question

Post open transverse coly 5 days ago, nurse recognizes the wound has eviscerated. After covering with sterile, saline-soaked dressing, which of following actions should nurse take first? Go to Nurses station to seek assistance, reinsert organs into abdominal cavity, place client in reverse trendelenburg, obtain V/S to assess for shock.

answer

Obtain V/S to assess for shock

question

When caring for postop patient with JP drain, which intervention should nurse use to ensure proper functioning of drain? Secure to clients bed sheet, clamp when ambulating, empty and compress drain as needed, keep drain higher than surgical incision

answer

empty and compress as needed

question

When completing initial PACU assessment of patient postop knew arthroplasty who received spinal anesthesia, which finding indicates need to notify provider? Client states bilateral numbness to lower extremities, spinal anesthesia is at T10 level, client rouses to tactile stimuli, patient reports chest pain

answer

patient report chest pain

question

Surgical nurse enters surgical suite to ensure surgical asepsis is maintained. Which observation requires an intervention. Scrub tech wearing a watch under his scrubs, circulating nurse opens dressing packages before applying sterile gloves, surgeon has hands folded 2 in (5cm) above waist, holding area nurse is performing patient education

answer

scrub tech wearing a watch under his scrubs

question

When caring for a postoperative patient, what should the nurse do to prevent formation of thrombi in the postoperative period? Change patient's position q4h, have patient perform dorsal and plantar flexion of feet q1h, place patient in bed with pillow under knees, assess pedal and posterior tibial pulses q2h

answer

have patient perform dorsal and plantar flexion every hour

question

when caring for a patient 2 days postop following cholecystectomy, the patient has been vomiting for past 24hrs & reports pain level of 8 on scale 0-10. Nurse notes hard, distended abdomen and absent bowel sounds. After conferring with provider, which of following actions should nurse take first? Draw blood for electrolytes, insert NG tube, administer pain medication, initiate intake & output

answer

Insert NG tube

question

When caring for patient 2hrs postop following appendectomy, which finding should nurse report to provider? Urine output 20mL/h, Temp 36.4 (97.7), 2cmx2cm area bloody drainage on dressing, JP drainage 30ml?h

answer

Urine output 20mL/hr

question

When completing prep assessment for a client who is a Jehovahs witness, which of following should nurse recognize as situation that could pose special care needs for this client? Having preop blood drawn, giving information about sexual history, providing informed consent to receive blood products, receiving care from nurse of opposite gender.

answer

providing informed consent to receive blood products

question

When receiving afternoon report on 4 patient who have returned from PACU this morning, which patient first? Posted thoracotomy w/chest tube w/150mL bright-red blood in collection chamber from first hour, postop small bowel resection w/temp colostomy and absent bowel sounds x4 quadrants, postop tonsillectomy with 1 episode of coffee-ground emesis, postop following total knee arthroplasty and PCA reporting knee pain of 7

answer

postop thoracotomy w/chest tube w/150mL bright red blood in collection chamber from first hour

question

When providing discharge instructions for a patient postop following abdominal surgery, which patient statement indicates need for further teaching? I will call doctor if increase in temp or wound draining, I will eat foods high in protein and Vit C during my recovery, I will complete entire course of antibiotics, I will remain on bed rest until follow-up with doctor.

answer

I will remain on bedrest until follow-up appt with doctor

question

When preparing patient for surgery, patient appears apprehensive and asks multiple questions about risks of procedure. Which action should nurse take before witnessing patients signing of informed consent form? Explain risks and benefits of surgery, ask surgeon to speak to patient for clarification, reassure that procedure is necessary for recovery, document patients lack of preop teaching

answer

ask surgeon to speak to client for clarification

question

When assessing patient who's 2 days postop following total prostatectomy, nurse notes patients right calf is red, edematous, warm to the touch. Which action should nurse take? Apply ice pack to right calf, elevate right extremity, administer testosterone, ,gently massage right calf

answer

elevate right extremity

question

When providing preop teaching for patient scheduled for mastectomy, which patient statement indicates need for further treatment? I should wait 3-4 weeks after surgery to do water aerobics, I'll wait until a week after surgery to start hand strengthening exercises, I should avoid having blood drawn fro arm on side I had my mastectomy, I'll be able to shower after doctor removes drain

answer

I'll wait until a week after surgery to start hand strengthening exercises

question

When providing teaching for patient scheduled to undergo moderate (conscious) sedation for bronchoscopy. Which statement verifies that the patient understands the procedure? I will need to complete a bowel prep the day before the procedure, I will drink plenty of fluids the morning of the procedure, I can eat as soon as the procedure is over, I can expect to feel sleepy for several hours after the procedure.

answer

I can expect to feel sleepy for several hours after the procedure

question

When caring for patient postop after abdominal surgery, which of the following nursing interventions should nurse perform to prevent respiratory complication? Instruct patient to exhale into incentive spirometer every 1-2 hrs, minimize amount of pain meds patient receives to prevent sedation, advise patient to splint surgical incision when coughing and deep breathing, reposition client q8h for first 48hrs

answer

Advise patient to splint surgical incision when coughing and deep breathing

question

When monitoring a patient receiving succinylcholine during a surgical procedure, which of following actions should nurse take if patient develops malignant hyperthermia? Administer dantrolene, institute seizure precautions, measure blood glucose, give IV atropine

answer

administer dantrolene

question

When caring for patient has NG tube set to continuous low suction following gastrectomy, which of following findings should nurse report to the provider? gastric distention, absent bowel sounds, incisional pain of 9 on scale 0-10, small amount of bloody drainage in NG tube.

answer

gastric distension

question

Nurse providing teaching for patient who's in the immediate postop period and has PCA pump. Which of following statements should nurse include in teaching? You will receive a dose of medication every time you push the button, do not allow your family to push the PCA button if you're sleeping, you cannot receive too much medication by pushing the button, do not push the PCA button until your pain reaches a severe level

answer

Do not allow your family to push PCA if you're sleeping

question

When caring for patient during surgery, what action should be taken to prevent neuromuscular complications during surgical procedure? administer IV bolus of normal saline, massage lower extremities during procedure, support bony prominences with foam padding, extend joints and maintain position w/padded straps

answer

support bony prominences with foam padding

question

When assessing patients recovery from spinal anesthesia, which of following sensations should nurse expect to return to patient first? Pain, Cold, touch, warmth

answer

touch

question

When taking preoperative medication history on client scheduled for surgery, which of the following medications should nurse recognize as placing patient at risk for complications due to interaction w/anesthetic agents? Captopril, Atorvastatin, Ranitidine, Ciproflaxin

answer

Captopril

question

When providing preop teaching for patient, which of following prescribed medications should nurse instruct patient to d/c 48hrs prior to surgery? Furosemide, Digoxin, Prednisone, Warfarin

answer

Warfarin

question

When working in surgical suite, check rooms are maintained at cool temperature with low humidity to decrease which of the following? Risk for malignant hyperthermia, amount of anesthetic agents clients need, risk of infection, amount of O2 patient needs

answer

risk of infection

question

when caring for patient receiving moderate (conscious) sedation with midazolam and fentanyl, patient's respirations decrease from 16/min to 6/min and O2 sat decreases from 92% to 85%. Which of following actions should nurse take first? Gather suction equipment, obtain equipment necessary for CPR, administer reversal agents, start additional IV line.

answer

administer reversal agents

question

When caring for patient postop following total hip arthroplasty, which assessment data indicates patient is at increased risk for infection? Use of herbal remedies, long term use of corticosteroids, excessive exposure to sunlight, diet high in cholesterol

answer

long term use of corticosteroids

question

When reviewing medical record of patient who is to undergo general anesthesia for surgery, which of the following findings should nurse report to provider? Potassium 2.8, sodium 140, INR 1.5, BUN 12

answer

potassium 2.8

question

When caring for patient with surgical wound and penrose drain in place, which interventions should nurse plan to perform? Cut slit in 4inch square gauze pad to place around drain, use sterile technique when performing dressing changes, establish clamping schedule prior to removal, apply negative pressure when emptying drain

answer

use sterile technique when performing dressing changes

question

when assessing patient in PACU to determine if he's ready for discharge, which finding indicates he is ready? Preop BP was 140/90, postop BP 100/65, pain rating at 4 on 0-10 scale, able to move all four extremities on command, requires tactile stimulation to awaken

answer

able to move all four extremities on command

question

Patient transferred from surgical suite to PACU following oral surgery, while monitoring clients vital signs, nurse finds that tongue has become swollen and is obstructing the airway. Which of the following actions should nurse take first? Contact anesthesiologist, assist with ET intubation, increase clients flow of O2, Use head-tilt, chin-lift method to open the airway

answer

use head-tilt, chin-lift method to open airway

question

When providing preop teaching to patient scheduled for gastrectomy in 1 week, patient is anxious about upcoming surgery. Which of following is appropriate action for nurse to take? Sympathize with clients feelings, reassure, patient that surgery will go fine, change topic of discussion, provide concise factual information

answer

provide concise, factual information

question

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect to find? A: decreased muscle strength B: decreased gastric motility C: increased heart rate D: increased blood pressure

answer

A: decreased muscle strength

question

A nurse is assessing a patient who is receiving hydrochlorothiazide and notes that the patient is confused and lethargic. Which of the following lab values should the nurse report to the provider? A: sodium 128 mEq/L B: potassium 4.8 mEq/L C: Calcium 9.1 mg/dL D: Magnesium 2.0 mEq/L

answer

A: sodium 128 mEq/L

question

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has respirations of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3 -24 mEq/L. Which of the following actions should the nurse take? A: instruct the client to cough forcefully B: assist the client with ambulation C: provide calming interventions D: Discontinue the PCA

answer

C: provide calming interventions

question

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following finding is the priority for the nurse to assess? A: deep-tendon reflexes B: cardiac rhythm C: peripheral sensation D: bowel sounds

answer

B: cardiac rhythm

question

A nurse is caring for a client who is experiencing respiratory distress as a result of acute pulmonary edema. Which of the following actions should the nurse take first? A: assist with intubation B: initiate high-flow oxygen therapy C: administer rapid-acting diuretic D: administer morphine IV

answer

B: initiate high-flow oxygen therapy

question

A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following lab finding indicates that the fluid therapy has been effective? A: BUN 26 mg/dL B: serum sodium 138 mEq/L C: Hct 56% D: urine specific gravity 1.035

answer

B: serum sodium 138 mEq/L

question

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? A: "I will eat extra cheese because I can't drink milk." B: I need to avoid foods with vitamin D because I am allergic to milk." C: I will stop taking my calcium supplements if they irritate my stomach." D: "I will add broccoli and kale to my diet."

answer

D: "I will add broccoli and kale to my diet."

question

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? A: increased urine specific gravity B: hypoactive bowel sounds C: bounding peripheral pulses D: decreased respiratory rate

answer

C: bounding peripheral pulses

question

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PsO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3 -26 mEq/L. The nurse should interpret these lab values as which of the following imbalances? A: respiratory acidosis B: respiratory alkalosis C: metabolic acidosis D: metabolic alkalosis

answer

A: respiratory acidosis

question

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? A: sodium polystyrene sulfonate 30 g/day B: 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr C: bumetanide 8 mg/day D: 100 mL of dextrose 10% in water with 10 units of insulin

answer

B: 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr

question

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates and understanding of the instructions? A: "If my stockings feel tight, I'll just roll them down for a while." B: "I'll put on my elastic stockings at the first sign of swelling." C: "When I sit down to watch television, I'll be sure to put my feet up." D: "It's ok to cross my legs as long as it's for less than an hour."

answer

C: "When I sit down to watch television, I'll be sure to put my feet up."

question

A nurse is reviewing the laboratory data on four clients. Which of the following serum lab values should the nurse expect for the client who is experiencing 2+ pitting ankle edema? A: sodium 138 mEq/L B: Hematocrit 34% C: BUN 22 mg/dL D: Protein 9 g/dL

answer

B: Hematocrit 34%

question

A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the following IV fluid prescriptions should the nurse anticipate administering? A: 1,000 mL dextrose 5% in 0.9% sodium chloride B: 1,000 mL dextrose 5% in lactated ringer's C: 1,000 mL dextrose 10% in water D: 1,000 mL 0.225% sodium chloride

answer

D: 1,000 mL 0.225% sodium chloride

question

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? A: "I should conserve energy by limiting my physical activity." B: "I will wait until my pain is at least 6/10 before I use the PCA." C: "I will limit my daily fluid intake to 2 to 3 glasses." D: "I will use the incentive spirometer every hour."

answer

D: "I will use the incentive spirometer every hour."

question

A nurse is planning dietary teaching for a client who has hypermagnesemia. Which of the following food choices contains the most magnesium and is, therefore, a food the nurse should plan to instruct the client to avoid? A: hard boiled eggs B: cheddar cheese C: raw rhubarb D: raw spinach

answer

D: raw spinach

question

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? A: administer a hypertonic solution B: repeat the potassium level C: withold the medication D: monitor for parasthesia

answer

C: withold the medication

question

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respirations are 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? A: PaO2 B: PaCO2 C: Sodium D: Bicarbonate

answer

B: PaCO2

question

While reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? A: implement seizure precautions B: administer phosphate C: initiate diuretic therapy D: prepare the client for hemodialysis

answer

A: implement seizure precautions

question

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (select all that apply) A: administer IV fluids evenly over 24 hour. B: provide the client with a salt substitute C: assess for pitting edema D: encourage the client to rise slowly when standing up E: weigh the client every 8 hr

answer

A: administer IV fluids evenly over 24 hours. D: encourage the client to rise slowly when standing up E: weigh the client every 8 hr

question

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? A: skin turgor B: urine output C: weight D: mental status

answer

D: mental status

question

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? A: hyperactive DTR's B: increased bowel sounds C: drowsiness D: decreased blood pressure

answer

A: hyperactive DTR's

question

A nurse is reviewing the medical record of a client who has sdiabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? A: urine output of 30 mL/hr B: blood glucose of 180 mg/dL C: serum potassium of 3.0 mEq/L D: BUN 18 mg/dL

answer

C: serum potassium of 3.0 mEq/L

question

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? A: hypotension B: peripheral edema C: facial flushing D: hyperreflexia

answer

A: hypotension

question

A nurse is assessing a client who has a serum phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? A: hepatic failure B: abdominal pain C: slow peripheral pulsations D: increase in cardiac output

answer

C: slow peripheral pulsations

question

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? A: hyperactive DTR's B: orthostatic hypotension C: rapid, deep respirations D: strong, bounding pulse

answer

B: orthostatic hypotension

question

A nurse is caring for a client who has heart failure and is receiving furosemide. The client is experiencing irritability and anxiety. Which of the following actions should the nurse anticipate taking? A: offer whole grain wheat breads with meals B: recommend a potassium-sparing diuretic C: give potassium 20 mEq/L by IV bolus D: restrict oral fluids

answer

B: recommend a potassium-sparing diuretic

question

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following lab values supports this finding? A: sodium 152 mEq/L B: chloride 102 mEq/l C: magnesium 1.8 mEq/L D: potassium 6.1 mg/l

answer

D: potassium 6.1 mg/l

question

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? A: monitor the client's bowel sounds B: review the client's daily lab results C: auscultate the client's lungs D: palpate the client's peripheral pulses

answer

C: auscultate the client's lungs

question

A nurse is teaching an assistive personnel about standard precautions when caring for a client who has vancomycin resistant Enterococcus of the urine. Which of the following images of personal protection equipment should the nurse recommend the AP to use when caring for this client?

answer

The nurse should don clean gloves when caring for a client who has vancomycin-resistant enterococcus of the urine. This protects the nurse form coming in contact with bodily fluids contaminated with the bacteria of the client.

question

A nurse is teaching a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching?

answer

"Apply a warm compress to the lesions."

question

A nurse is planning discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse plan to include?

answer

"Monitor your body temperature and report any elevations promptly."

question

A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching.

answer

"Wash your genitalia using an antimicrobial soap"

question

A nurse is caring for a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate and elevation in which of the following laboratory tests?

answer

IgE (immunoglobulin E)

question

A nurse is preparing to administer a Mantoux skin test to a client. The nurse should inform the client that the purpose of a Mantoux skin test using purified protein derivative (PPD) is to do which of the following actions?

answer

Identify if a client has been infected with mycobacterium tuberculosis

question

A nurse in a provider's office is providing teaching to a client who has a recent diagnosis of rheumatoid arthritis and has a new prescription for naproxen tablets. Which of the following statements by the client requires further teaching?

answer

"I can take this medication with aspirin."

question

A nurse is caring for a client who has human immunodeficiency virus (HIV). The client asks the nurse, "should I tell my partner that I am HIV positive?" Which of the following statements should the nurse give?

answer

"It sounds like you are unsure what to say to your partner."

question

A nurse is teaching a client who has Raynaud's disease. Which of the following information should the nurse include in the teaching?

answer

Protect against the cold by wearing layers of clothing.

question

A nurse is reviewing the laboratory results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. The nurse should recognize that an increase in which of the following laboratory tests can indicate arthritis?

answer

Rheumatoid factor

question

A nurse is caring for a client who has systemic lupus erythematosus (SLE) and is concerned abouth the skin lesions on her face and neck. The client asks the nurse, "What should I do about these spots?" Which of following responses should the nurse give?

answer

"Apply moisturizer after bathing the lesions with warm water."

question

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE?

answer

Exercise

question

A nurse is caring for a client who is 2 days postoperative. Which of the following findings should alert the nurse that the client is developing an infection?

answer

Erythema at the incision site

question

A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest x-ray. The nurse should instruct the newly licensed nurse to take which of the following actions?

answer

Have the client wear a surgical mask

question

A nurse is providing discharge instructions to a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of the sexually transmitted infection (STI)?

answer

"I will bring my sexual partner in for treatment."

question

A nurse is teaching a client who has AIDS about the transmission of Pneumocystis jiroveci pneumonia (PCP). Which of the following information should the nurse include in the teaching?

answer

"PCP results from an impaired immune system."

question

A nurse is teaching a client about manifestations of an allergic reaction. The nurse should explain that histamine release causes which of the following reactions?

answer

Increased mucus secretion

question

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

answer

"I can expect this medication to turn my skin orange."

question

A nurse is caring for a client who is concerned about the possibility of contracting Lyme disease after receiving a tick bite. For which of the following early manifestations of Lyme disease should the nurse assess the client?

answer

A progressive, circular rash

question

A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect?

answer

Unilateral, localized, nodular skin lesions

question

A nurse is assessing a client who has Kaposi's sarcoma. Which of the following findings should the nurse expect?

answer

Reddish-purple skin lesions

question

A nurse is assessing a client who has systemic scleroderma. Which of the following findings should the nurse expect?

answer

Finger contractures

question

A nurse is teaching a client who has tested positive for an allergy to dust. The nurse should determine that the client understands how to reduce her exposure to this allergen when she states which of the following?

answer

"I will apply a mattress cover to my bed."

question

A nurse is teaching a client who has human immunodeficiency virus about how the virus is transmitted. Which of the following statements should the nurse include the teaching?

answer

"HIV can be transmitted to anyone who has had contact with the infected blood."

question

A nurse is teaching a client who has human immunodeficiency virus about the early manifestations of acquired immune deficiency syndrome. Which of the following statements should the nurse include in the teaching?

answer

"You can expect a persistent fever and swollen glands."

question

A nurse is providing teaching to a client who has a diagnosis of Hepatitis A. Which of the following statements by the client indicates an understanding of the teaching?

answer

"I should stop eating raw clams."

question

A nurse is caring for a client who is experiencing an acute exacerbation of rheumatoid arthritis. The nurse should anticipate that the client's affected joints will requires which of the following treatments?

answer

Heat paraffin therapy applied to the client's joints

question

A nurse is teaching a client who was recently diagnosed with Raynaud's disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching?

answer

I should not smoke.

question

A nurse is caring for client who has human immunodeficiency virus. Which of the following types of isolation should the nurse implement to prevent transmission of HIV?

answer

Standard Precautions

question

A nurse is providing discharge teaching to the partner of a client who has acquired immune deficiency syndrome. Which of the following statements by the client's partner indicate the need for further teaching?

answer

"I'll clean up blood spills immediately with hot water."

question

During a pain assessment, a nurse asks questions about the quality of an adult patient's pain. Which of the following statements by the patient refers to pain quality?

answer

My pain feels like I'm being stabbed by a knife This statement describes the quality of the patients pain

question

A nurse is caring for a patient just transferred from the PACU following an abdominal hysterectomy. The patient receiving PCA with IV morphine sulfate 2mg every 15 min with a 30mg/4hr lockout. One hour after the patient has returned to the unit, the patient tells the nurse that her pain is still unbearable. The nurse checks the PCA monitor and determines that the patient has made six attempts within the last hour. Which of the following actions should the nurse take after performing a pain assessment?

answer

Check the IV site and PCA pump for proper functioning The PCA delivery system should be assessed to determine if there is any malfunction in the delivery of the medication

question

A nurse is about to use the Wong-Baker FACES pain level. Which of the following should the nurse know in order to use this pain scale?

answer

Correct Answer: C- this scale is useful for adult patients who have cognitive impairments Rationale: This pain scale is used for young children as well as for adult patients who have cognitive impairments that create difficulty with descriptive and numeric pain scales.

question

A nurse is caring for a patient admitted to the emergency department with severe pain following a fall from a ladder. The initial assessment reveals long-term use of opioids for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question?

answer

Pentazocine (Talwin) Pentazocine is an opioid agonist/antagonist agent. This is not an appropriate medication for this patient because it may cause opioid withdrawal in a patient who is physically dependent on opioids

question

A nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery 2 hours ago. Which of the following should the nurse expect to be the same for both patients?

answer

Correct Answer: B- class of medication used to treat acute postoperative pain Rationale: Opioid analgesics are the class of medication used to treat acute postoperative pain;this is true regardless of the patient's cultural background.

question

A nurse is planning to administer a dose of intravenous morphine sulfate for a postoperative patient. Which of the following is a pain management protocol that should be used by the nurse in this situation?

answer

Correct answer: D- Have an opioid antagonist available during the administration Rationale: The nurse should assure that an opioid antagonist, such as naloxone (Narcan), is available, as well as equipment for providing respiratory support

question

A patient who has been experiencing frequent, severe migraine headaches tells the nurse she has heard that biofeedback is effective in treating migraines. The patient asks the nurse to describe how this pain-relief method works. The nurse should reply that biofeedback involves:

answer

Correct answer: A- measuring skin tension and using learned techniques to relieve pain Rationale- This describes biofeedback, which gradually helps the patient to identify physiological responses that can control migraines and other types of pain

question

a nurse is collecting a health history from a client. which of the following findings is the highest risk factor for the client developing bladder cancer?

answer

The client uses tobacco

question

A nurse is providing discharge teaching to a client who is postoperative following a right mastectomy for breast cancer. the client will be discharged with two jackson-pratt draining tubes. which of the following information should the nurse include in the teaching

answer

"the drainage tubes often are removed at the same time as the stitches"

question

A nurse is admitting a client who has multiple myeloma and a wbc count of 2,200/mm3. which of the following foods should the nurse prohibit the family members from bringing to the client.

answer

A fresh fruit basket

question

A nurse is providing preoperative teaching for a client who has colorectal cancer and is to undergo placement of a colostomy with a perineal wound. which of the following statements by the client indicates an understanding of the teaching.

answer

"i can have only liquids for 2 days before my surgery"

question

A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. which of the following factors places the client at a high increased risk for developing breast cancer?

answer

over 50 years of age

question

A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. which of the following information should the nurse include in the teaching? (select all that apply)

answer

"take you temperature twice each day" "it is important to always wear shoes" "avoid wearing tampons"

question

A nursing is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. which of the following explanation should the nurse provide?

answer

the chemotherapy medications act at different stages of cell division so more tumor cells are destroyed

question

a nurse is obtaining a health history from a client who has cancer the cervix. which of the following manifestations should the nurse expect?

answer

vaginal bleeding

question

a nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. which of the following client manifestations is an expected finding of peripheral neuropathy?

answer

tingling of the hands and feet

question

A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral iv infusion. the client reports pain at the insertion site and the nurse notes the fluid leaking around the catheter. which of the following actions should the nurse take first?

answer

stop the infusion

question

a nurse is providing discharge teaching to client following open radical prostatectomy. the client is going home with an indwelling urinary catheter. which of the following statements by the client indicates an understanding of the teaching?

answer

"i will change the catheter drainage bag once each week"

question

a nurse is providing teaching to a client who has cancer and is receiving external radiation therapy. which of the following statements by the client indicates an understanding of the teaching?

answer

"i need to protect the area from sunlight"

question

a nurse in an oncology is assessing a client who has early stage Hodgkin's lymphoma. which of the following findings should the nurse except?

answer

enlarged lymph nodes

question

A hospice nurse is providing education about palliative care to the partner of a client who has end-stage liver cancer. which of the following statements by the partner indicates an understanding of teaching?

answer

"i will continue to talk to him even when he's sleeping"

question

a nurse is collecting a health history from a client. which of the following findings is the highest risk factor for the client developing skin cancer?

answer

overexposure to sun light

question

a nurse is providing postoperative discharge teaching to a client following a pan hysterectomy for uterine cancer. which of the following information should the nurse include in the testing?

answer

"you might experience manifestations of menopause"

question

A nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer. which of the following intervention should the nurse include in the plan of care?

answer

change the collection pouch in the early morning.

question

a nurse is caring for a client who has lung cancer that has metastasized. which of the following findings indicates the client is developing superior vena cava syndrome?

answer

facial edema

question

a nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. which of the following precautions should the nurse minimize the adverse effects of thromboytopenia?

answer

remind the client to use an electric razor

question

A nurse is caring for a client who is receiving chemotherapy to treat cancer. which of the following adverse effects should the nurse anticipate from the chemotherapy?

answer

pancytopenia

question

A nurse is caring for a client who had a spontaneous abortion at 9 weeks of gestation. The nurse walk into the client's room and finds her crying uncontrollably. Which of the following is a therapeutic response? a. "It is hard to deal with a pregnancy loss. Here is the number of a local support group that you could attend." b. "When a pregnancy ends spontaneously, there is often something wrong with the fetus." c. "You are young and will have other children." d. "The best thing for you is to go home and try again."

answer

a. "It is hard to deal with a pregnancy loss. Here is the number of a local support group that you could attend."

question

A client with a suspected brain tumor is scheduled for a CAT scan. When the procedure is explained, the client expresses fear of entering the enclosed space of the scanner. Which of the following responses by the nurse is appropriate? a. "The procedure only takes a few minutes to complete." b. "Let me review some breathing exercises with you." c. "I can ask the doctor to prescribe a sedative for you." d. "This is a routine test so there is no reason to worry."

answer

b. "Let me review some breathing exercises with you."

question

An adolescent client is just diagnosed with testicular cancer. When the nurse asks the client a question, he angrily spits in there nurse's face. Which response by the nurse would be appropriate? a. "I will come back to change your linens when you are feeling better." b. "Your parents call every day and I will have to tell them about your behavior." c. "The nurses will not want to take care of you if you treat us this way." d. "That behavior makes me very angry, and I will not tolerate it."

answer

d. "That behavior makes me very angry, and I will not tolerate it."

question

A nurse is caring for a client with diabetes who is to receive hemodialysis. The client says to the nurse, "I don't even know why I'm doing this. There is no cure." Which of the following is an appropriate nursing response? a. "It sounds as though you have given up." b. "Dialysis will help you live longer." c. "You shouldn't complain. You are fortunate to have this option available to you." d. "There is always a chance that, through research, a cure will be found."

answer

a. "It sounds as though you have given up."

question

After teaching a client how to perform personal colostomy care prior to discharge, the client says to the nurse, "I don't think that I am going to be able to take care of this myself." Which of the following is an appropriate response by the nurse? a. "In time, you will become better at this than I am." b. "Don't worry about it. Most clients feel like that at first." c. "What part of the colostomy care are you having trouble with?" d. "A home health nurse will be visiting you, so if you have any problems, this nurse can help you."

answer

c. "What part of the colostomy care are you having trouble with?"

question

A nurse is caring for an adolescent client in the community health center who has a positive HCG test. She tells the nurse, "I don't think I can tell my parents that I am pregnant." Which of the following is an appropriate response? a. "Do you think you may terminate the pregnancy?" b. "Give them a chance; your parents will understand." c. "You must tell your parents as soon as possible." d. "You seem frightened to tell you parents."

answer

d. "You seem frightened to tell you parents."

question

A nursing assistant is caring for a client who is unconscious. While bathing the client, the nursing assistant describes the weather and chats about current events. The client's wife says to the nurse, "Why does the nursing assistant talk to my husband? He's unconscious." The nurse should respond by stating, a. "I'll speak to the nursing assistant about it. Your husband should not be stimulated like that." b. "I'm really not sure why the nursing assistant is talking to him. Perhaps you should ask." c. "Clients like your husband, who are unconscious, may still be able to hear." d. "The nursing assistant must not realize that your husband cannot hear."

answer

c. "Clients like your husband, who are unconscious, may still be able to hear."

question

A nurse is assessing a client. For which of the following client statements should the nurse use a close-ended question? a. "I wonder what the world would be like without me." b. "I'm bleeding." c. "I am just so sad today." d. "I don't like the way that person is looking at me."

answer

b. "I'm bleeding."

question

An emergency department nurse takes a telephone call from a client who reports "I have just taken 100 Elavil tablets to kill myself." The client is crying and says, "I want to die. I have no reason to live." Which of the following responses by the nurse is appropriate? a. "Please stay on the phone with me so we can talk about your feelings." b. "Why do you think you have no reason to live?" c. "How do you feel about what you have just done?" d. "I'm sure things are not as bad as they seem to you now."

answer

a. "Please stay on the phone with me so we can talk about your feelings."

question

When approached by a nurse, a client with major depressive disorder says, "Don't bother me. Find someone else to talk with. I don't have anything worth saying. go find someone you can help." Which of the following is a therapeutic response? a. "I have the feeling that I upset you. Don't you want to talk to me?" b. "I would like to sit quietly with you for a while." c. "I'm assigned to take care of you, so I intend to spend time with you." d. "OK. I'll go now and be back in a half-hour."

answer

b. "I would like to sit quietly with you for a while."

question

A client who has just been diagnosed with cancer tells the nurse, "I would rather be dead than go through the treatment for cancer." Which of the following is an appropriate response by the nurse? a. "That wouldn't be fair to your family, would it?" b. "How can you feel that way when you have so much to live for?" c. "Why don't you talk to your doctor about your feelings?" d. "What is it about the cancer treatment that concerns you?"

answer

d. "What is it about the cancer treatment that concerns you?"

question

An older adult client is admitted to the hospital for surgery for a fractured hip. The client says to the nurse, "I guess I've lived long enough, and it's my time." Which is the therapeutic response by the nurse? a. "The doctors and nurses are going to take good care of you while you are here. There's nothing to worry about." b. "This is just a minor setback. You will be on your feet in no time." c. "You are in really good shape for your age." d. "You feel that your life is ending?"

answer

d. "You feel that your life is ending?"

question

An adult child has come to take a parent home from the hospital following a colon resection. The adult child tells the nurse, "I don't know how I am going to take care of my parent now." Which of the following is an appropriate response? a. "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask then." b. "Your parent has been taught to care for the colostomy independently." c. "What part of your parent's care you concerned about?" d. "It is quite simple. I'll make sure that the colostomy bag is clean before your parent leaves."

answer

c. "What part of your parent's care you concerned about?"

question

A nurse is caring for a client who is a victim of rape. The client says to the nurse, "I feel so humiliates. I don't want anyone to know what happened to me." Which of the following is a therapeutic response? a. "You should not be so hard on yourself. It was not your fault." b. "Are you saying that you are fearful about what others will think?" c. "This is a normal feeling after what has happened to you." d. "The best thing for you to do is to put this out of your mind and think positive thoughts."

answer

b. "Are you saying that you are fearful about what others will think?"

question

A nurse is caring for a client with leukemia. The client says to the nurse, "The doctor told me that my condition is too severe to be treated successfully, and I am no longer a candidate for chemotherapy. I guess I don't have long to live." Which of the following responses by the nurse is therapeutic? a. "Having a positive attitude can help you." b. "Let's talk about how you are feeling about this information." c. "Have you considered getting a second opinion?" d. "How long do you feel that you have left to live?"

answer

b. "Let's talk about how you are feeling about this information."

question

A client is scheduled for a lumbar puncture to rule out bacterial meningitis and tells there nurse that he is fearful of becoming paralyzed from the needle being placed in the spinal column. Which of the following is a therapeutic response by the nurse? a. "The danger of hitting the spinal cord is minimal. You will be lying very still with you back in an arched position." b. "What concerns you the most about this procedure?" c. "The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends." d. "Your doctor is very skilled in this procedure and it's highly unlikely that a mistake would be made."

answer

c. "The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends."

question

When nurse is making morning rounds, a client says, "I almost died last night." Which of the following is a therapeutic response by the nurse? a. "Are you feeling okay now?" b. "Clients do have dreams that they die when they are hospitalized." c. "That must have been frightening for you. Tell me more about it." d. "You made it through the night."

answer

c. "That must have been frightening for you. Tell me more about it."

question

A nurse is caring for an older adult client who dies during the night with his wife at this side. The wife says to the nurse, "I can't believe he's gone." Which of the following is a therapeutic response by the nurse? a. "It must be hard to accept that this has happened." b. "His suffering is over now. He is in a better place." c. "I know how you are feeling. I just lost my father." d. "He lived a really long and full life."

answer

a. "It must be hard to accept that this has happened."

question

A nurse is caring for a client following a spontaneous abortion. The client is cry8ing and says to the nurse, "I tried to get pregnant for so long. My husband and I wanted this baby so much. Now what will we do?" Which response by the nurse is appropriate? a. "There are many options available, such as genetic counseling." b. "You can have another baby soon." c. At this time, your husband's support is really important." d. "Are you feeling overwhelmed?"

answer

d. "Are you feeling overwhelmed?"

question

A nurse is caring for a 13 y.o who is admitted for an emergency appendectomy. While doing the preoperative teaching, the client asks, "Will I have a large scar from the surgery?" Which of the following is a therapeutic response? a. "It will be small enough so it won't show when you're wearing a bathing suit." b. "That isn't our biggest concern right now. Let's get you well first." c. "Don't worry. Scars fade a lot in just a few months." d. "Did your friends tell you that you will have a big scar?"

answer

a. "It will be small enough so it won't show when you're wearing a bathing suit."

question

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure?

answer

Protect the client's head R: The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. the client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.

question

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dyreflexia?

answer

Report of headache R: Autonomic dysreflexia is a neurological emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

question

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insidious (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI?

answer

Specific gravity R: Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.

question

A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurologic status?

answer

Level of consciousness R: The nurse should apply the urgent vs. non urgent priority-setting framework. Using the framework, the nurse should consider urgent needs the priority because they pose more of a risk to the client. The nurse might also use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify the most urgent finding. Therefore, the priority assessment is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurological status.

question

A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions?

answer

I will avoid bending over R: The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can result in intraocular hemorrhage.

question

A nurse is reviewing the medical history of a client who is scheduled for magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure?

answer

The client has a pacemaker R: An MRI uses strong magnets and radio waves that are evaluated using computer technology to view three-dimensional images of the body. Since an MRI is magnetically generated, it is not indicated for use in the presence of certain medicinal implants. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the sting magnetic force can interfere with these devices obscure surrounding anatomical structures.

question

A nurse assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations?

answer

Cheyne-Stokes R: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

question

A nurse is reviewing the laboratory result of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect?

answer

Elevated protein R: An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.

question

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations?

answer

Severe eye pain R: Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision headache, brow pain, and nausea and vomiting.

question

A nurse is teaching a client who has a diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding the teaching?

answer

"An aura is sensory warning that a seizure is imminent." R: An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.

question

A nurse is assessing a client who has a closed head injury and received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

answer

The client's serum osmolarity is 310 mOsm/L R: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 most/L is desired. A decrease in cerebral edema should result in a decrease in ICP.

question

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. The nurse should include in the teaching that which of the following is an adverse affect of LASIK surgery?

answer

Dry eyes

question

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? (Select all that apply)

answer

Driving can be dangerous due to loss of peripheral vision Laser surgery can help reestablish the flow of aqueous humor

question

A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority?

answer

Dysphagia

question

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS?

answer

Weakness of the distal extremities

question

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching?

answer

"You should avoid reading for 1 week."

question

A nurse is providing teaching to a family of a client who has stage II Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching?

answer

Limit choices offered to the client

question

A Nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions?

answer

Semi - Fowler's

question

A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

answer

Widened pulse pressure

question

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching?

answer

Darken the lights

question

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect?

answer

Difficulty with speech

question

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?

answer

Instill diluted alcohol solution into the ear after swimming

question

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?

answer

Feeling of fullness in the ear

question

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect?

answer

Swelling behind the affected ear

question

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample?

answer

The client rigidly extends his arms

question

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching?

answer

Avoid sudden movements

question

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching?

answer

A TIA can precede an ischemic stroke

question

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect?

answer

Weakness of the lower extremities

question

A nurse in an acute care facility is preparing to admit a client who has myasthenia graves. Which of the following supplies should the nurse place at the client's bedside?

answer

Oral-nasal suction equipment

question

A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement?

answer

Dysphagia

question

The goal of surgical asepsis is to

answer

Create and maintain a micro organism free environment

question

You are about to open a sterile pack. place the following steps in the proper sequence for opening the sterile pack

answer

Open the flap furthest from your body first, followed by the side flaps, and finally the flap closest to your body. Any other would risk your gown coming into contact with the sterile wrap or your arm reaching over the sterile field both of which would result in contamination

question

When opening a sterile pack, which of the following actions would compromise the sterility of the instruments and supply inside the pack

answer

Holding the sterile pack below the waist or table level Anything below waist/table level not sterile

question

A nurse preparing to flush and change the dressing on a patient central venous catheter and should understand that the primary purpose for them wanting this intervention using surgical asepsis is to

answer

Control the introduction of micro organisms at the catheter site

question

Which area of the hands require special attention before you begin a surgical hand scrub

answer

The area under the finger nail

question

While waiting for a surgical procedure to begin, how do you position your hands and arms

answer

With your hands clasped together in front of your body above waist level

question

A nurse donning sterile gloves knows that the proper technique for gloving the dominate hand prevents contact between the contaminated hand and the non-contaminated gloves because

answer

The inner edge of the cuff will lie under the skin and thus will not be sterile

question

Prior to entering the surgical scrub area, which of the following personal protective equipment items to the team members don

answer

Protective eyewear, hair cover, mask, shoe covers Gown considered sterile and not donned til after hand scrub and dry

question

During surgical handwashing, the hands are kept to

answer

Encourage water and soap to flow away from the clean hands

question

When donning sterile gloves using the "open glove method, it is important remember

answer

Grasp Only the inside of the glove with your ungloved hand

question

A nurse preparing a sterile field knows that the field have been contaminated when

answer

A cotton ball dampened with Sterile normal saline is placed on the field, the nurse turns to address the patient's question concerning the procedure, the procedure is postponed for 30 minutes to accommodate the patient

question

A nurse is abt to transfer to a chair a patient who has a weak left leg...

answer

aligning the nurse's knees w/the pt's knees just before transfer

question

A nurse is observing an assistive personnel (AP) who is using a mech lift with a hammock sling to transfer a pt from the bed to a chair. The nurse should intervene if the AP

answer

leaves the bed in the lowest position throughout the procedure

question

A nurse stands facing a pt to demonstrate active range of motion exercises. Which of the following should the nurse do when demonstrating hyperextension of the hip?

answer

Move the leg behind the body

question

A nurse ambulates an unsteady patient, the pt becomes light-headed and begins to fall. Which of the following interventions by the nurse is appropriate in this situation?

answer

Extend one leg and allow the pt to slide down it

question

A nurse is performing a physical assessment on a patient and instructs the pt to stat with his feet together and arms at his sides. The purpose of positioning the pt in this manner is to test which of the following?

answer

Balance

question

A nurse in the emergency department is caring for a pt who has a knee injury. The pt will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include when discharging this pt?

answer

hold the cruthces on the unaffected side when preparing to sit in a chair

question

A nurse is caring for a hospitalized pt who is performing active range of motion exercises. Which of the following body movements should indicate the nurse the patient has full range of motion of the shoulder?

answer

flexing the shoulder by raising the arm from a side position to a 180* angle.

question

146

answer

A nurse is counseling a client who is 48 years old and is about to start a physical activity program. Calculate the upper range of the clients target heart rate. To do this subtract pts age from 220. Then obtain target HR as 60% to 85% of her max HR

question

School Age - 6 to 12 years

answer

RN is giving a presentation at a family oriented recreation center about getting children involved in physical activities. The nurse should explain that children develop exercise related abilities and preferences during what stage?

question

Exercise with a companion or group, Consider a regular program of walking, Get up and stretch regularly through out the day

answer

A nurse is presenting a program on safe and effective exercise for older adults with rheumatoid arthritis. What should she recommend for this client population? (3)

question

A single calorie fuels about 25 steps of walking

answer

A RN in encouraging an older adult client to invest in a pedometer to track the amount of walking she does each day and to challenge herself to increase her activity level gradually each day. What should the nurse say the benefit of walking is?

question

Cancer, Liver Disease

answer

A fitness trainer is giving a presentation on weight training is pointing out the dangers of using androgenic anabolic steroids to build muscle strength. What is an adverse outcome of using these products for this purpose?

question

Sustain the target range for at least 20 minutes

answer

A nurse is teaching a client who is starting an exercise program to calculate his target heart rate. What should the nurse instruct him to do?

question

soft

answer

A tai chi master is teaching an introductory session on the basics of this health-promoting activity. He explains that "to boost energy without causing stress, a tai chi movement are"

question

Anemia and Heart Failure

answer

A RN is giving a presentation at a senior community center about factors that affect the ability to engage in physical activity. The nurse should explain that these two following disorders specifically affect exercise endurance.

question

Working out on an elliptical trainer

answer

A RN is counseling a client who has multiple risk factors for osteoporosis. What following exercise strategies should the RN recommend to help the client maintain bone density?

question

Choose rhythmic exercise of large muscle groups

answer

Using the FITTE factor, what should a nurse recommend as a general fitness and health guideline for clients who wish to improve their physical activity level?

question

A client is admitted for treatment of a malignant melanoma of the left upper leg. Initially, the nurse plans to prepare the client for which of the following?

answer

Surgical excision

question

A client arrives at the emergency department with a snakebite of the lower left leg. What should the nurse do?

answer

Immobilize the limb below the level of the heart

question

A client comes to the clinic reporting skin lesions. The nurse assesses the lesions and notes that they are 0.5 cm in size, elevated and solid, with very distinct borders. Based on the findings, which of the following should the nurse document the presence of?

answer

Papules

question

A client is being discharged after surgical excision of a malignant melanoma. Which statement indicates to the nurse an understanding of the danger of ultraviolet light?

answer

"I'll reapply my sunscreen every 2 hours when I'm out in the sun."

question

A client is hospitalized with extensive full thickness burns of both legs. In response to the client's questions, the nurse explains that the acute phase of burn injury, biological dressings are used primarily to

answer

promote healing

question

A client with an un-diagnosed lesion on his right hand is concerned about the possibility of skin cancer. When the client asks what the most serious type of skin cancer is, the nurse responds based on knowledge that most malignant tumors are

answer

melanomas

question

A client is about to undergo a biopsy of a 6-mm, bluish-red lesion. In addition to a thorough skin examination, the nurse knows the most critical assessment to be made at this time is the status of the client's

answer

regional lymph nodes

question

To promote healing for a client with a large wound healing by secondary intention, the nurse recommends a diet high in protein and which of the following?

answer

Vitamin C

question

A client is brought to the emergency department with severe frostbite. The nurse assessing the client knows the burned appearance of frostbitten tissue is a direct result of which of the following?

answer

Red blood cell aggregation with microvascular occlusion

question

When assessing a bedridden client admitted from home, the nurse notes a shallow crater in the epidermis of the client's sacral area. The nurse documents the presence of a pressure ulcer, noting that it is stage

answer

II

question

A nurse is caring for a client who sustained a thermal burn 4 days ago. Most of the burns are superficial partial-thickness and deep partial-thickness, but there are large areas of full-thickness burns as well. Which assessment finding should the nurse report to the client's provider?

answer

Temperature of 39.1 C (102.4 F)

question

A client is prescribed 1% silver sulfadiazine cream (Silvadene) to be applied to her burn wounds twice daily. After 3 days of treatment, the nurse suspects an adverse reaction to the medication when the client develops which of the following?

answer

Leukopenia

question

A client with a large healing deep partial-thickness burn of the forearm and wrist is being discharged from the burn treatment clinic. Which of the following should the nurse tell the client to avoid for a year?

answer

Exposure to the sun

question

A nurse plans to teach a group of young adults health promotion techniques to reduce the risk of skin cancer. Which of the following should the nurse include?

answer

Avoid exposure to the midday sun.

question

When targeting a group of clients for health teaching, the nurse should be aware that which group is at greatest risk for developing malignant melanoma?

answer

Clients who are fair-haired, fair-skinned, and of Celtic descent

question

A nurse is bathing a client with burn injuries in a hydrotherapy tub. The nurse limits the client's hydrotherapy session to no more than 30 min to

answer

minimize sodium loss

question

A client has had a basal cell carcinoma removed by surgical excision. The nurse instructs the client to watch for indications of potential malignancy in other moles, including which of the following?

answer

Ulceration

question

A nurse teaches a wheelchair bound client to reduce the risk of pressure ulcer formation by instructing the client to do which of the following?

answer

"Shift your weight in the wheelchair every 15 min."

question

A 15 year old girl was admitted with burns of her face and hands. Which statement indicates to the nurse that the client has adapted to her changed body image?

answer

"Can I go with my family to the visitor's lounge."

question

A nurse on a surgical unit is caring for four clients with healing wounds. Which of the four clients' wounds should the nurse anticipate will heal by primary intention?

answer

Gastroplasty incision

question

A nurse is caring for a patient with type 1 diabetes mellitus who reports feeling anxious and having palpitations. The glucometer reads 50mg/dL. The nurse should give the patient

answer

6 oz of apple juice

question

A nurse is reviewing the results of routine laboratory tests performed as part of a 50-year-old woman's annual physical examination. The nurse notes a blood glucose level of 120 mg/dL. The nurse should interpret this as an abnormal result for a

answer

fasting blood glucose measurement

question

A nurse is documenting the plan of care for a patient who has type 1 diabetes mellitus that has remained unstable despite conventional insulin therapy. The provider has explained to the patient that the new plan will incorporate the use of a long-acting insulin preparation. The nurse should anticipate seeing a prescription for the addition of which of the following insulin preparations?

answer

insulin glargine (Lantus)

question

A nurse is teaching a patient newly diagnosed with type 2 diabetes mellitus about the biguanide she has been prescribed, which is metformin (Glucophage). The nurse should explain that this type of medication acts by

answer

reducing hepatic glucose production

question

A nurse is reviewing self-administration of insulin using a prefilled pen administration system with a patient who started using the pen system the previous week. The patient asks what he can do to reduce injection pain. The nurse should suggest that he

answer

keep the pen at room temperature for a few minutes

question

A nurse is teaching a patient newly diagnosed with type 1 diabetes mellitus how to check blood glucose levels. Which of the following is the appropriate instruction for transferring the patient's blood to the reagent portion of the test strip/monitor in most situations?

answer

hold the test strip next to the blood on the patient's fingertip

question

A nurse is instructing a patient about using an insulin pump should explain that the risk of diabetic ketoacidosis (DKA) increases with the use of a pump because

answer

the tubing could be become occluded

question

A nurse is teaching a patient with type 1 diabetes mellitus who is beginning a complex regimen of glycemic control about the properties and actions of the various types of insulin. The nurse should explain that the type of insulin that has an onset of 60 to 120 minutes, peaks in 6 to 14 hours, and has a duration of 16 to 24 hours is

answer

neutral protamine hagedorn NPH insulin

question

With OSA, oral structures relax during sleep and block the air flow

answer

A nurse is teaching a client who is undergoing a sleep study to confirm obstructive sleep apnea. What should the nurse include in the teaching?

question

emotional stress

answer

A nurse should share with a group of attendees at a sleep disorders workshop that the primary cause of short-term sleep disturbances is....

question

excessive daytime sleepiness

answer

A nurse is talking with a parent whose teenage boy is undergoing a sleep study. The parent asks the nurse about narcolepsy. The nurse should explain that the most common manifestation of narcolepsy is..

question

Sleep on their side, Avoid alcohol, Do not smoke

answer

A nurse is talking with a client who is about to begin using a continuous positive airway pressure device to treat obstructive sleep apnea. Which of the following instructions should the nurse also recommend for the clients who have sleep apnea?

question

12

answer

Between the ages of 3 - 6 years, a child needs an average of how many hours of sleep per night?

question

Antidysrhythmics

answer

Pt reports having difficulty sleeping. What type of medication should alert the nurse to the possible adverse effect of insomnia?

question

Being awake when body temperature peaks

answer

A nurse is talking with coworkers about changing a rotating shift policy. She explains the importance of circadian synchronization for optimal health, and well being. What is an example of this phenomenon?

question

develop a positive outlook about sleep

answer

SN is giving a presentation about treating sleep disorders as part of a continuing education program. She should explain that the purpose of using cognitive therapy to treat insomnia is to help clients....

question

Install gates to block the children's access to stairways

answer

A nurse is talking with a patient who has two young children who sleepwalk. What is the priority for the nurse to emphasize with this patient?

question

Slowed Reflexes, Loss of Fine Motor Control, Blurred Vision, Cardiac Dysrhythmias

answer

RN is preparing a "lunch and learn" presentation for a group of coworkers about sleep deprivation. She should explain that people who are sleep deprived can develop what manifestations?

question

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?

answer

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

question

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?

answer

Calf swelling

question

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?

answer

A nurse asks a nurse from another unit to assist with her documentation.

question

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?

answer

Remove the stockings at least once per shift.

question

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

answer

Auscultate lung sounds

question

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?

answer

"I can concentrate best in the morning."

question

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

answer

Have the client stand with her arms at her side and her feet together.

question

A nurse is planning an deduction 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?

answer

Allow extra time for the client to respond to questions.

question

A nurse is teaching an older 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?

answer

Walking briskly

question

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?

answer

Erythema on pressure points

question

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?

answer

Gently shake the container of medication prior to administration.

question

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?

answer

Check the client for injuries

question

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?

answer

Reassure the client that this is an expected response to grief.

question

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 routine screening. What does that involve?" Which of the following responses should the nurse make?

answer

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

question

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?

answer

"Use the complete name of the medication magnesium sulfate."

question

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

answer

Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene.

question

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

answer

Have family members wear a gown and gloves when visiting.

question

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

answer

Wrap monitoring cords with stockinette and tape them in place.

question

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

answer

Use progressive relaxation techniques at bedtime.

question

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.

answer

?

question

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?

answer

Initiate an enteral feeding through a gastrostomy tube.

question

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?

answer

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

question

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

answer

Pupil clarity Visual fields Visual acuity

question

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?

answer

The client holds the cane on the stronger side of her body.

question

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

answer

Narrowed arterial lumen

question

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

answer

Airborne

question

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?

answer

Flush the tube with 15 mL of sterile water.

question

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

answer

Cleanse the wound from the center outward.

question

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

answer

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

question

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?

answer

Skin blanching

question

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?

answer

Situation, background, assessment, and recommendation (SBAR)

question

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?

answer

Contact precautions

question

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?

answer

Assist the client to an upright position.

question

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

answer

Potassium 5.4 meq/L

question

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?

answer

Stand close to the cabinet when lifting it.

question

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?

answer

The dose

question

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

answer

(fried egg)

question

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?

answer

"What could I have done to deserve this illness?"

question

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

answer

Withhold the blood transfusion.

question

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?

answer

Select a suction catheter that is half the size of the lumen.

question

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?

answer

Have the client use a trapeze bar when changing position.

question

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?

answer

Role overload

question

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?

answer

"Are you able to help with your hygiene care?"

question

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?

answer

Acupuncture

question

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?

answer

"I'll check the wires and cables on my TV to make sure they are in good working order."

question

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?

answer

Ask another nurse to observe the medication wastage.

question

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

answer

0.3 mg

question

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?

answer

"This is a difficult time, but we are helping each other through this."

question

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?

answer

Use a clock pattern to describe food on the client's plate.

question

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?

answer

?

question

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?

answer

"The pain is like a dull ache in my stomach."

question

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

answer

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

question

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?

answer

Rapid heart rate

question

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?

answer

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

question

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (round)

answer

8 mL/hr

question

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?

answer

Tell the client to keep the head of the bed elevated at least 30 degrees.

question

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?

answer

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

question

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?

answer

Subtract the amount of irrigant used from the client's urine output.

question

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?

answer

Place the client's arm in a dependent position.

question

A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?

answer

Semi-fowler's

question

A nurse is administering 1L 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?

answer

decrease in heart rate

question

A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?

answer

1. A 16 yo client who is married 2. a 27 yo who has schizophrenia 3. an adoptive parent who brings in his 8 yo son 4. a 17 yo mother who brings in her toddler.

question

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?

answer

Apply intermittent suction when withdrawing the catheter.

question

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

answer

Avocados

question

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?

answer

assess the client for orthostatic hypotension

question

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

answer

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

question

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?

answer

talk directly to the client, instead of the interpreter, when speaking

question

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?

answer

bladder scan shows 525mL of urine

question

a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?

answer

wash her hands before and after contact with the client

question

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

answer

Compare prescriptions with medications the client received during hospitalization.

question

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?

answer

Thread the IV catheter so that the hub rests at the insertion site.

question

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?

answer

Cheddar cheese

question

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?

answer

1. Check the cord routinely for frays or tearing 2. consider purchasing a generator for power backup 3. observe for signs of hypoxia

question

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

answer

Check the IV tubing for obstruction

question

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

answer

evaluate electrolytes

question

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?

answer

Insert the IV catheter without using a tourniquet

question

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?

answer

Second intercostal space at the left sternal boarder

question

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?

answer

elevate the head of the client's bed

question

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

answer

"We can talk about advance directives, and I can also give you some brochures about them."

question

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?

answer

"Is your pain sharp or dull?"

question

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?

answer

breath sounds

question

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?

answer

albumin level of 3g/dL

question

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?

answer

bruises on the arms in various stages of healing

question

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 vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

answer

Notify the nursing manager

question

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

answer

Swelling and coolness are observed at the IV site

question

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?

answer

evacuate the client

question

A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

answer

"We need to document the exact medication you were taking because you might be allergic to it."

question

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?

answer

a client who has asthma

question

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?

answer

Pad the client's wrist before applying the restraints.

question

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

answer

Make sure two fingers can fit under the sleeves.

question

A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The nurse should set the pump to deliver how many mL/Hr?

answer

107mL/hr

question

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?

answer

Make sure the client wears a mask when outside her room if there is construction in the area?

question

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

answer

administer the medication with the needle at a 45 degree angle

question

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?

answer

examine personal values about the issue

question

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

answer

8 oz ice chips

question

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?

answer

practice sessions

question

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

answer

use tracheostomy covers when outdoors

question

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?

answer

"We will apply oxygen through a tube in your nose"

question

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?

answer

regulate oxygen via nasal cannula at a flow rate no more than 6l/min

question

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)?

answer

1. Assist the client with a partial bed bath 2. Measure the client's BP after the nurse administers an antihypertensive medication 3. use a communication board to ask what the client wants for lunch

question

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?

answer

The nurse opens the sterile field on a wet surface

question

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?

answer

an uneven shape

question

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?

answer

"I am available to talk if you should change your mind."

question

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

answer

wrap blankets around all four side rails

question

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

answer

abdominal cramping

question

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?

answer

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

question

A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds.

answer

normal breath sounds

question

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?

answer

The family member washed out the feeding bag with warm water once every 24 hours.

question

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?

answer

An x-ray shows the end of the tube above the pylorus

question

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?

answer

Clean sutures along the incision site.

question

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

answer

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask the client's family members if they would like to view the body 5. place a name tag on the body

question

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

answer

tap just bellow the kneecap

question

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action?

answer

administer pain medication 45 min before changing the client's dressing

question

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?

answer

"when descending stair, I will first shift my weight to my right leg."

question

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

answer

"It might help me to listen to music while im lying in bed."

question

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

answer

droplet

question

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?

answer

during the admission process

question

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?

answer

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

question

A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document?

answer

"client was found lying on floor."

question

A nurse is caring for a patient with behind the ear hearing aid.

answer

remove before shower

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