ATI Practice Exam – Flashcards
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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 indication that the treatment was successful? a. Decrease in heart rate b. Decrease in capillary refill c. Increase in hematocrit d. Increase in respiratory rate
answer
a. Decrease in heart rate
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A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legally witness? (Select all that apply) a. Teacher bringing in a 7 year old student b. 16 years old client who is married c. 27-year-old client with schizophrenia d. adoptive parent bringing in their child e. 17-year-old mother bringing in her toddler
answer
B, C, D, and E
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A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a. Apply intermittent suction when withdrawing the catheter b. Insert the suction catheter while the client is swallowing c. Place the catheter in a location that is clean and dry for later use d. Hold the suction catheter with her clean, nondominant hand
answer
a. Apply intermittent suction when withdrawing the catheter
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A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet? a. Beef liver b. Shellfish c. Egg yolks d. Avocados
answer
d. Avocados
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A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a. Rock the client to a standing position b. Pivot on the foot that is farthest from the chair c. Assess the client for orthostatic hypotension d. Apply a gait belt to the client
answer
c. Assess the client for orthostatic hypotension
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A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? a. Carry a client's soiled linens out of the room in a mesh linen bag b. Place a client who has TB in a room with negative pressure airflow c. Provide disposable plates and utensils for a client who is HIV-positive d. Dispose of a client's blood saturated dressing in a trash bag inside a second trash bag
answer
b. Place a client who has TB in a room with negative pressure airflow
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A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? a. Talk directly to the client, instead of the interpreter, when speaking b. Use a family member as the interpreter c. Make sure that the interpreter has a college degree d. Avoid asking the client personal questions through the interpreter
answer
a. Talk directly to the client, instead of the interpreter, when speaking
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A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation? a. Urine has an unusual color b. Urine specific gravity is 1.035 c. Bladder scan shows 525 mL of urine d. Urine is positive for ketones
answer
c. Bladder scan shows 525 mL of urine
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A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? a. Have the client wear a mask when receiving visitors b. Wash her hands before and after contact with the client c. Assign the client to a room with negative-pressure airflow d. Instruct all visitors to limit their time with the client
answer
b. Wash her hands before and after contact with the client
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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? a. Seal unused hospital medications in a plastic bag b. Evaluate the client's ability to self-administer the medications c. Report an identifier discrepancy to the Joint Commission d. Compare prescriptions with medications the client received during hospitalization
answer
d. Compare prescriptions with medications the client received during hospitalization
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A nurse is preparing to insert an IV catheter into a client's arm prior to initiative IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a. Thread the IV catheter so that the hub rests at the insertion site b. Shave excess hair from around the insertion site c. Cleanse the site with hydrogen peroxide before IV catheter insertion d. Palpate the site carefully just before inserting the IV catheter
answer
a. Thread the IV catheter so that the hub rests at the insertion site
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A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? a. Oat cereal b. Refried beans c. Peanut butter d. Cheddar cheese
answer
d. Cheddar cheese
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A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply) a. Check the cord routinely for frays or tearing b. Keep the unit at least 4 feet away from a gas stove c. Consider purchasing a generator for power backup d. Observe for signs of hypoxia e. Select synthetic clothing and bedding
answer
A,C,D
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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 hours. Which of the following actions should the nurse take? a. Reposition the client b. Document the client's IV intake in the medical record c. Request a new IV fluid prescription d. Check the IV tubing for obstruction
answer
d. Check the tubing for obstruction
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A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? a. Reduce dietary sodium b. Administer a loop diuretic c. Evaluate electrolytes d. Restrict intake of oral fluids
answer
c. Evaluate electrolytes
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A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? a. Insert the IV catheter into the back of the client's hand b. Massage the area of venipuncture site vigorously c. Insert the IV catheter without using a tourniquet d. Apply traction to the skin proximal to the insertion site to stabilize the vein
answer
c. Insert the IV catheter without using a tourniquet
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A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. What location should the nurse place the bell? a. Second intercostal space at the left sternal border b. Fourth intercostal space at the right sternal border c. Fourth intercostal space at the left sternal border d. Second intercostal space at the right sternal border
answer
a. Second intercostal space at the left sternal border
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A nurse is caring for a client who has terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which action should the nurse take? a. Turn the client every 4 hours b. Elevate the head of the bed c. Hold oral care d. Increase the room temperature
answer
b. Elevate the head of the bed
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A nurse is caring for a client who has terminal diagnosis and whose health is declining. The client requests information about advance directives. Which response should the nurse make? a. "We can talk about advance directives, and I can also give you some brochures about them" b. "You should set up a time to talk with your provider about that" c. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" d. "Why do you want to discuss this without your partner here to plan this with you?
answer
a. "We can talk about advance directives, and I can also give you some brochures about them"
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A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? a. Is your pain constant or intermittent? b. What would you rate your pain on a scale of 0-10? c. Does the pain radiate? d. Is your pain sharp or dull?
answer
d. Is your pain sharp or dull?
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A nurse is giving a change of shift report about a client he admitted earlier that day who has pneumonia. Which of following pieces of information is the priority for the nurse to provide? a. Admitting diagnosis b. Breath sounds c. Body temperature d. Diagnostic test results
answer
b. Breath sounds
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A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? a. Albumin 3 g/dL b. HDL level of 90 mg/dL c. Norton scare score of 18 d. Braden scale score of 20
answer
a. Albumin 3 g/dL
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A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? a. Loss of skin turgor on the back of hands b. Varicosities on lower extremities c. Thick, discolored nail ridges d. Bruises on arms in various stages of healing
answer
d. Bruises on arms in various stages of healing
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A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 minds and call him back in an hour. From a legal perspective, which of the following actions should the nurse take? a. Document the provider's statement in the medical record b. Notify the nursing manager c. Consult the facility risk manager d. Complete an incident report
answer
b. Notify the nursing manager
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A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? a. Small air bubbles in the tubing b. IV flow stops when the client bends arm c. Swelling and coolness are observed at the site d. Blood is visible in the IV catheter and tubing
answer
c. Swelling and coolness are observed at the site
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A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. Activate the emergency fire alarm b. Extinguish the fire c. Evacuate the client d. Confine the fire
answer
c. Evacuate the client
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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 she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client? a. Rashes are common, especially with dry skin. Did it go away on its own? b. Virtually all medications have adverse effects and it sounds like this could have been an adverse effect of the antibiotic c. It is unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection so we shouldn't be concerned about that rash d. We need to document the exact medication you were taking because you might be allergic.
answer
d. We need to document the exact medication you were taking because you might be allergic
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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 type of therapy? a. A client who has a history of physical abuse b. A client who has a pacemaker c. A client who has ulcerative colitis d. A client who has asthma
answer
d. A client who has asthma
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A nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints Which of the following actions should the nurse take? a. Pad the client's wrists before applying the restraints b. Evaluate the client's circulation once per shift after application c. Remove the restraints every 4 hours to evaluate the client's status d. Secure the restraint ties to the client's bed side rails
answer
a. Pad the client's wrists before applying the restraints
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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 action should the nurse take? a. Assist the client into a prone position b. Place a sleeve over the top of each leg with the opening at the knee c. Make sure two fingers can fit under the sleeves d. Set the ankle pressure at 65 mmHG
answer
c. Make sure two fingers can fit under the sleeves
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A nurse is preparing to administer 750 mL of 0.9% NaCl IV to infuse over 7 hours. The nurse should set the infusion pump to deliver how many mL/hr?
answer
107 mL/hr
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A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. Make sure the client's room has a t least 6 air exchanges per hour b. Make sure the client wears a mask when outside her room if there is construction in the area c. Place the client in a private room with negative-pressure airflow d. Wear an N95 respirator when giving the client direct care
answer
b. Make sure the client wears a mask when outside her room if there is construction in the area
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A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. Administer the medication with the needle at 45-degree angle b. Administer the medication into the client's nondominant arm c. Pull the client's skin laterally or downward prior to administration d. Massage after administration at the injection site
answer
a. Administer the medication with the needle at 45-degree angle
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Nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? a. Examine personal values about the issues b. Tell the parents that this is a necessary procedure c. Inform the parents that the staff does not require their consent d. Contact a spiritual support person to explain the importance
answer
a. Examine personal values about the issues
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A nurse is calculating a client's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client's intake and output record as 120mL? a. 2 cups soup b. 1-quart water c. 8 oz ice chips d. 6 oz of teat
answer
c. 8 oz ice chips
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A nurse is planning teaching for a group of adolescents who each recently had a surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? a. Role play b. Guided discussions c. Question answer meetings practice sessions d. Practice sessions
answer
d. Practice sessions
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A nurse is teaching a client and his family how to care for the client's trach at home. Which instructions should be given? a. Remove outer cannula cautiously for routine cleaning b. Use covers when outdoors c. Use sterile technique when preforming trach care at home d. Cleans irritated skin when full strength hydrogen peroxide
answer
b. Use covers when outdoors
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A nurse is educating a client who has a terminal illness about her request to decline resuscitation. The client asks what would happen if she arrived having difficulty breathing. Which response should be given? a. Determine who the POA is b. We will apply oxygen through a tube in your nose c. We will ask if you have changed your mind d. We will insert a breathing tube while evaluating the condition
answer
b. We will apply oxygen through a tube in your nose
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A nurse is reviewing evidence based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? a. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter b. Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min c. Make sure the reservoir bag of a particular mask remains deflated d. Use petroleum jelly to lubricate their nose, face and hips
answer
b. Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min
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A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which tasks should be assigned to an assistive personnel (AP)? (Select all that apply) a. Assist the client with a partial bed bath b. Measure the client's BP after the nurse administers an antihypertensive medication c. Test the client's swallowing ability by providing thickened liquids d. Use a communication board to ask what the client wants for lunch e. Irrigate the client's indwelling urinary catheter
answer
A,B,D
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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 field? a. The nurse opens the sterile field on a wet surface b. The nurse opens the first fold away from the body c. The nurse holds sterile objects above the waist d. The outer edge of the sterile field is touching a bottle
answer
a. The nurse opens the sterile field on a wet surface
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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 as a possible indication of a a skin malignancy? a. Uniform pigmentation b. Regular border c. Uneven shape d. A diameter smaller than 6 mm
answer
c. Uneven shape
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A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the room. The nurse asks if the client would like to discuss any concerns and the client declines. Which of the following statements should the nurse make? a. I will return shortly after I document this in your record. b. Most men live a long time with prostate cancer c. I am available to talk if you change your mind d. I will make a referral to a cancer support group for you
answer
c. I am available to talk if you change your mind
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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? a. Wrap blankets around all four sides of the bed b. Apply restraints during seizure activity c. Place the client in a supine position during seizure activity d. Have a tongue depressor at the bedside
answer
a. Wrap blankets around all four sides of the bed
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A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a. Numbness of the extremities b. Bradycardia c. Positive Chvostek's sign d. Abdominal cramping
answer
d. Abdominal cramping
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A nurse is caring for a group of clients on a medical surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. A client unaware of her recent cancer diagnoses asks the nurse if she has cancer and the nurse responds affirmatively b. A client who has a prescription for a NG tube refuses it, and the nurse complies with the client's wishes c. A client with a DNR has cardiac arrest and the nurse does not perform CPR despite requests from the family d. A client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse promised she would give to her
answer
a. A client unaware of her recent cancer diagnoses asks the nurse if she has cancer and the nurse responds affirmatively
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A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? a. The client is receiving formula at room temperature b. The feedings infuse at a slow, continuous drip over 8 hr each night c. The family member washes out the feeding bag with warm water once every 24 hours d. The family member flushes the tubing with water before and after giving medications
answer
c. The family member washes out the feeding bag with warm water once every 24 hours
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A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement? a. The tube aspirate has a pH of 7 b. An x-ray shows the end of the tube above the pylorus c. Bowel sounds are present on auscultation d. The client reports relief of nausea
answer
b. An x-ray shows the end of the tube above the pylorus
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A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next? a. Clean sutures along the incision site b. Grasp at the knot of the sutures with forceps c. Cut the sutures close to the skin on one side d. Pull out the sutures with forceps in one piece
answer
a. Clean sutures along the incision site
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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 1. Remove tubing and indwelling lines 2. Place a name tag 3. Obtain the death pronouncement from the provider 4. Clean the body 5. Ask the family if they wish to view the body
answer
3,1,4,5,2
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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 intervention should be the nurse's priority action? a. Encourage the client to relax and take deep breaths during the dressing change b. Educate the client about the importance of the dressing change to prevent infection c. Assist the client to a comfortable position for the dressing change d. Administer pain medication 45 min before changing the dressing
answer
d. Administer pain medication 45 minutes before changing the dressing
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A nurse is teaching a client whose left leg is in a case about using crutches. Which of the following statements should the nurse use to identify as an indication that the client understands the teaching? a. When descending stairs, I will shift my weight to my right leg b. I should place my crutches 12 inches in front and to the side of each foot c. As I sit down I will hold on crutch in each hand d. I will make sure the shoulder rests are snug against my armpits
answer
a. When descending stairs, I will shift weight to my right leg
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A client who is postoperative is verbalizing pain as a 1 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? a. I think I should take my pain medication more often since it is not controlling my pain b. Breathing faster will help keep my mind off of the pain c. It might help me to listen to music while lying in bed d. I don't want to walk today because I have some pain
answer
c. It might help me to listen to music while lying in bed
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A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? a. Contact b. Droplet c. Airborne d. Protective
answer
b. Droplet
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A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? a. During admission b. As soon as the client is stable c. During initial team conference d. After consulting family
answer
a. During admission
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A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore" Which response should the nurse make? a. Most people are happy when their children grow up and leave home b. You should be proud that your children are becoming independent c. Maybe you should consider why you are feeling useless d. People in middle adulthood often find satisfaction in nurturing and guiding young people
answer
d. People in middle adulthood often find satisfaction in nurturing and guiding young people
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A nurse enters a client's room and finds her on the floor. The client's roommate reports the client was trying to get out bed and fell over the bedrail. Which statement should the nurse document about this incident? a. Incident report completed b. Client climbed over bedrails c. Client found on floor d. Client was trying to get out of bed
answer
c. Client found on floor
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A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which statement should the nurse identify as an indication that she understands the use of this assistive device? a. This type of hearing aid does not allow for fine tuning of volume b. I shouldn't have trouble keeping this hearing aid in place during exercise c. I expect to hear a whistling sound when I first insert the hearing aid d. I will be sure to remove my hearing aid before taking a shower
answer
d. I will be sure to remove my hearing aid before taking a shower
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A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C.False Imprisonment D. Invasion of Privacy
answer
A. Assault
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A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False Imprisonment C. Negligence D. Breach of confidentiality
answer
B. False Imprisonment
question
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery tomorrow unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in to the hospital."
answer
C. "I plan to write that I don't want them to keep me on a breathing machine."
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A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply). A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about having alternatives to having the surgery
answer
A and B
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A nurse has noticed several occasions in the past week then another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Alert the American Nurses Association B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep
answer
C. Report the observations to the nurse manager on the unit
question
A nurse is preparing information for change of shift report. Which of the following information should the nurse include? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for the day D. Medication routine from the medication administration record
answer
C. Bone scan scheduled for the day
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A nurse is discussing the HIPPA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? (Select all that apply). A. A single electronic records password is provided for nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses' station D. A client can request a copy of her medical record. E. A nurse may photocopy a client's medical record for transfer to another facility
answer
B, C, D and E
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A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, write in the correct information B. Put the data and time on all entries C. Document objective data, leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document
answer
B and C
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A nurse is discussing occurrences that require communication of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply). A. Medication Error B. Needle sticks C. Conflict with provider and nursing staff D. Omission of prescription E. Complaint from a client's family member
answer
A,B and D
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A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply). A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the provider's signature on the prescription within 24 hours D. Decline the verbal prescription because it is not an emergency situation E. Tell the charge nurse that the provider has prescribed morphine by telephone
answer
A, B and C
question
A nurse on a medical-surgical unit has received change of shift report and will care for four clients. Which of the following client's needs should the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer
answer
C. Reapplying a condom catheter for a client who has urinary incontinence
question
A nurse manager of a medical surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign the client? A. Charge nurse B. RN C. Practical Nurse (PN) D. Assistive Personnel (AP)
answer
B. RN
question
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply). A. The roommate ambulates independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain medication 30 minutes ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning
answer
B,C and D
question
An RN is making assignments for a practical nurse at the beginning of the shift. Which of the following assignments should the PN question? A. Assisting a client who is 24-hour postoperative to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma how to use a metered-dose inhaler
answer
D. Teaching a client who has asthma how to use a metered-dose inhaler
question
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply) A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances
answer
B, C, and E
question
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief B. Wait to see whether the pain lessens during the next 24 hours C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing his pain
answer
A. Reassess the client to determine the reasons for inadequate pain relief
question
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
answer
A. Assessment
question
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply). A. Respiratory rate is 22/min with even, unlabored respirations B. The client's partner states, "He said he hurts after walking about 10 minutes. C. Pain rating is 3 on a 0 to 10 scale D. Skin is pink, warm and dry E. The assistive personnel reports the client walked with a limp
answer
A, D and E
question
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following should be included? (Select all that apply). A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric tube to relieve gastric distension C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hours to reduce pressure ulcer risk
answer
C, D and E
question
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. "I will review the past medical history on the client's record to get more information." C. "I will go carry out the new prescriptions from the provider." D. "I will ask the client if his nausea has resolved."
answer
A. "I will determine the most important client problems that we should address."
question
A nurse is caring for a client who is 24 hour postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity
answer
A. Basic
question
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk Taking D. Creativity
answer
B. Responsibility
question
A nurse is caring for a client who is 24 hour postoperative following abdominal surgery. The nurse suspects the client's pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply). A. The client seems easily agitated B. The client is nonadherent with coughing, deep breathing and dangling C. The client may have pain medication every 4-6 hours but accepts it every 6-7 hours D. The client reports tenderness in his lower right leg E. The client's vital signs are heart rate of 110/min, respiratory rate 20/min, temperature of 98.6 and blood pressure 136/80 mmHg
answer
B, C and E
question
A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on the client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence
answer
A. Knowledge
question
A nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline
answer
D. Discipline
question
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 feet away from the client's bedside B. Instruct the client to refrain from coughing and sneezing during the dressing change C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound D. Keep a box of facial tissues nearby for the client to use during the dressing change.
answer
C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound
question
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap furthest from the body
answer
D. The flap furthest from the body
question
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply). A. A bottle containing sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand
answer
C, D, and E
question
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing hand washing? (Select all that apply). A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash hands with soap and water for at least 15 seconds C. Rinse hands with hot water D. Use a clean paper towel to turn off faucets E. Allow the hands to air dry after washing
answer
B and D
question
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply). A. The provider drops a sterile instrument onto the near side of the sterile field B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field C. The procedure is delayed 1 hour because the provider receives an emergency call D. The nurse turns to speak to someone who enters through doors behind the nurse E. The client's hand brushes against the outer edge of the sterile field
answer
B, C and D
question
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply). A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks
answer
A, B, C and E
question
A nurse is caring for a client who presents with linear clusters of fluid containing vesicles with some crustings. The nurse should identify the client has manifestations of which condition? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster
answer
D. Herpes Zoster
question
A nurse is caring for a client who reports having a severe sore throat, pain when swallowing and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness
answer
D. Illness
question
A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply). A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate
answer
A, B and E
question
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply). A. Place the client in a negative pressure room with at least 6 exchanges per hour B. Wear a mask when providing care within 3 feet of the client C. Place a surgical mask on the client if transportation to another department is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when performing care that might result in contamination from secretions
answer
B, C, and E
question
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply). A. Place a belt restraint on the client when using the bedside commode B. Keep the bed in its lowest position with all side rails up C. Make sure that the client's call light is within reach D. Provide the client with nonskid footwear E. Complete a fall risk assessment
answer
C, D and E
question
A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side" B. "I will go to the nurses' station for assistance" C. "I will administer his medications" D. "I will prepare to insert an airway"
answer
B. "I will go to the nurses' station for assistance"
question
A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all the open doors on the unit
answer
C. Move clients who are nearby
question
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aids in his possessions
answer
A. Complete a fall-risk assessment
question
A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is postoperative following an open reduction internal fixation of the ankle D. An older adult who is postoperative following a below the knee amputation
answer
D. An older adult who is postoperative following a below the knee amputation
question
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply). A. Family members who smoke must be at least 10 feet from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen C. A "No Smoking" sign should be placed on the front door D. Cotton bedding and clothing should be replaced with items made from wool E. A fire extinguisher should be readily available in the home.
answer
B, C and E
question
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
answer
A. Hypotension
question
A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 degrees" B. "Once my baby can sit up, he should be safe in the bathtub" C. "I will place my baby on his stomach to sleep" D. "Once my infant starts to push up, I will remove the mobile from over the crib."
answer
D. "Once my infant starts to push up, I will remove the mobile from over the crib"
question
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body
answer
D. Carbon monoxide binds with hemoglobin in the body
question
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply). A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw and fresh food separately can prevent food poisoning
answer
B, C, and E
question
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of the client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg
answer
B. Semi-Fowler's
question
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use in transfer back to bed B. Call for additional staff to assist with the transfer C. Use a transfer belt and assist the client back to bed D. Determine the client's ability to help with the transfer
answer
D. Determine the client's ability to help with the transfer
question
A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow B. Lie flat on her stomach with her head to one side C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table D. Lie on her side with her weight on her hip and should with her arm flexed in front of her
answer
C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table
question
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply) A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at the waist C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2-3 hours to flex and stretch your joints and muscles
answer
A,B,D
question
A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply) A. "My line of gravity should fall outside my base of support" B. "The lower my center of gravity, the more stability I have" C. "To broaden my base of support, I should spread my feet apart" D. "When I lift an object, I should hold it as close to my body as possible" E. "When pulling an object, I should move my front foot forward"
answer
B, C and D
question
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head C. A client who has partial thickness burns to the face, neck and chest D. A client who has a fractured fibula and tibia
answer
C. A client who has partial thickness burns to the face, neck and chest
question
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply). A. Open doors to client rooms B. Place blankets over clients who are confined to beds C. Move beds away from windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms
answer
B,C and D
question
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Wash the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive
answer
C. Brush the chemical off the skin and clothing
question
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understand of proper procedures? A. "I will get the caller off the phone as soon as possible so I can alert the staff" B. "I will begin evacuating clients using the elevators" C. "I will not ask any questions and just let the caller talk" D. "I will listen for background noises"
answer
D. "I will listen for background noises"
question
A nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? A. A client who is dehydrated and receiving IV fluid electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mmHg E. A client who has acute appendicitis and is scheduled for an appendectomy
answer
C and D
question
A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. The client is able to discuss the appropriate technique B. The client is able to demonstrate the appropriate technique C. The client states that he understands D. The client is able to write the steps on a piece of paper
answer
B. The client is able to demonstrate the appropriate technique
question
A nurse in a provider's office is collecting data from the mother of a 12-month-old infant. The client states that her son is older enough for toilet training. Following an education session with the nurse, the client now states that she will postpone toiler training until her son is older. Learning has occurred in which domain? A. cognitive B. affective C. psychomotor D. kinesthetic
answer
B. affective
question
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision" B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say."
answer
C. "Can you tell me about how long the surgery will take?"
question
A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning B. Select instructional materials appropriate for the older adult C. Identify goals the nurse and the client agree are reasonable D. Determine what the client knows about stress incontinence
answer
D. Determine what the client knows about stress incontinence
question
A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions B. Ask the client to explain how to select or prepare meals C. Encourage the client to fill out an evaluation form D. Ask the client if she has resources for further instruction on this topic
answer
B. Ask the client to explain how to select or prepare meals
question
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish had my job back" B. "It's been so stressful for me to have to depend on my son to help around the house" C. "I just heard my friend Al died. That's the third one in 3 months" D. "I keep forgetting which medications I have taken during the day"
answer
D. "I keep forgetting which medications I have taken during the day"
question
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply). A. "Eat three large meals a day" B. "Eat your meals in front of the television" C. "Eat foods that are easy to eat, such as finger foods" D. "Invite family members to eat meals with you" E. "Exercise every day to increase appetite"
answer
C, D and E
question
A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply). A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test
answer
B, C, D, and E
question
A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply). A. Increase protein intake to increase muscle mass B. Decrease fluid intake to prevent urinary incontinence C. Increase calcium intake to prevent osteoporosis D. Limit sodium intake to prevent edema E. Increase fiber intake to prevent constipation
answer
A, C, D and E
question
A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity
answer
B, D and E
question
A nurse is caring for an 82 year old client in the emergency department who has an oral body temperature of 38.3 degrees celsius (101 degrees F), pulse rate 114 bpm and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply). A. Obtain cultural specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to rest and limit activity D. Allow the client to shiver to dispel excess heat E. Assist the client with oral hygiene frequently
answer
A, C and E
question
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the client's temperature rectally" B. "Count the client's radial pulse for 30 seconds and multiply it by 2" C. "Do not let the client know you are counting her respirations" D. "Let the client rest for 5 minutes before you measure her blood pressure"
answer
A. "Do not measure the client's temperature rectally"
question
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply). A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate D. Count the rate for 30 seconds if it is irregular E. Count and report any signs the client demonstrates
answer
A, B and C
question
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety medication D. Return in 30 min to recheck the client's blood pressure
answer
B. Ask the client if she is having pain
question
A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating
answer
B. Reflecting
question
Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply). A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Respond positively when giving feedback
answer
A,C and E
question
A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) A. "You will do great! You just have to get used to it" B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home" D. "Tell me about your support system you'll have after you leave the hospital" E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming"
answer
C,D and E
question
Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and the client B. Encourage the client to communicate his thoughts and feelings C. Give the nurse client communication no time limits D. Allow communication to occur spontaneously throughout the nurse client relationship
answer
B. Encourage the client to communicate his thoughts and feelings
question
A nurse is caring for a school age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture
answer
B. Sit at eye level with the child
question
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following responses should the nurse make? A. "Really, you look just fine to me. There's no need to feel undesirable" B. "I'm interested in finding out more about how your body feels to you" C. "Consider an afternoon at a spa. A facial will make you feel more attractive" D. "It's still too son to expect to feel normal. Give it a little more time"
answer
B. "I'm interested in finding out more about how your body feels to you"
question
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at risk for body image disturbances? (Select all that apply). A. 30-year-old male client following laparscopic appendectomy B. 45-year-old female client following a mastectomy C. 20-year-old female client following left above the knee amputation D. 65-year-old male client following cardiac catherization E. 55 year old male client following a stroke with right sided hemiplegia
answer
B, C and E
question
A nurse is caring for a client who is 3 days postoperative following a below the knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident" B. "I just can't stop crying" C. "I am so mad at that guy who hit us. I wish he lost his leg" D. "I don't even want to look at my leg. You can check the dressing"
answer
D. "I don't even want to look at my leg. You can check the dressing"
question
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states "I am concerned that things might be a little, you know, different with my wife when I get home." Which of the following statements should the nurse make? A. "Sounds like something you should discuss with her when you get home" B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns" C. "Oh, I wouldn't be too concerned. Things will be just fine when you get home" D. "Just make sure you take your medication as directed and you should be fine"
answer
B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns"
question
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements would alert the nurse that one of the clients is having an issue with self concept? A. "I was having difficulty with attaching the appliance at first, but my wife was able to help" B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and he taught me a few things" D. "It may take me a while to get the hang of this. I have to admit, I am pretty nervous"
answer
B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?"
question
A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply). A. Talk to the interpreter about the family while the family is in the room B. Ask the family one question at a time C. Look at the interpreter when asking the family questions D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk
answer
B,D and E
question
A nurse is caring for a client who shares the nurse's religious background. Which of the following information should the nurse anticipate? A. Members of the same religion share similar feelings about their religion B. A shared religious background generates mutual regard for one another C. The same religious beliefs can influence individuals differently D. The nurse and client should discuss the differences and commonalities in their beliefs
answer
C. The same religious beliefs can influence individuals differently
question
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? A. Contact the hospital's spiritual services B. Ask him what is making him cry C. Provide quiet moments for times like these D. Turn on the television as a distraction
answer
C. Provide quiet moments for times like these
question
A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the client? A. "I will make sure the menu includes kosher items" B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer" C. "I will make sure to use direct eye contact when speaking with the client" D. "I will make sure daily communication is available for this client"
answer
B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer"
question
A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a MVA. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive the blood transfusion. Which statement should the nurse make? A. "I believe in this case you should really make an exception and accept the blood transfusion" B. "I know your family would approve of your decisions to have a blood transfusion" C. "Why does your religion mandate that you cannot receive blood transfusions" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution"
answer
D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution"
question
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to this family? A. Allowing the client to function independently will strengthen her muscles and promote healing B. The client needs to be given privacy at times for self reflecting and organizing her life C. The client's sense of loss can be lessened through retaining control of certain areas of her life D. Performing ADLs is required prior to discharge from an acute care facility
answer
C. The client's sense of loss can be lessened through retaining control of certain areas of her life
question
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to see my daughter's wedding." Based on the Kubler Ross model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance
answer
C. Bargaining
question
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate the mourning and grieving partner? (Select all that apply) A. "Would you like me to contact the chaplain to come speak with you?" B. "You will feel better soon. You have been expecting this for a while now" C. "Let's talk about your children and how they are going to react" D. "You know, it is quite normal to feel anger toward your husband at this time" E. "Tell me more about how you are feeling"
answer
A,D and E
question
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hours. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone
answer
D. Decreased muscle tone
question
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicates an understanding of the procedure? (Select all that apply) A. "I will remove the dentures from the body" B. "I will make sure the body is lying completely flat" C. "I will apply fresh linens and place a clean gown on the body" D. "I will remove all equipment from the bedside" E. "I will dim the lights in the room"
answer
C, D and E
question
A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side B. Place two fingers in the client's mouth to open C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the client's mouth
answer
A. Turn the client's head to the side
question
A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply) A. Inspect the feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let air dry D. Use over the counter products to treat abrasions E. Wear cotton socks
answer
A, B and E
question
A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client
answer
A. Schedule rest periods during morning care
question
A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanker over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms
answer
A. Face
question
A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the denture with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them
answer
B. Brush the denture with a toothbrush and denture cleaner
