A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
answer
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
question
A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
answer
Calf swelling
question
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?
answer
A nurse asks a nurse from another unit to assist with her documentation.
question
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
answer
Remove the stockings at least once per shift.
question
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
answer
Auscultate lung sounds
question
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
answer
"I can concentrate best in the morning."
question
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?
answer
Have the client stand with her arms at her side and her feet together.
question
A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
answer
Allow extra time for the client to respond to questions.
question
A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?
answer
Walking briskly
question
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?
answer
Erythema on pressure points
question
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
answer
Gently shake the container of medication prior to administration.
question
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
answer
Check the client for injuries
question
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
answer
Reassure the client that this is an expected response to grief.
question
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?
answer
"You should have a fecal occult blood test every year."
question
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
answer
"Use the complete name of the medication magnesium sulfate."
question
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
answer
Place the client in a room with negative-pressure airflow.
Wear gloves when assisting the client with oral care.
Use antimicrobial sanitizer for hand hygiene.
question
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
answer
Have family members wear a gown and gloves when visiting.
question
A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
answer
Wrap monitoring cords with stockinette and tape them in place.
question
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend?
answer
Use progressive relaxation techniques at bedtime.
question
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
answer
To avoid contamination of regular insulin with NPH insulin: Inject 10 unites of air into the vial of NPH without touching the solution Inject 5 units of air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Then insert the needle into the NPH and withdraw the correct amount of insulin.
question
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
answer
Initiate an enteral feeding through a gastrostomy tube.
question
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
answer
Have the client take sips of water to promote insertion of the NG tube into the esophagus.
question
A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?
answer
Pupil clarity
Visual fields
Visual acuity
question
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
answer
The client holds the cane on the stronger side of her body.
question
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?
answer
Narrowed arterial lumen
question
A nurse is admitting a client who has influenza. Which of the following types of transmission precautions should the nurse initiate?
answer
Droplet
question
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
answer
Flush the tube with 15 mL of sterile water.
question
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
answer
Cleanse the wound from the center outward.
question
A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report?
answer
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
question
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
answer
Skin blanching
question
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
answer
Situation, background, assessment, and recommendation (SBAR)
question
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
answer
Contact precautions
question
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
answer
Assist the client to an upright position.
question
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
answer
Potassium 5.4 meq/L
question
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
answer
Stand close to the cabinet when lifting it.
question
A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day. "Which of the following components of the prescription should the nurse question?
answer
The dose
question
A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
answer
(fried egg)
question
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
answer
"What could I have done to deserve this illness?"
question
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
answer
Withhold the blood transfusion.
question
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
answer
Select a suction catheter that is half the size of the lumen.
question
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
answer
Have the client use a trapeze bar when changing position.
question
A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?
answer
Role overload
question
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
answer
"Are you able to help with your hygiene care?"
question
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?
answer
Acupuncture
question
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
answer
"I'll check the wires and cables on my TV to make sure they are in good working order."
question
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
answer
Ask another nurse to observe the medication wastage.
question
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
answer
0.3 mg
question
A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?
answer
"This is a difficult time, but we are helping each other through this."
question
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?
answer
Use a clock pattern to describe food on the client's plate.
question
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?
answer
-Ask the client if he can bear weight -Position the chair on the side on the left side of the bed -Have the client sit and dangle his feet at the bedside -Use the stand and pivot technique to move the client to the chair.
question
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
answer
"The pain is like a dull ache in my stomach."
question
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
answer
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
question
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?
answer
Rapid heart rate
question
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?
answer
Determine the reasons why the client is refusing to use the incentive spirometer.
question
A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (round)
answer
8 mL/hr
question
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
answer
Tell the client to keep the head of the bed elevated at least 30 degrees.
question
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
answer
Pressing gently on the tragus of the client's ear.
question
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
answer
Subtract the amount of irrigant used from the client's urine output.
question
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
answer
Place the client's arm in a dependent position.
question
A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?
answer
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
question
A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
answer
Calf swelling
question
A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?
answer
A nurse asks a nurse from another unit to assist with her documentation.
question
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
answer
Remove the stockings at least once per shift.
question
A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
answer
Auscultate lung sounds
question
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
answer
"I can concentrate best in the morning."
question
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?
answer
Have the client stand with her arms at her side and her feet together.
question
A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
answer
Allow extra time for the client to respond to questions.
question
A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?
answer
Walking briskly
question
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?
answer
Erythema on pressure points
question
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
answer
Gently shake the container of medication prior to administration.
question
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
answer
Check the client for injuries
question
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
answer
Reassure the client that this is an expected response to grief.
question
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?
answer
"You should have a fecal occult blood test every year."
question
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
answer
"Use the complete name of the medication magnesium sulfate."
question
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
answer
Place the client in a room with negative-pressure airflow.
Wear gloves when assisting the client with oral care.
Use antimicrobial sanitizer for hand hygiene.
question
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
answer
Have family members wear a gown and gloves when visiting.
question
A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
answer
Wrap monitoring cords with stockinette and tape them in place.
question
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend?
answer
Use progressive relaxation techniques at bedtime.
question
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
answer
To avoid contamination of regular insulin with NPH insulin: Inject 10 unites of air into the vial of NPH without touching the solution Inject 5 units of air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Then insert the needle into the NPH and withdraw the correct amount of insulin.
question
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
answer
Initiate an enteral feeding through a gastrostomy tube.
question
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
answer
Have the client take sips of water to promote insertion of the NG tube into the esophagus.
question
A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?
answer
Pupil clarity
Visual fields
Visual acuity
question
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
answer
The client holds the cane on the stronger side of her body.
question
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?
answer
Narrowed arterial lumen
question
A nurse is admitting a client who has influenza. Which of the following types of transmission precautions should the nurse initiate?
answer
Droplet
question
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
answer
Flush the tube with 15 mL of sterile water.
question
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
answer
Cleanse the wound from the center outward.
question
A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report?
answer
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
question
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
answer
Skin blanching
question
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
answer
Situation, background, assessment, and recommendation (SBAR)
question
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
answer
Contact precautions
question
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
answer
Assist the client to an upright position.
question
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
answer
Potassium 5.4 meq/L
question
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
answer
Stand close to the cabinet when lifting it.
question
A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day. "Which of the following components of the prescription should the nurse question?
answer
The dose
question
A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
answer
(fried egg)
question
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
answer
"What could I have done to deserve this illness?"
question
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
answer
Withhold the blood transfusion.
question
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
answer
Select a suction catheter that is half the size of the lumen.
question
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
answer
Have the client use a trapeze bar when changing position.
question
A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?
answer
Role overload
question
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
answer
"Are you able to help with your hygiene care?"
question
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?
answer
Acupuncture
question
A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
answer
"I'll check the wires and cables on my TV to make sure they are in good working order."
question
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
answer
Ask another nurse to observe the medication wastage.
question
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
answer
0.3 mg
question
A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?
answer
"This is a difficult time, but we are helping each other through this."
question
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?
answer
Use a clock pattern to describe food on the client's plate.
question
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?
answer
-Ask the client if he can bear weight -Position the chair on the side on the left side of the bed -Have the client sit and dangle his feet at the bedside -Use the stand and pivot technique to move the client to the chair.
question
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
answer
"The pain is like a dull ache in my stomach."
question
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
answer
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
question
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?
answer
Rapid heart rate
question
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?
answer
Determine the reasons why the client is refusing to use the incentive spirometer.
question
A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (round)
answer
8 mL/hr
question
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?
answer
Tell the client to keep the head of the bed elevated at least 30 degrees.
question
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
answer
Pressing gently on the tragus of the client's ear.
question
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
answer
Subtract the amount of irrigant used from the client's urine output.
question
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
answer
Place the client's arm in a dependent position.
question
A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?
answer
Semi-fowler's
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