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Allogeneic Stem Cell Transplant Foundations Of Professional Nursing Nursing

ATI study set- fundamentals – Flashcards 105 terms

Joseph Fraser

105 terms

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ATI study set- fundamentals – Flashcards

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? a. A client who has a history of physical abuse b. A client who has a permanent pacemaker c. A client who has ulcerative colitis d. A client who has asthma

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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 client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? a. "I will return shortly after I document this in your record." b. "Most men live a long time with prostate cancer." c. "I am available to talk if you should change your mind." d. "I will make a referral to a cancer support group for you."

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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 to 10?" c. "Does the pain radiate?" d. "Is your pain sharp or dull?"

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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 the venipuncture site vigorously. c. Insert the IV catheter without using a tourniquet. d. Apply traction to the skin proximal to the insertion site to stabilize the vein.

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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.

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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.

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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 tuberculosis in a room with negative-pressure airflow. c. Provide disposable plates and utensils for a client who is HIV-positive. d. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

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

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bcde

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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 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? a. Document the provider's statement in the medical record. b. Notify the nursing manager. c. Consult the facility's risk manager. d. Complete an incident report.

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

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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

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

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A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? a. turn the client every 4 hours b. elevate the head of the client's bed c. hold oral care d. increase the rooms temp

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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. re fried beans c. peanut butter d. cheddar cheese

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A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? a. "This type of hearing aid does not allow for fine tuning of volume." b. "I shouldn't have trouble keeping the hearing aid in place during exercise." c. "I expect to hear a whistling sound when I first insert the hearing aid." d. "I will be sure to remove my hearing aid before taking a shower."

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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 client's interpreter. c. Make sure that the interpreter has a college degree. d. Avoid asking the client personal questions through the interpreter.

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

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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. Over which of the following locations should the nurse place the bell of the stethoscope? a. Second intercostal space at the left sternal border b. Fourth intercostal space at the right sternal border c. Fourth intercostal space at the left sternal border d. Second intercostal space at the right sternal border

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A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "When descending stairs, I will first shift my weight to my right leg." b. "I should place my crutches 12 inches in front and to the side of each foot." c. "As I sit down, I will hold one crutch in each hand." d. "I will make sure the shoulder rests are snug against my armpits.

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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

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a pt with hyponatremia (low sodium level) will have what?

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abdominal cramping, weakness, headache and nausea

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Where should a nurse listen for a pt with a heart murmur

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second intercostal space at the left sternal border and apex

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A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? a. "We will determine who the durable power of attorney for health care form has designated." b. "We will apply oxygen through a tube in your nose." c. "We will ask if you have changed your mind." d. "We will insert a breathing tube while we evaluate your condition."

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A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. Increase in hematocrit b. Increase in respiratory rate c. Decrease in heart rate d. Decrease in capillary refill time

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

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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 to the provider as a possible indication of a skin malignancy? a. Uniform pigmentation b. A regular border c. An uneven shape d. A diameter smaller than 6 mm

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

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A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a. Thread the IV catheter so that the hub rests at the insertion site. b. Shaving excess hair from around the insertion site c. Cleanse the site with hydrogen peroxide before IV catheter insertion. d. Palpate the site carefully just before inserting the IV catheter.

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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 6 L/min. c. Make sure the reservoir bag of a partial rebreathing mask remains deflated.. d. Use petroleum jelly to lubricate the client's nares, face, and lips.

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

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

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A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? a. Role play b. Group discussions c. Question-answer meetings d. Practice sessions

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A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) a. Assist the client with a partial bed bath. b. Measure the client's BP after the nurse administers an antihypertensive medication. c. Test the client's swallowing ability by providing thickened liquids. d. Use a communication board to ask what the client wants for lunch. e. Irrigate the client's indwelling urinary catheter.

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a b d

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

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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.

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A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? a. Examine personal values about the issue. b. Tell the parents that this is a necessary procedure. c. Inform the parents that the staff does not require their consent. d. Contact a spiritual support person to explain the importance of the procedure.

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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? a. "I think I should take my pain medication more often, since it is not controlling my pain." b. "Breathing faster will help me keep my mind off of the pain." c. "It might help me to listen to music while I'm lying in bed." d . "I don't want to walk today because I have some pain."

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

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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? Contact Droplet Airborne Protective

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_________ precautions are a requirement for clients who have infections that spread via direct ________ with clients or from environmental ________. Examples are vancomycin-resistant enterococci and herpes simplex infections.

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contact

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___________ precautions are a requirement for clients who have infections that spread via _________ nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 ft) of the client who has a disorder requiring this precaution.

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Droplet

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precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.

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Airborne

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Clients who have an immune system compromise, such as those who have had an allogeneic stem cell transplant, require a _____________ environment. It keeps them from acquiring infections from others.

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protective

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

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A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea.

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

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

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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 the following pieces of information is the priority for the nurse to provide? a. Admitting diagnosis b. Breath sounds c. Body temperature d. Diagnostic test results

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

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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. Select synthetic clothing and bedding.

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a c d

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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.

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A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. Press gently on the tragus of the client's ear. b. Pack a small piece of cotton deep into the client's ear canal. c. Move the client's auricle down and back toward her head. d. Tilt the client's head backward for 5 min.

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A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? a. A nurse tied a client's restraint straps to the moveable part of the bed frame. b. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology. c. A nurse administers a medication to a client 30 min before the dose is due. d. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

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A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. Discuss the risk factors for colon cancer. b. Focus teaching on what the client will need to do in the future to manage his illness. c. Provide the client with written information about the phases of loss and grief. d. Reassure the client that this is an expected response to grief.

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A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? a. Dissolve each medication in 5 mL of sterile water. b. Draw up medications together in the syringe. c. Push the syringe plunger gently when feeling resistance. d. Flush the tube with 15 mL of sterile water.

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A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? a. Bend at the waist. b. Keep his feet close together. c. Use his back muscles for lifting. d. Stand close to the cabinet when lifting it.

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A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild pain." b. "The pain is like a dull ache in my stomach." c. "I notice that the pain gets worse after I eat." d. "The pain makes me feel nauseous."

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A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. BUN 15 mg/dL b. Creatinine 0.8 mg/dL c. Sodium 143 mEq/L d. Potassium 5.4 mEq/L

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A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? a. The top of the cane is parallel to the client's waist. b. When walking, the client moves the cane 46 cm (18 in) forward. c. The client holds the cane on the stronger side of her body. d. The client moves her stronger limb forward with the cane.

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A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. Assign the client to a room with a negative air-flow system. b. Use alcohol-based hand sanitizer when leaving the client's room. c. Clean contaminated surfaces in the client's room with a phenol solution. d. Have family members wear a gown and gloves when visiting.

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A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? a. Ask another nurse to observe the medication wastage. b. Notify the pharmacy when wasting the medication. c. Lock the remaining medication in the controlled substances cabinet. d. Dispose of the vial with the remaining medication in a sharps container.

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A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? a. Place the client in a side-lying position. b. Instill 15 mL of irrigation fluid into the catheter with each flush. c. Subtract the amount of irrigant used from the client's urine output. d. Perform the irrigation using a 20-mL syringe.

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A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) a. Lacrimal apparatus b. Pupil clarity c. Appearance of bulbar conjunctivae d. Visual fields e. Visual acuity

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b d e

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A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? a. Purulent exudate b. Warmth c. Skin blanching d. Bleeding

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A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. Gently shake the container of medication prior to administration. b. Transfer the medication to a medicine cup. c. Place the client in a semi-Fowler's position prior to medication administration. d. Verify the dosage by measuring the liquid before administering it.

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A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? a. Auscultate lung sounds. b. Measure urine output. c. Monitor blood pressure readings. d. Monitor serum electrolyte levels.

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A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? a. Tell the client which food she should eat first. b. Provide small-handle utensils for the client. c. Thicken liquids on the client's tray. d. Use a clock pattern to describe food on the client's plate.

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A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? a. Erythema on pressure points b. Lower-extremity pulse strength of 2+ c. Fluid intake of 3,000 mL per day d. A bowel movement every other day

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A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. Use a resuscitation bag with 80% oxygen prior to the procedure. b. Select a suction catheter that is half the size of the lumen. c. Place the end of the suction catheter in water-soluble lubricant. d. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

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A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? a. Airborne b. Droplet c. Contact d. Protective environment

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A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? a. Drink a cup of hot cocoa before bedtime. b. Exercise 1 hr before going to bed. c. Use progressive relaxation techniques at bedtime. d. Reflect on the day's activities before going to bed.

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A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. Check the client for injuries. b. Move hazardous objects away from the client. c. Notify the provider. d. Ask the client to describe how she felt prior to the fall.

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A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? a. "When do you usually bathe, in the morning or in the evening?" b. "Do you prefer a bath or a shower?" c. "At what temperature do you prefer your bath water?" d. "Are you able to help with your hygiene care?"

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A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? a. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." b. "I'll use a woolen blanket if I get chilly while I'm using my oxygen." c. "I'll check the wires and cables on my TV to make sure they are in good working order." d. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over."

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A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. Rinse the feeding bag with water between feedings. b. Tell the client to keep the head of the bed elevated at least 30°. c. Make sure the enteral formula is at room temperature. d. Wipe the top of the formula can with alcohol.

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A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? a. Touch the face with a cotton ball. b. Apply a vibrating tuning fork to the client's forehead. c. Have the client stand with her arms at her side and her feet together. d. Perform direct percussion over the area of the kidneys.

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A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." b. "Beginning at age 60, you should have a colonoscopy." c. "You should have a fecal occult blood test every year." d. "The recommendation is to have a sigmoidoscopy every 10 years."

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A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention b. Decreased blood pressure c. Calf swelling d. Diminished bowel sounds

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A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? a. Neck vein distention b. Urine specific gravity 1.010 c. Rapid heart rate d. Blood pressure 144/82 mm Hg

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A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? a. Allow extra time for the client to respond to questions. b. Expect the client to have difficulty understanding the information. c. Avoid references to the client's past experiences. d. Keep the learning session private and one-on-one.

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A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a. Protective environment b. Airborne precautions c. Droplet precautions d. Contact precautions

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A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? a. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse. b. A nurse asks a nurse from another unit to assist with her documentation. c. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care. d. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside.

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A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. Wear sterile gloves when removing the old dressing. b. Warm the irrigation solution to 40.5° C (105° F). c. Cleanse the wound from the center outward. d. Use a 20-mL syringe to irrigate the wound.

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A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 unites of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle

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c a d b

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A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine." b. "I have a specimen in the bathroom from about 30 minutes ago." c. " I flushed what I urinated at 7:00 a.m. and have saved all urine since." d. "I drink a lot, so I will fill up the bottle and complete the test quickly."

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A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. Insert an implanted port. b. Close a laceration with sutures. c. Place an endotracheal tube. d. Initiate an enteral feeding through a gastrostomy tube.

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A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. b. Remove the NG tube if the client begins to gag or choke. c. Apply suction to the NG tube prior to insertion. d. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

answer

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

answer

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

answer

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

answer

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

answer

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

answer

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

answer

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

answer

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? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a. position the chair on the left side of the bed b. ask the client if he can bear weight c. have the client sit and dangle his feet at the bedside d. use the stand and pivot technique to move the client to the chair

answer

b a c d

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

answer

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

answer

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

answer

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

answer

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

answer

question

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. Ensure sterilization of nondisposable items with ethylene oxide. b. Wrap monitoring cords with stockinette and tape them in place. c.Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. d. Wear hypoallergenic latex gloves that contain powder.

answer

question

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) a. Place the client in a room with negative-pressure airflow. b. Wear gloves when assisting the client with oral care. c. Limit each visitor to 2-hr increments. d. Wear a surgical mask when providing client care. e. Use antimicrobial sanitizer for hand hygiene.

answer

a b e

question

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. Walking briskly b. Riding a bicycle c. Performing isometric exercises d. Engaging in high-impact aerobics

answer

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

answer

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

answer

STUDY

Allogeneic Stem Cell Transplant Extinguish The Fire Nursing Surgery

ATI fundamentals 2016 B – Flashcards 60 terms

Dennis Jennings

60 terms

Preview

ATI fundamentals 2016 B – Flashcards

question

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

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

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

answer

Second intercostal space at the left sternal boarder

question

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

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

answer

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

question

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

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

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

answer

an uneven shape

question

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

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

STUDY

Allogeneic Stem Cell Transplant Foundations Of Professional Nursing Nursing

Management of Patients with non-malignant Hematologic disorders – Flashcards 64 terms

Marta Browning

64 terms

Preview

Management of Patients with non-malignant Hematologic disorders – Flashcards

question

Which nursing intervention is most appropriate for a client with MM

answer

Preventing bone injury

question

An elderly client is hospitalized for induction of chemotherapy to treat leukemia. The client reports fatigue to the nurse. What nursing intervention would best address the client's fatigue

answer

Assist the client to sit in a chair for meals

question

A client with leukemia is being discharged from the hospital to hospice care. Which statement by the client indicates the client has not achieved the goal for the nursing diagnosis Spiritual distress

answer

I do not understand why this happened to me

question

The oncology advanced practice nurse is assessing a client with leukemia. How would the oncology APN assess for enlargement and tenderness over the liver and spleen?

answer

By palpating the abdomen

question

Which of the following is only curative treatment for chronic myeloid leukemia (CML)

answer

Allogeneic steam cell transplant

question

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential

answer

Health history, such as bleeding, fatigue or fainting

question

Which statement best describes the function of stem cells in the bone marrow

answer

Produce all blood cells

question

For a client with Hodgkin lymphoma, who is at a risk for ineffective airway clearance and impaired gas exchange, the nurse places the client in a high Fowler's position to

answer

Increase lung expansion

question

Which statement indicates the client understands teaching about induction therapy for leukemia

answer

I will be in the hospital for several weeks

question

A client who is undergoing chemotherapy for AML reports pain in the low back. What is the nurse's first action

answer

Assess renal function

question

A client presents with peripheral neuropathy and hypothesis of the feet. What is the best nursing intervention

answer

Assess for signs of injury

question

A client with MM is complaint about pain. What interventions will the nurse give the client. To help reduce pain during activity

answer

Do not lift more than 10 pounds

question

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?

answer

The client with enlarged lymph nodes in the neck

question

A patient with acute myeloid leukemia has a neutrophil count that persists at less than 100 mm3. What should the nurse cautiously monitor this patient for

answer

Infection

question

The nurse is caring for a patient with hodgkin lymphoma in the hospital and preparing discharge planning education. Knowing that this patient is at risk for the development of a second malignancy, what education would be beneficial to reduce the risk factors. Select al that apply

answer

Reduce exposure to excessive sunlight Smoking cessation Decrease alcohol intake

question

Clinical assessment of a patient with AML includes observing for signs of infection, the major cause of earth for AML . The nurse should assess for indicators of

answer

Splenomegaly

question

The nurse is aware the CLL, a common malignancy in those older than 60, has an early stage and a late stage. The nurse assesses a patient for late stage CLL by looking for

answer

Thrombocytopenia

question

The nurse practitioner suspects that a patient has MM based on his major presenting symptom and the analysis of his laboratory results. Select the classic symptom for this disease

answer

Bone pain in the back of the ribs

question

A nurse prepares a client for a bone marrow biopsy who is suspected of having acute myeloid leukemia. What results from the bone marrow biopsy does the nurse expect

answer

Excess of immature leukocytes

question

A client has been diagnosed with polycythemia Vera. It is most important for the nurse to teach the client about

answer

Maintaining adequate blood pressure control

question

A client is receiving radiation therapy for lesions in the abdomen from non-Hodgkin;s lymphoma. Because of the effects of the radiation treatments, the nurse now assesses for

answer

Diarrheal stools

question

A 40 year old client has multiple myeloma. Prior to starting treatment with thalidomide (thalomid) it is most important for the nurse to

answer

Contract with the client regarding birth control methods

question

The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has

answer

A general education in all white blood cells

question

The nurse is assisting the client with MM to ambulated. What is the most important nursing diagnosis to help prevent fractures in this client

answer

Safety

question

What is the rationale for the classification of leukemia

answer

Which bone marrow stem cell is dysfunctional

question

The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristics of erythrocytosis

answer

Polycythemia vera

question

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia

answer

Apply prolonged pressure to needle sites or other sources of eternal bleeding

question

A client is receiving chemotherapy for acute myeloid leukemia and has poor nutritional intake. The first action of the nurse is to

answer

Ask "are you experiencing nausea"

question

The hospitalized client is experiencing gastrointestinal bleeding. Laboratory test results show that the client platelets are 9000mm3. The client is prednisone and azathioprine (imuran) the nurse

answer

Performs a neurological assessment with vital signs

question

Which of the following are complications related to polycythemia vera? Select all that apply

answer

CVA MI Ulcers Hematuria

question

A 48 year old female recently diagnosed with leukemia presents with increased immature lymphocytes, decreased granulocytes and normal erythrocytes. The client most likely has which type of leukemia

answer

Chronic lymphatic leukemia

question

A client was admitted to the hospital with a pathological pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms?

answer

Multiple myeloma

question

Which term is used to refer to a primitive cell that is capable of self-replication and differentiation

answer

Stem cell

question

A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal?

answer

Maintain nutrition

question

What assessment finding best indicates that the client has recovered from induction therapy?

answer

Neutrophil and platelet counts within normal limits

question

The nurse is teaching a client with acute lymphocytic leukemia about therapy. What statement should be included in the plan of care

answer

Intrathecal chemotherapy is used primarily as preventive therapy

question

A patient with acute myeloid leukemia is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host?

answer

Graft versus host disease

question

The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What lab study should the nurse be concerned about?

answer

Platelet count of 9000mm3

question

A nurse assesses a patient who has been diagnosed with DIC. Which of the following indicators are consistent with this diagnosis? Select all that apply

answer

Cyanosis in the extremities Dyspnea and hypoxia Increased blood area use nitrogen (BUN) and creatinine

question

A nurse prepares teaching for a group of clients with chronic myeloid leukemia (CML). When planning the teaching on a medication adherence, which factors associated with lower oral therapy adherence will the nurse keep in mind? Select all that apply

answer

Living alone Low socioeconomic status Not participating in a clinical trial Taking medication independent of meals

question

A nurse reviews the lab results of a client with PV. Which findings will the nurse find. Select all that apply

answer

Decreased erythropoietin Increased hemoglobin

question

A client with PV presents to the primary care clinic for an annual physical. Which health care provider prescriptions does the nurse recognize as preventive measures to prevent thrombosis in the client. Select all that apply

answer

Statin therapy Beta blocker therapy

question

A nurse is caring for an asymptomatic client with acute myelogenous leukemia. The client has a total WBC count of 0, a platelet count of 3,000mm2 and a hemoglobin level of 9mg/dL. He has a single lumen central venous catheter in place and physician has ordered the nurse to administer imipenem cilastatin (Primaxin) 500 mg every 8 hours, transfuse 1 unit packed RBC, give amphotericin B (Fungizone) 40 mg IV over 4 hours and transfuse 2 pheresis units of platelets. In what order should the nurse infuse these medications and blood products?

answer

Platelets, imipenem cilastatin, amphotericin B, packed RBCs

question

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential

answer

Health history, such as bleeding, fatigue or fainting

question

Which statement best describes the function of stem cells in the bone marrow

answer

Produce all blood cells

question

For a client with Hodgkin lymphoma, who is at risk for ineffective airway clearance and impaired gas exchange, the nurse places the client in a high Fowler's position to

answer

Increase lung expansion

question

Which statement indicates the client has understands teachings about induction therapy for leukemia

answer

I will be in the hospital for several weeks

question

A client with leukemia has developed a cough and increased fatigue. What is the primary nursing intervention

answer

Evaluate the client for potential infection

question

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma

answer

The client with enlarged lymph nodes in the neck

question

A patient with acute myeloid leukemia (AML) has a neutrophil count that persists at less than 100/mm3. What should the nurse cautiously monitor this patient for

answer

Infection

question

The nurse is aware that chronic lymphocytic leukemia, a common malignancy in those older than 60, has an early stage and a late stage. The nurse assesses a patient for late stage CLL by looking for

answer

Thrombocytopenia

question

A nurse is teaching a client with MM about the therapeutic benefits of radiation therapy. Which statements will the nurse include in the teaching. Select all that apply

answer

It helps to strengthen the bone It helps to decrease the bone pain

question

A nurse has established for a client the nursing diagnosis of risk for infection. Which of the following interventions would the nurse include in the plan of care for this client? Select all answers that apply.

answer

Encourage the client to take deep breath every 4 hours while awake Assess skin and mucous membrane every shift Auscultate lung sounds every shift and prn

question

The clinic nurse is caring for client diagnosed with leukopenia. What does the nurse know this client has

answer

A general reduction in all white blood cells

question

Which term refers to a form of white blood cell involved in immune response

answer

Lymphocyte

question

Which assessment findings support the client's diagnosis of acute myeloid leukemia? Select all that apply

answer

Weakness and fatigue Petechiae Enlarged lymph nodes Bone pain

question

After chemotherapy for AML, what interventions will best to help to prevent renal complications. Select all that apply

answer

Increase hydration Administer allopurinol Administer rasburicase

question

A client presents with peripheral neuropathy and hypothesis of the feet. What is the best nursing intervention

answer

Assess for signs of injury

question

The nurse is caring for a patient with chronic CML who is taking gleevec. In what phase of leukemia does the nurse understand that this medication is most useful to induce remission

answer

Chronic

question

The nurse is assessing a patient with polycythemia vera. What skin assessment data would the nurse determine is a normal finding for this patient

answer

Ruddy complexion

question

A patient is schedule for a test to help confirm the diagnosis fo AML. Which of the following is the result that the nurse knows is consistent with the diagnosis

answer

Excess of immature blast cells

question

The nurse cares for a client with AML with severe bone pain. What pathophysiological concept does the nurse understand is the reason for the client's pain

answer

Bone marrow expans

question

A nurse is providing teaching to a client who will undergo chemotherapy and radiation prior to hematopoietic stem cell transplantation for AML. What statement will the nurse use to describe the purpose of chemotherapy and radiation

answer

These therapies destroy the ability of your body to produce blood cells inside your bone marrow

question

A nurse cares for a client with early Hodgkin lymphoma. While assessing the client, the nurse will most likely find painless enlargement of which lymph node

answer

Cervical

STUDY

Allogeneic Stem Cell Transplant Foundations Of Professional Nursing Nursing

ATI Practice Exam – Flashcards 152 terms

Ken Ericksen

152 terms

Preview

ATI Practice Exam – Flashcards

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 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

question

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

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? 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

question

answer

d. 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? 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

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? 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

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? 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

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? 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

question

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

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? 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

question

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

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? a. Oat cereal b. Refried beans c. Peanut butter d. Cheddar cheese

answer

d. 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? (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

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 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

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

answer

c. 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? 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

question

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

question

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

question

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"

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? 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?

question

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

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? 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

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? 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

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 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

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? 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

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

answer

c. 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 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

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 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

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? 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

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 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

question

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

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? 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

question

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

question

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

question

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

question

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

question

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

question

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

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? 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

question

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

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 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

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 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

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 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

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? 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

question

answer

d. 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? 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

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? 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

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? 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

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? 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

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 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

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 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

question

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

question

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

question

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

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? a. During admission b. As soon as the client is stable c. During initial team conference d. After consulting family

answer

a. During admission

question

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

question

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

question

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

question

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

question

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."

question

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

question

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

question

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

question

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

question

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

question

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

STUDY

Acute Myeloid Leukemia Allogeneic Stem Cell Transplant Foundations Of Professional Nursing Graft Versus Host Disease Hematopoietic Stem Cell Nursing

Study – Flashcard Answers 19 terms

Clarence Louder

19 terms

Preview

Study – Flashcard Answers

question

"I do not understand why this happened to me."

answer

A client with leukemia is being discharged from the hospital to hospice care. Which statement by the client indicates the client has not achieved the goal for the nursing diagnosis Spiritual Distress?

question

Which bone marrow stem cell line is dysfunctional

answer

What is the rationale for the classification of leukemia?

question

Multiple myeloma

answer

A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms?

question

Health history, such as bleeding, fatigue, or fainting

answer

When assessing a female patient with a disorder of the hematopoietic or the lymphatic system, which of the following assessments is most essential?

question

Increase the lung expansion.

answer

For a patient with Hodgkin disease, who is at a risk for an ineffective airway clearance and an impaired gas exchange, the nurse places the patient in a high Fowler's position to do which of the following?

question

Stem cell

answer

The term that is used to refer to a primitive cell, capable of self-replication and differentiation, is which of the following?

question

Neutrophil and platelet counts within normal limits

answer

What assessment findings best indicate that the patient has recovered from induction therapy?

question

Assess for signs of injury.

answer

A patient presents with peripheral neuropathy and hypothesia of the feet. What is the best nursing intervention?

question

Do not lift more than 10 pounds.

answer

A patient with multiple myeloma is complaining about pain. What instructions will the nurse give the patient to help to reduce pain during activity?

question

The patient with enlarged lymph nodes in the neck.

answer

The nurse is assessing several patients. Which patient does the nurse determine is most likely to have Hodgkin lymphoma?

question

Graft-versus-host disease

answer

A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host?

question

Hypercalcemia

answer

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

question

Assess for mental state changes. Administer prescribed docusate (Colace) daily.

answer

Following bone marrow aspiration of a 19-year-old client, analysis reveals more than 20% immature blast cells. Platelet counts are 9000/mm³. What nursing interventions should the nurse employ for the care of this client? Select all answers that apply.

question

The nurse delays position changes and bathing if the client is experiencing pain. The nurse instructs the client to avoid activities that may cause injury.

answer

A home care nurse is caring for a client with multiple myeloma. Which of the following nursing interventions are appropriate for this client? Select all that apply.

question

They produce all blood cells.

answer

Which of the following statements best describes the function of stem cells in the bone marrow?

question

Induction therapy

answer

A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will receive?

question

A 72-year-old patient with a history of cancer

answer

Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)?

question

Ruddy complexion

answer

The nurse is assessing a patent with polycythemia vera. What skin assessment data would the nurse determine is a normal finding for this patient?

question

Frequent infections Fatigue from anemia Easy bruising

answer

A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply.

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