical chart with the nursing student who is working with the nurse.
b. A nurse asks a nurse from another unit to assist with her documentation.
c. A nurse who is caring for a client returns a call to the client’s durable power of attorney for health care designee to discuss the client’s care.
d. A nurse discusses a client’s status with the physical therapist that is caring for the client at the client’s bedside.

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

a. Wear sterile gloves when removing the old dressing.
b. Warm the irrigation solution to 40.5° C (105° F).
c. Cleanse the wound from the center outward.
d. Use a 20-mL syringe to irrigate the wound.

c
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

a. inject 5 units of air into the bottle of regular insulin
b. withdraw the correct dose of NPH insulin from the bottle
c. inject 10 unites of air into the bottle of NPH insulin
d. withdraw the correct dose of regular insulin from the bottle

c a d b
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

a. “I had a bowel movement, but I was able to save the urine.”
b. “I have a specimen in the bathroom from about 30 minutes ago.”
c. ” I flushed what I urinated at 7:00 a.m. and have saved all urine since.”
d. “I drink a lot, so I will fill up the bottle and complete the test quickly.”

c
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

a. Insert an implanted port.
b. Close a laceration with sutures.
c. Place an endotracheal tube.
d. Initiate an enteral feeding through a gastrostomy tube.

d
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

a. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube.
b. Remove the NG tube if the client begins to gag or choke.
c. Apply suction to the NG tube prior to insertion.
d. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

d
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

a. Place the client in high-Fowler’s position.
b. Increase the client’s intake of carbohydrates.
c. Massage reddened areas with unscented lotion.
d. Have the client use a trapeze bar when changing position.

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

a. Request that a respiratory therapist discuss the technique for incentive spirometry.
b. Determine the reasons why the client is refusing to use the incentive spirometer.
c. Document the client’s refusal to participate in health restorative activities.
d. Administer a pain medication to the client.

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

a. Insert the catheter at a 45° angle.
b. Place the client’s arm in a dependent position.
c. Shave excess hair from the insertion site.
d. Initiate IV therapy in the veins of the hand.

b
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

a. “Use the complete name of the medication magnesium sulfate.”
b. “Delete the space between the numerical dose and the unit of measure.”
c. “Write the letter U when noting the dosage of insulin.”
d. “Use the abbreviation SC when indicting an injection.”

a
A nurse is reviewing a client’s medication prescription, which reads, “digoxin 0.25 by mouth every day.” Which of the following components of the prescription should the nurse question?

a. The medication
b. The route
c. The dose
d. The frequency

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

a. Apply the stockings so the creases are on the front side of the leg.
b. Apply the stockings while the client’s legs are in a dependent position.
c. Remove the stockings at least once per shift.
d. Remove the stockings while the client is sitting in a reclining chair.

c
A nurse is talking with the partner of an older adult male client who has dementia. The client’s partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

a. Role ambiguity
b. Sick role
c. Role overload
d. Role conflict

c
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

a. position the chair on the left side of the bed
b. ask the client if he can bear weight
c. have the client sit and dangle his feet at the bedside
d. use the stand and pivot technique to move the client to the chair

b a c d
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

a. Critical pathway
b. Situation, background, assessment, and recommendation (SBAR)
c. Transfer report
d. Medication administration record (MAR)

b
A nurse is assessing a client’s readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

a. “I can concentrate best in the morning.”
b. “It is difficult to read the instructions because my glasses are at home.”
c. “I’m wondering why I need to learn this.”
d. “You will have to talk to my wife about this.”

a
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

a. Biofeedback
b. Aloe
c. Feverfew
d. Acupuncture

d
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

a. Suction the client’s airway.
b. Administer a bronchodilator.
c. Increase the humidity in the client’s room.
d. Assist the client to an upright position.

d
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

a. “What could I have done to deserve this illness?”
b. “I blame medical science for not curing me.”
c. “Where is my daughter at a time like this?”
d. “Will I ever begin to feel in charge of my life again?”

a
A nurse in a surgical suite notes documentation on a client’s medical record that he has a latex allergy. In preparation for the client’s procedure, which of the following precautions should the nurse take?

a. Ensure sterilization of nondisposable items with ethylene oxide.
b. Wrap monitoring cords with stockinette and tape them in place.
c.Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
d. Wear hypoallergenic latex gloves that contain powder.

b
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)

a. Place the client in a room with negative-pressure airflow.
b. Wear gloves when assisting the client with oral care.
c. Limit each visitor to 2-hr increments.
d. Wear a surgical mask when providing client care.
e. Use antimicrobial sanitizer for hand hygiene.

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

a. Walking briskly
b. Riding a bicycle
c. Performing isometric exercises
d. Engaging in high-impact aerobics

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

a. “They allow the court to overrule an adult client’s refusal of medical treatment.”
b. “They indicate the form of treatment a client is willing to accept in the event of a serious illness.”
c. “They permit a client to withhold medical information from health care personnel.”
d. “They allow health care personnel in the emergency department to stabilize a client’s condition.”

b
A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client’s family member is coping effectively with the situation?

a. “We are not worried. We still have hope that everything will be okay.”
b. “This is a difficult time, but we are helping each other through this.”
c. “After he comes home, we can plan our family reunion.”
d. “We don’t need to talk about funeral arrangements at this time.”

b