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ATI MEDSURG Assessment A

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B. use trach covers when outdoors *protects the airway from dust, cold air, other airborne particles
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A nurse is teaching a family and a client how to care for the client’s trach at home. Which of the following instructions is appropriate for the client and family? A. remove the outer cannula cautiously for routine cleaning B. use trach covers when outdoors C. use sterile technique when performing trach care at home D. cleanse irritated skin with full-strength hydrogen peroxide
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D. breath sounds * When using the ABC approach to client care, the nurse determines the priority information to provide are the client’s breath sounds
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A nurse is giving an end-of shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide? A. admitting diagnosis B. diagnostic test results C. body temp D. breath sounds
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B. client with elevated LDL
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A nurse is checking blood pressure at a community health screening. Which of the following clients is at high risk for primary hypertension? A. pregnant client B. client with elevated LDL C. client who takes oral contraceptives D. client who has kidney disease
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A. Assist client with partial bed bath B. Measure BP after nurse administers anti-hypertensive D. Use communication board to ask client needs
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A nurse is planning care for a client who has had stroke resulting in aphasia and dysphagia. Which of the following task should the nurse assign to an AP? Select all that apply A. Assist client with partial bed bath B. Measure BP after nurse administers anti-hypertensive C. Test client’s swallowing ability D. Use communication board to ask client needs E. irrigate indwelling urinary catheter
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B. remove each restraint one at a time every 2 hours *allows client to perform ROM exercises and the nurse to perform neurovascular checks
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A nurse is caring for a client who is combative in the ED. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take? A. tie restraints to lower edge of side rail B. remove each restraint one at a time every 2 hours C. ensure 3 fingers width of space between restraint and clients wrist D. use a square knot to securely tie the restraints to the bed
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C. have a second nurse witness disposal of remaining medication
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A nurse is preparing to administer morphine 4mg IV bolus to a client. Available is 5mg/ml. Which of the following is an appropriate nursing intervention? A. return unused portion to automatic dispensing system B. keep remainder at bedside for later use C. have a second nurse witness disposal of remaining medication D. lock remaining medication in secure cabinet
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C. it indicates a form of treatment a client is willing to accept in the event of a serious illness
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A nurse is caring for a client who asks about the purpose of advanced directives. Which of the following is an appropriate response by the nurse? A. it allows the court to overrule an adult client’s refusal of medical treatment B. it permits a client to withhold medical information from health care personnel C. it indicates a form of treatment a client is willing to accept in the event of a serious illness D. it allows healthcare personnel in the ED to stabilize a client’s condition
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C. client found lying on the floor
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A nurse finds a client on the floor upon entering the client’s room. The roommate reports that the client was trying to get of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident? A. incident report completed B. client climbed over bedrails C. client found lying on floor D. client was trying to get out of bed
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C. it may help to listen to music while i am lying in bed
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A client who is postop is verbalizing pain as a 2 on a pain scale of 0-10. The nurse understands that the preop teaching regarding pain control has been effective when the client states which of the following? A. I think I should take my pain meds more often, it’s not controlling my pain B. breathing faster will help keep my mind off the pain C. it may help to listen to music while i am lying in bed D. I do not want to walk today because I am experiencing some pain
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C. It must be frustrating. I have a few minutes now
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A Client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse? A. I am sorry but another client needed my attention B. I arrived as soon as I could; what can I do for you? C. It must be frustrating. I have a few minutes now D. We had an emergency on the unit but I am here now
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A. during admission process
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A nurse is admitting a client who is experiencing exacerbation of heart failure. In planning the client’s care when should the nurse initiate discharge planning? A. during admission process B. as soon as clients condition is stable C. during the initial team conference D. After consulting with client’s family
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D. a nursing student consults a former class mate to assist with her documentation
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A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPPA? A. the assigned nurse views the medical chart with a nursing student B. a nursing student discusses a client status with the assigned nurse at the bedside C. the assigned nurse returns a call to the client’s POA to discuss client’s care D. a nursing student consults a former class mate to assist with her documentation
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A. the client inserts the needle at a 30 degree angle
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A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a need for further teaching? A. the client inserts the needle at a 30 degree angle B. the client rolls the vial between both hands C. the client holds the syringe in place for 5 seconds following administration D. the client uses her anterior thigh for the injection site
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D. potassium 5.4
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A nurse is reviewing a client’s electrolyte status. Which of the following findings should the nurse report? A. BUN 15 B. creatinine 0.8 C. sodium 143 D. potassium 5.4
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B. explain the purpose of the communication to the interpreter
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A nurse contacts the facility’s interpreter to explain a therapeutic procedure to a client who does not speak English. Which of the following guidelines should the nurse follow when working with the interpreter? A. speak slowly to allow the interpreter to interpret each word B. explain the purpose of the communication to the interpreter C. address the interpreter when explaining the procedure information D. supplement words with gestures and non verbal reinforcement
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D. perform suctioning while removing catheter
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A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate? A. use clean technique B. insert catheter as client exhales C. apply suction for 20 seconds D. perform suctioning while removing catheter
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A. wipe away first drop of blood from clients finger
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A nurse is caring for a client and performing BG monitoring. Which of the following is a appropriate nursing intervention? A. wipe away first drop of blood from client’s finger B. gently massage finger in a distal to proximal direction C. puncture the tip of the client’s finger D. hold finger in elevated position prior to testing
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A. When I get out of the chair, I hold both crutches on the side next to my weak leg
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A nurse is caring for a client who cant bear weight on his fractured ankle. Which of the following client statements indicates a need for further teaching regarding 3 point gait crutch walking? A. When I get out of the chair, I hold both crutches on the side next to my weak leg B. When I sit down, I will transfer my weight to my crutches and my strong leg C. When I go upstairs, I will alternate putting weight on my crutches and my strong leg D. When I go downstairs, I will start by moving both crutches to the step below
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C. offer each medication one at a time
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A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse? A. have client drink from a straw after taking meds B. instruct client to lift chin upward when swallowing C. offer each medication one at a time D. place the medication in the client’s mouth
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A. increase infection rates * because skin integrity is broken; risks infection
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A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route? A. increase infection rates B. is safest option C. has slowest absorption rate D. decrease client risk for reactions
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A. ask if any special rituals they would like followed
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A nurse is working with an orthodox Jew who has just given birth to a stillborn infant. Which of the following interventions is appropriate? A. ask if any special rituals they would like followed B. inform parents of importance of conforming to hospital policy regarding death of a fetus C. remain in the room giving parents the opportunity to initiate a discussion about cultural rituals D. take fetus out of the room and allow parents to grieve together
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B. place a client who has TB in a neg pressure airflow
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A nurse is caring for four clients. Which of the following should the nurse take to prevent the spread of infection? A. carry soiled linen out of the room in a mesh bag B. place a client who has TB in a neg pressure airflow C. provide disposable plates and utensils to a client with HIV D. dispose of a clients blood saturated dressing in a garbage bag placed inside a second garbage bag
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B. reschedule lab for next morning * lab fasting should be 8-12 hours prior to draw
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A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, “All I have since midnight is water and some juice. Which of the following nursing actions is appropriate? A. document caloric intake B. reschedule lab for next morning C. notify lab to obtain another specimen D. obtain prescription for glucose tolerant test
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D. notify security for placement of necklace
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A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia is administered. Which of the following interventions should be initiated? A. leave necklace on client B. give necklace to family member C. place necklace in client’s chart D. notify security for placement of necklace
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D. I will replace the old throw rug in the kitchen with a new one
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Nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse? A. I will tape electrical cords to the baseboards in each room B. I will hire someone to trim that tree that overhangs the front porch stairs C. I will remove the table from the hall D. I will replace the old throw rug in the kitchen with a new one
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A. clean the sutures/the incision site
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A nurse has an order to remove sutures from a client. Which of the following actions should the nurse take next? A. clean the sutures/the incision site B. grasp sutures at knot with pair of forceps C. cut sutures close to skin on one side D. pull out sutures with forceps in one piece
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D. use a clock pattern to describe food on the plate
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A nurse is planning care to promote improved self-feeding for a client who has a visual impairment. Which of the following interventions should the nurse include in the POC? A. direct the client in the order to consume the food B. provide small handled utensils C. thicken liquids on the tray D. use a clock pattern to describe food on the plate
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B. 02 sats 86%
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A nurse is caring for a patient who has contusions to the chest wall from a MVA. Which of the following should the nurse report? A. HCT 40 B.02 sats 86% C. WBC 9,000 D. potassium 4.1
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D. I want you to tell me about measures available to keep me comfortable
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A nurse is caring for a client with terminal cancer. The nurse understands that the client is ready to hear information regarding palliative care when the client states which of the following? A. I am ready to hear about chemo to cure my cancer B. I just want you to give me something to get over with this soon C. I know that many people have recovered fully and so will I D. I want you to tell me about measures available to keep me comfortable
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D. notify nursing manager
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A nurse is caring for a client who is postop and has signs of hemorrhagic shock. The nurse notifies the surgeon who directs her to continue taking vitals every 15 min and call back in 1 hour. From a legal perspective, which of the following action should the nurse take next? A. document provider statement in medical record B. complete an incident report C. consult facility’s risk manager D. notify nursing manager
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D. obtain BP 2 min after assisting to sitting position
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A nurse is checking a client’s blood pressure to check for orthostatic hypotension. Which of the following actions should the nurse take? A. obtain BP 30 min after each meal B. obtain BP immediately after ambulation C. obtain BP in each arm and leg D. obtain BP 2 min after assisting to sitting position
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A. instruct family to refrain from pushing button for client while she is asleep
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Which of the following is the responsibility of a nurse who is caring for a client receiving PCA? A. instruct family to refrain from pushing button for client while she is asleep B. inform client that because she is on a PCA, VS will be taken every 8 hours C. teach client to avoid pushing button until pain >7 D. increase basal rate and shorten lock out interval time if clients pain level is too high
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A. newly licensed nurse places the cap of the sterile saline bottle on the sterile field
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The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse should cause the nurse to intervene? A. newly licensed nurse places the cap of the sterile saline bottle on the sterile field B. newly licensed nurse places sterile objects 1 inch from the border of the field C. newly licensed nurse holds the bottle of sterile saline outside of the edge of the field when pouring D. table is positioned at nurse’s waist level
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D. use role play and imitation when explaining
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A nurse is planning to teach a preschool child how to use a metered dose inhaler. Which of the following methods is appropriate for this child? A. hold child in lap while explaining B. help child identify feelings about using inhaler C. encourage independent learning D. use role play and imitation when explaining
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A. face shield
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A nurse is preparing to care for a client who has MRSA in the lungs. Besides gown and gloves what other PPE is required? A. face shield B. high infiltration mask C. shoe covers D. surgical cap
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A. examine personal values about the issue
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A nurse is caring for a young child who is prescribed 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 parents this is a necessary procedure C. inform parents their consents is not required D. contact the chaplain to explain importance of procedure
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A. stoma appears purple in color *indicates impaired circulation
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A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider? A. Stoma appears purple in color B. protrusion of stoma from abdomen C. mucosa of stoma bleeds slightly when touched D. red peristomal skin under adhesive
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B. determine client’s learning style
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A nurse is planning teaching for a child who has new dx of diabetes 1 about self administration. which of the following actions should the nurse take first? A. encourage client to include family member in the teaching B. determine client’s learning style C. provide written directions D. schedule series of teaching sessions
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B. Levothyroxine 125 mcg given at 0800 Provider notified
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Following administration of levothyroxine 125 mcg at 0800, the nurse discovers the medication was given to a client for whom it was not prescribed. Which of the following is the correct way to document this error in the medical record of the client who received the medication? A. Levothyroxine 125mcg given at 0800 in error. Client in no distress B. Levothyroxine 125 mcg given at 0800 Provider notified C. Levothyroxine 125mg given at 0800. Incident report filed D. Levothyroxine 125mg given at 0800 in error. Client informed of error
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C. compare client’s home meds with prescribed meds
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A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. verify clients name on ID bracelet with MAR B. call pharmacy to verify client’s meds are available C. compare client’s home meds with prescribed meds D. place client’s home med bottles in a secure location
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D. i will be sure to remove my hearing aid before I take a shower
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A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he 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 I take a shower
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D. place client’s feet against foot board perpendicular to mattress
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To prevent foot drop in a client with decreased mobility, the nurse should? A. place a pillow under the client’s knees B. position trochanter roll under clients feet C. advise client to wear rubber soled slippers D. place client’s feet against foot board perpendicular to mattress
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B. xray show end of tub above pylorus
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A nurse just inserted an NG tube for a client Which of the following assessment findings indicates that the tube is properly positioned? A. tube aspirate has a PH of 7 B. xray show end of tub above pylorus C. bowel sounds present on auscultation D. client reports relief of nausea
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C. discontinue IV
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A client is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. Which of the following actions should the nurse take first? A. place warm compress over site B. restart IV line at different site C. discontinue IV D. document findings
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B. call provider to discuss concerns
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A nurse is caring for a preschooler with heart disease. The provider prescribes digoxin at the maximum adult dose. Which of the following actions should the nurse take? A. give as prescribed using 6 rights B. call provider to discuss concerns C. assess heart rate and rhythm before deciding whether to give the medication D. administer pediatric dose as recommended in a medication reference book
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A. avocados
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A nurse is caring for a client who is at risk for hypokalemia, Which of the following foods should be included in the diet? A. avocados B. corn C. asparagus D. cucumbers
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D. check IV tubing for obstruction
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A nurse receives report on a client who is receiving 0.9% sodium chloride at 125ml/hr. When the nurse performs the initial assessment, she notes that the client has received 80 ml for the last 2 hours. Which of the following actions should the nurse first take? A. reposition the client B. document clients IV intake in the MAR C. request new IV prescription D. check IV tubing for obstruction
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A. I will remove the heating pad in 30 min
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A nurse is providing instruction for an older adult client who has a prescription for an electric heating pad to his lumbosacral area. Which of the following client statements indicates a correct understanding of the teaching? A. I will remove the heating pad in 30 min B. I will need to turn up the heating pad after 10 min of applying C. I will sleep on top of the pad to get better heat penetration D. I can pin the heating pad to my gown to keep it in place
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D. is the pain sharp or dull
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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 pain constant or intermittent B. rate pain on scale of 0-10 C. does the pain radiate D. is the pain sharp or dull
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A. identify religious and spiritual beliefs, affiliations, and practices
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A nurse is performing a spiritual assessment on a client newly admitted to the unit. The purpose of performing this assessment is to? A. identify religious and spiritual beliefs, affiliations, and practices B. apply commonly accepted concepts of spirituality to the nurses interactions with the client C. allow the nurse to make educated assumptions about the client’s spiritual needs related to health care D. encourage the client to focus on beliefs that are consistent with health care interventions
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B. position clients arm in dependent position
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A nurse is planning to insert a peripheral IV catheter in an older adult client. Which of the following actions should the nurse plan to take? A. insert IV at 45degree angle B. position clients arm in dependent position C. shave excess hair from insertion site D. initiate IV therapy in the veins of the hand
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C. bladder scan reveals 525 ml of urine
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A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter should be irrigated? A. urine has unusual odor B. specific gravity is 1.035 C. bladder scan reveals 525 ml of urine D. urine is positive for ketones
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A. protein intake is often inadequate in older adults
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A nurse in a clinic is providing teaching to an older adult client about nutritional considerations associated with aging. Which of the following should the nurse include in the teaching? A. protein intake is often inadequate in older adults B. vitamin and mineral requirements decline in older adults C. thirst sensation increases in older adults D. lack of adequate fat in the diet is often seen in older adults
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D. evacuate the client
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A client who is non ambulatory tells the nurse that her trash can is on fire. Which of the following actions should the nurse first take? A. call emergency fire code B. extinguish fire C. confine fire D. evacuate the client
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A. edema B. crackles in lungs D. elevated BP E. jugular venous distention
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A nurse is monitoring an older adult client who is receiving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse effect of excess fluid therapy? (Select all that apply. A. edema B. crackles in lungs C. oliguria D. elevated BP E. jugular venous distention
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C. show child Oucher pain scale
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A nurse is developing a POC for an african american child who is preschool aged and experiencing pain. Which of the following is the best way for the nurse to assess the child’s pain? A. ask parents to describe pain B. measure vital signs C. show child Oucher pain scale D. observe child’s facial expressions