Nur 165 ati fundamentals proctored exam test bank comprehensive 2022 2023

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  NUR 165-ATI Fundamentals Proctored Exam Test Bank- comprehensive-2022-2023  Rationale: Morphine can cause respiratory depression if given too much. ... Also you should ALWAYS ASSESS the patient first when a med error is performed to make sure med error doesn‟t put the client‟s health in risk. 4. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? (Round the answer to the nearest whole number.) Click on the syringe that has 8 mL of med. 20 mg x (5mL/12.5mg) = 8 mL 5. A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)  So it says each dose for the final answer, but we are given 80 mg/kg/day.  80 x 20 = 1600 / 4 (dose is given every 6 hours a day) =400 mg  Rationale: 80 mg x 20 kg = 1,600  1,600/4 x day (q6h) = 400 mg 6. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? a. Label the pump with a defective equipment sticker. b. Unplug the pump. c. Obtain a replacement pump. d. Notified the biomedical department to fix the pump.  Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire. 7. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing? a. Serum albumin 3 g/dL b. Total lymphocyte count 2400 mm3 c. HCT 42% d. HGB 16g/dL  Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk forpoor wound healing. The other lab values are within normal limits. 8. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? Chapter 27 Vitals signs page 244 a. Apply the cuff above the client‟s antecubital fossa. b. Use a cuff with a width that is about 60% of the client's arm circumference. - width of the cuff should be 40 % of arm circumference c. How the clients sit with his arm resting above the level of his heart. - MUST BE AT HEART LEVEL d. Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should not be more than 2 to 3 mm hg per second  Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff. 9. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? Chapter 53 Airway management page 563 a. Hold the suction catheter with the clean non-dominant hand. b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum. c. Place the catheter in a location that is clean and dry for later use new line.- NEVER EVER REUSE THE SUCTION CATHETER . you throw it away after being used. d. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing .  Rationale: sterile technique for trachea  Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No longer than 10-15 seconds to avoid hypoxemia 10. A nurse is documenting client care. Which of the following abbreviations should the nurse use?ati book was not thorough so i had to go on different sites for charts - not confident with this, please double check. a. “SS” for sliding scale b. “BRP” for bathroom privileges c. “OJ” for orange juice- do not d. “SQ” for subcutaneous- do not 11. MISSING 12. A nurse is collecting A blood pressure reading from a client who is sitting in a chair period the nurse determines that the clients BP is 158/96 mmhg. which of the following actions should the nurse take? a. Ensure that the width of the BP cuff is 50% of the client‟s upper arm circumference. It says 40% b. Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC HYPOTENSION c. Recheck the clients BP and her other arm for comparison. d. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes 13. A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? Chapter 53 Airway Management page 562 e. Supine and low-Fowler's position f. Right lateral in Trendelenburg position g. Side lying with the right side of the chest elevated h. Prone with pillows under the extremities 14. A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify? a. Dietitian consult b. Speech therapy referral c. Oral suction at the bedside d. Clear liquids- liquids must be THICK. Clear liquids can cause aspiration  Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular. 15. A nurse is administering a large volume enema to a client. Identify the sequence of steps the nurse should follow after preparation and lubricating the enema set.(ati funds video enema) 1. Administer the enema solution.(2) 2. Remove the enema tube from the clients rectum.(4) 3. Wrap the end of the enema tube with a disposable tissue.(5) 4. Insert the enema tube into the client's rectum.(1) 5. Clamp the enema tube.(3) 16.A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a. Place the end of the NG tube in water to observe for bubbling. b. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. AIR NOT WATER OR BY ASPIRATING GASTRIC FOR PH. c. Assess the client's gag reflex. d. Measure the pH of the gastric aspirate. 17. A nurse is teaching a group of newly licensed nurses about the Braden Scale. Which of the following responses by the newly licensed nurse indicates an understanding of the teaching? a. “The client‟s age is part of the measurement.” - rationale is same as b. b. “The scale measures six elements.”  Rationale: The six elements are 1. Sensory Perception, 2. Moisture, 4. activity, 5. mobility ,6. nutrition , 7. friction and shear. c. “The higher the score, the higher the pressure ulcer risk.”- the higher the score the better chance the patient has of NOT getting an ulcer . score of 12 or less is high risk. Anything above 18 is healthy. d. “Each element has a range from 1 to 5 points.”- each elements is scored from 1-4 actually . 18. A nurse is caring from a client who has a tracheostomy. Which of the following actions should the nurse take? a. Clean the skin around the stoma with normal saline. b. Secure the tracheostomy ties with one finger to fit snugly underneath. → 2 snug fingers widths under neck strap c. Soak the outer cannula in warm tap water. STERILE NS d. Use a cotton tip applicator to clean the inside in the inner cannula. <to clean OUTER cannula surfaces, cllity-approved solution>ean the inside with the faci  Rationale: according to POTTER, funda pg. 866 using NS-saturated cotton-tipped sterile swabs and 4x4 gauze, clean exposed outer cannula surfaces and soma under faceplate, extending 5-10cm (2-4in) in all directions from stoma. 19. A nurse is documenting in a client‟s medical record . Which of the following entries should the nurse record? a. “Incision without redness or drainage.” b. “Drink adequate amounts of fluid with meals.” WHATS THE AMOUNT c. “Oral temperature slightly elevated at 0800.” WHATS THE TEMP d. “Administered pain medication.” <Any action & change to the client‟s condition should be recorded> 20. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include? a. “Use full-length side rails on the client‟s bed.” b. “Check on the client frequently while he is in the restroom.” c. “Encourage physical activity throughout the day to expand energy.” d. “Remove clocks from the client‟s room.” 21. A nurse in an emergency department is assessing a client who reports RIGHT lower quadrant pain, nausea and vomiting for the past 48 hr. Which of the following actions should the nurse take first? a. Auscultate bowel sounds. b. Administer an antiemetic. c. Offer a pain med. d. Palpate the abdomen. Possible appendicitis “nausea/vomiting” with RLQ pain. (IAPP) INSPECTION. AUSCULTATE. PERCUSS. PALPATE- FOR BOWEL 22. A nurse is assessing a client‟s extraocular eye movements. Which of the following should the nurse take? a. Instruct the clients to follow a finger through the six cardinal fields of gaze.  Rationale: Cardinal fields of gaze test for cranial nerves 3, 4, and 6 which are for eye movement b. Hold a finger 46 cm (18 in) in front of the client‟s eyes. c. Ask the clients to cover her right eye during assessment of her left eye. d. Position the client‟s 6.1 m (20 feet) away from the Snellen chart. (This is for cranial nerve 2) 23. A nurse is providing a teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? a. Urticaria b. Ptosis c. Nausea d. Hematuria 24. A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessments findings should the nurse identify as a contraindication to the application of cold? a. Cap refill 4 seconds-ITS CONTRAINDICATED TO USE APPLICATION OF COLD b. 7.5 cm (3 in) diameter bruise on the ankle IT HELPS ON BRUISE c. Warts on the affected ankle d. 2+ pitting edema -HELPS REDUCE INFLAMMATION (EDEMA) 25. A nurse is caring for a client who has TB. Which of the following precautions should the nurse plan to implement when working with the client? Chapter 11 fundamentals 9.0 infection control page 52 a. Airborne  Rationale:measle, varicella, pulmonary or laryngeal tuberculosis b. Droplet-streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). c. Protective d. Contact 26. A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document? Chapter 55 Pressure ulcers, wounds and wound management? fundamentals pdf page 330 a. Stringy, white tissue- same as slough. Means that it is sepatated from the body. b. Translucent, red tissue- red means healthy and its healing c. Soft, yellow tissue= means presence of slough and drainage. d. Thick, black tissue- black is necrotic = eschar is present and needs removal 27. A nurse is screening several clients at a neighborhood health fair. Which of the following assessments findings is the priority for referral for further care? a. Blood glucose 45 mg/dL  Rationale: low/hypoglycemia may lead to shock  level is abnormally low, [74-106 mmol/L] b. Blood pressure 148/92 mm Hg STAGE 1 HYPERTENSION c. Body mass index 28 kg/m2 OVERWEIGHT d. Heart rate 105/min 28. A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care? a. Obtain a random blood glucose daily. b. Change the PN infusion bag every 48 hr. CHANGE Q24HR c. Prepare the client for a central venous line. d. Administer the PN and fat emulsion separately. ATI FUNDA PG. 298 Administer separate IV line below the filter using a Y-connector or as a admixture to PN solution (3-in-1 admixture consisting dextrose, AA, and Lipids 29. A nurse is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the nurse include? a. “Obtain a tetanus booster every 5 years.” b. “Obtain a herpes zoster immunization by age 50.” c. “Have a dental examination every 6 months.”(funds atipg 201 says they need dental cause they are prone to infection) d. “Have a testicular examination every 2 years.” 30. A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include? a. “Use tracheostomy covers when going outdoors.” Google b. “Maintain sterile technique when performing tracheostomy care.” c. “Remove the outer cannula for routine cleaning.” d. “Clean around the stoma with povidone-iodine.” NS 31. A nurse in the emergency department is measuring a client‟s oral temperature using an electronic thermometer. Which of the following actions should the nurse take? Chapter 27 Vital sigsn p.133 a. Provide oral hygiene prior to measuring the client‟s temperature. b. Ask the client if he has smoked within the past 30 min c. Attach the red tip probe to the thermometer unit. d. Place the tip of the probe along the client‟s buccal mucosa.- must be unde the tongue in the posterior sublingual pocket lateral to the center of the lower jaw. 32. A nurse is caring for a client who had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult? a. Registered dietician- helps with healthy food planning. b. Occupational therapistchapter 2 page 7 the interprofessional team. c. Speech-language pathologist- yes the question said stroke , but the question wants who will help him with every day ADLS. speech patho help them if they have a hard time swallowing. d. Physical therapist- is used of the patients cannot even move his muscles. 33. MISSING 34. A nurse overhears a colleague informing a client that he will administer her medication by injection if she refuses to swallow her pills. The nurse should recognize that the colleague is committing which of the following torts? a.) Defamation- you embarass someone by making fun of them. b.) Malpractice- you did something by accident c.) Assault- verbal threatening d.) Battery- actually causing physical harm or trauma. 35. A nurse is caring for clients who is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication? a. “I will first dissolve the tablet in water.” b. “I will insert the tablet between my cheek and teeth.” c. “I will place the tablet under my tongue.”- this is sublingual d. “I will chew the tablet.”- this is oral 36. A nurse is admitting a client who is malnourished. The client states my wedding ring is loose and I'm worried I will lose it if it falls off. Which of the following is an appropriate response by the nurse? a. “I can pin it to your hospital gown, so you won't lose it.” b. “I will place it in your drawer, so it won't get lost.” c. “I will hold onto it until a family member can take it home.” d. “I can put it in a locked storage unit for you.” 37. A nurse is changing a client's colostomy pouch and notices peristomal skin irritation. Which of the following actions should the nurse take? a. Change the pouch once every 24 hour. b. Apply the pouch while the skin Barrier is still damp.(no ) c. Rub the peristomal skin dry after cleaning. (No it will irritate skin more ) d. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. rationale : ATI FUNDA PG 241 38. A nurse is preparing change of shift report after the night shift using one sbar communication tool. which of the following data should the nurse include when reporting background information? a. “Blood pressure 160/92 mm Hg”- part of ASSESSMENT b. “Start first dose of penicillin at 1200”- c. “Pain rating of 5 on a scale from 0 to 10” d. “Code status: do-not-resuscitate” 39. A nurse is caring for a client who has extracellular fluid volume deficit. Which of the following findings should the nurse expect? Chapter 57 fluid volume imbalances page 343. a. Postural hypotension b. Distended neck veins c. Dependent edema d. Bradycardia - would be TACHY since SNS system kicks in when detects low blood volume TACHYCARDIA is for fluid overload. Isnt wherever the water goes the sodium follows. The lady on ati gave me a remediation hw about manifestation of hypernatremia: hyperthermia, tachycardia, and orthostatic hypotension. Therefore it‟s opposite→ bradycardia. TBC by the group 40. A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely increase the client‟s motivation to learn? a. The nurse empathy about the client having to self-inject b. The client's belief that his needs will be met through education c. The client seeking family approval by agreeing to a teaching plan d. The nurse explaining the need for education to the client 41. A nurse is conducting a Weber test on a client. Which of the following is an appropriate action for the nurse to take? a. Deliver a series of high-pitched sounds at random intervals. b. Place an activated tuning fork in the middle of the client's forehead. c. Hold and activated tuning fork against the client's mastoid process. d. Whisper a series of words softly into one ear. 42. A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. a. “I need to check my medications for expiration dates.” b. “I will use the grab bars when getting in and out of the bathtub.” c. “I need to have a fire escape plan with my family.” d. “I need to set my hot water heater to 140 degrees Fahrenheit.”- no more than 120 degrees e. “I will apply tapes over frayed areas of electrical cord.” 43. A nurse is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the nurse provide to the assistive personnel? a. Collect at least 2 inches of formed stool. b. Wear sterile gloves while obtaining the specimen. c. Use a culturette for specimen collection. d. Record the date and time the stool was collected.(funds ati pg423) 44. A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first? a. Peripheral pulses ABCS always first b. Comfort level c. Elimination needs d. Skin integrity 45. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take? a. Remove the restraints every 4 hr. b. Attach the restraints securely to the side of the client's bed. c. Apply the restraints to allow as little movement as possible. d. Allow room for two fingers to fit between the client's skin and the restraints.- for circulation 46. A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?Page 244 and 240 chapter 44 urinary elimination THIS IS CONFUSING. 244 SAYS FOR CLIENTS WHO MUST REMAIN SUPINE BUT 240 SAYS THAT CLIENTS MUST HAVE Hob UP AT 30 DEGREES. a. Place the shallow end of the fracture pan under the client's buttocks. b. Hyperextend the client's back while the fracture pan is in place. c. Keep the bed flat while the client is on the fracture pan- head of bed must be 30 degrees. page 240 d. Encourage the client to try to defecate for 20 min while on the fracture pan. 47. A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? a. Exercise 1 hr before bedtime. b. Eat a light carbohydrate snack before bedtime. This was on the fundamentals practice test on ATI funds 2013 c. Drink a cup of hot cocoa before bedtime. d. Take a 30 min nap daily. 48. A nurse is performing an admission assessment of a client. Which of the following actions should the nurse take when recording the client's medication? a. Council the client about medication adherence. b. Assess the client for medication reactions. c. Compile a list of the client's current medications. d. Evaluate the client's understanding of medications. 49. During an admission history a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress? a. Blood glucose- common stress response. Tiamson said it b. Intestinal peristalsis → per padgham? Not sure c. Peripheral blood vessels diameter- should be constricted since youll have HIGH blood pressure . d. Urine output 50. A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a. “I should roll the NPH between my hands before drawing it up.”- it says ROLL so that makes sense , this would be wrong if it said SHAKE becasue that will break up the proteins. b. “I should wait 10 minutes after mixing the insulin to inject it.”- i believe it is up to 5 minutes but ima double check. c. “I should draw up the NPH insulin before the regular insulin.”- nope its clear to cloudy always so you must draw up regular beofre NPH d. “I should inject air into the vial of regular insulin first.”- nope, when doing clear to cloudy, you inject AIR into NPH first 51. A nurse is caring for a client who is grieving the loss of her partner. The client states I don't see the point of living anymore. which of the following actions should the nurse take? a. Request the client's family provide additional support. b. Ask the client if she plans to harm herself.- safety first c. Tell the client that this is a normal response to grief. d. Recommend that the client seek spiritual guidance. 52. A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? Chapter 19 pharm p. 145 a. “I will take a hot bath before going to bed.”- they are old also, so sensation is impaired. b. “I will take my new medication in the evening.”- this is a diueretic so this must be in the MORNING c. “I will leave a light on in my bathroom at night.”-some clients might have to take it twice per day usually last dose taken before 1400. You leave a light on in the bathroom because they might have to go urinate at night time ( since nocturia is a possible side effect ) d. “I will weigh myself once weekly.”- patients must weight themselves ONCE per day usually upon awakening. 53. A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? a. Monitor the client for pain in the suprapubic region. b. Ensure the client is free of metal objects. c. Administer 240 mL (8 oz) of oral contrast before the procedure. d. Assist the client with a bowel cleansing.  Fundamentals Textbook pg 1114  IVP = imaging of the urinary tract after iv injection of iodine  Prep – assess allergies & dehydration, cleanse bowel, restrict food 4 hrs prior 54. To ensure client safety a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning? a. Case manager- they do no provide direct client care ,over see case load of clients b. Client educator c. Client advocate 55. A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?P .222 chapter 40 mobility and immobility a. Ankle-foot orthotic b. Continuous passive motion machine- range of motion prevents ankylosis ( permanant fixation of a joint ). c. Abduction splint d. Sequential compression device 56. A nurse is planning to use non formal logical pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan? a. Apply an ice pack to the client's back for 1 hr.  Cold therapy = reduced inflammation & slows down nerve impulses  Heat therapy = stimulates blood flow & inhibits pain messages  Avoid long applications of either cold or heat b/c results in tissue damage b. Remove distractions from the client‟s room. c. Instruct the client to take deep rhythmic breaths. d. Encourage the client to apply a heating pad for 2 hr at a time.- 2 hours seems too long 57. A nurse is caring for a client who is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? Sacrum , buttock and heals are prone for ulcers. NON blanckingerthyema in merks manual . blanching is considered good since that means tissue perfusion a. Flat rash on the client's ankle b. Non blanching red area over my clients trochanter c. Ecchymosis on the clients left shoulder d. Petechiae on the client's right anterior thigh 58. A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?Chapter 40 mobiltiy page 220 a. Musculoskeletal weakness b. Loss of appetite c. Increased heart rate during physical activity d. Left lower extremity tenderness- warmth and tenderness = DVT= PE if it dislodges!!! Effects on the heart and blood Like the muscular system, the cardiovascular system functions best when the body is in an upright position, working against gravity. After just a few days of bed rest, blood starts to pool in the legs. On standing, this can lead to dizziness and falls. Immobility also causes the heart to beat more quickly, and the volume of blood pumped is lower. The volume of blood generally in the body is lower, and there is less oxygen uptake by the body. This results in poorer aerobic fitness and fatigue sets in more easily. The blood also becomes thicker and stickier, which increases the risk of a blood clot forming, especially in the legs (deep vein thrombosis) and the lungs (pulmonary embolism). 59. A nurse is assessing a client's ability to balance. Which of the following actions is appropriate when the nurse conducts a Romberg test? Page 168 chapter 31 musculosketal and neuro systems a. Ask the client to extend her arms in front of her body. b. Ask the client to walk in a straight line heel To toe. c. Have the client stand with her feet together.- also with eyes closed. There should not be swaying d. How the client place her hands on her hips. 60. A nurse is providing care for a client who is to undergo total laryngectomy. which of the following interventions is the nurse‟s priority? a. Schedule a support session for the client. b. Explain the techniques of esophageal speech. c. Review the use of artificial larynx with the client. d. Determine the client's reading ability. ESOPHAGEAL SPEECH is based on the technique in which the patient transports a small amount of air into the esophagus. 61. MISSING 62. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include? a. Avoid taping electrical cords to the floor. b. Clean electrical equipment prior to disconnection. c. Cover exposed wires with tape before used. d. Disconnect electrical equipment by grasping the plug. 63. A nurse is caring for a client who has a tracheostomy collar. As the nurse is performing tracheal suctioning, the client‟s heart rate and oxygen saturation decrease. which of the following actions should the nurse take? a. Elevate the head of the bed. b. Remove the inner cannula. c. Irrigate the stoma. d. Discontinued suctioning. 64. A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is a priority? a. Teach the client to use progressive relaxation techniques. b. Help the client to find a local support group. c. Discuss the client's prior coping mechanism. d. Develop a list of goals with the client. 65. A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. the stop should include that the nurse signature on the form confirms which of the following requirements? (Select all that apply.) a. The client was not coerced. b. The client does not have a mental health condition. c. The client Signed in the nurse‟s presence. d. The client speaks the same language as the nurse. e. The client has legal authority to do so. ATI: FUNDA PG. 17 66. A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel? a. Teach deep breathing and coughing to the client.- Teaching is always RNS job b. Assist the client to select food choices from the menu. c. Evaluate the client‟s response to pain medication. NURSING PROCESS is always RNS job d. Monitor the characteristics of the client's chest tube drainage.- Evaluating treatment, is part of nursing process and is always RNS job. 67. A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss? a. A family whose only child recently died due to cancer. b. A family whose head of household lost her job. c. A family whose house was destroyed in a fire. d. A family whose oldest child is moving away for college Rationale: Flashcardmachine: Maturational loss- experienced as a result of natural developmental processes. E.g. The first child may experience a loss of status when her sibling is born. Also, happens when sending children off to kindergarten or college. 68. A nurse on a medical-surgical unit is dividing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she “doesn't like him.” b. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions. c. The family of a client who has a terminal illness as the provider not to tell the client the diagnosis. d. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications. Rationale: ATI FUNDA pg. 11 it involves between two moral imperatives; answer will have a profound effect on the situation and the client. 69. A nurse is caring for a client who has chronic back pain and asked about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this shipment? a. Obesity b. Hypertension c. Migraines d. Cellulitis  Rationale: Google: You can‟t have acupuncture in a very swollen area e.g. Cellulitis; and it‟s a risk for infection  Rationale: Contraindicated in people who have bleeding disorders and skin infections. Fundamentals pg 694 70. A nurse is auscultating a client's abdomen. The nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following? a. Gallop b. Bruit c. Thrill d. Murmur Rationale: Bruit- turbulent blood flow within the aorta. ATI FUNDAMENTALS 1. A nurse is providing teaching to a client who has a new med prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? a. Ptosis b. Hematuria c. Urticaria d. Nausea 2. A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood glucose test. Which of hte following instructions should the nurse include in the teaching? a. Don sterile gloves prior to puncturing the site b. Puncture site after cleansing and before antiseptic dries. c. Gently squeeze the puncture site until a large droplet of blood forms d. Hold the finger to puncture above the level of the heart 3. A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures . b. I will hold my breath when rising from a sitting position c. I will remove my antiembolic stockings while I am in bed d. I will have my partner help me change positions every 4 hours 4. A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phelbitisat the IV site? a. Erythema along the path of the vein b. Pitting edema at the insertion site- infiltration since water is probably displaced. c. Coolness of the client‟s left forearm - infiltration d. Pallor of the client‟s left forearm 5. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime? a. Provide a late supper b. Offer a wet washcloth for the client to wash her face c. Perform range of motion excercise d. Prepare a hot cocoa or tea for the client 6. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? a. I will place the client in a private room b. I will tell the client‟s visitors to wear a mask when they are within 3 feet of the client c. I will remove my gown after leaving the client‟s room d. I will wear an N95 respirator mask when caring for the client 7. A nurse is teaching a client who requires maximal support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching. a. The client moves the walker ahead 25.4cm with each step b. The client picks up the walker with each step c. The client stands with her elbow slightly while holding the walker d. The client stoops slightly forward when moving the walker 8. A nurse in a provider‟s office is caring for a client who states “I always have trouble sleeping”. Which of the following actions should the nurse take first? a. Teach the client stress reduction techniques b. Recommend that the client avoid caffeine intake in the evening c. Identify the client typical bedtime routine d. Encourage the client to exercise regularly during day time hours. 9. A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the nurse include when developing the plan of care? a. The hispanic culture views late adulthood as a negative time in the client‟s life b. The hispanic culture identifies the eldest female family member as the decision maker c. The Hispanic culture expects individuals to make their own decisions when death is imminent. d. The hispanic culture expects adult children to care for older adult parents. 10. A nurse is teaching about home safety with a client. Which of the following instructions should the nurse include? a. Unplug electronics by grasping the cord b. Use electrical tape to secure extension cords next to baseboards on the floor c. To use a fire extinguisher, aim high at the top of the flames. d. Replace carpeted floors with tile 11. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take? a.) Perform deep palpation at the end of the admission assessment b.) Auscultate the client‟s abdomen before palpation c.) Begin palpation of the abdomen at the site of pain d.) Assess the client‟s bowel sounds using the bell of the stethoscope <inspect - auscultate - palpate - percuss> 12. A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take? a.) Allow the client to hear running water while attempting to void b.) Provide the client a bedpan while lying supine c.) Insert an indwelling urinary catheter and connect it to gravity drainage d.) Encourage fluid intake up to 1,000 mL daily <least invasive first, bedpan doesn‟t promote independence, fluid intake more than 2L> 13. A nurse on a medical surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first? a. ) A client who has new onset of dyspnea 24 hr after a total hip arthroplasty0 can mean dvt b.) A client who has acute abdominal pain of 4 on a scale from 0 to 10 c.) A client who has a UTI and low-grade fever d.) A client who has pneumonia and an oxygen saturation of 96% <always look for new onset of anything, other findings are normal also.> 14. A nurse is caring for a client who is nauseated and unable to eat after taking her antibiotic. Identify the steps the nurse should take to address the nausea. a.) Identify possible nursing interventions that address the client‟s nausea (1) b.) Review the potential benefits and consequences of each intervention (2) c.) Select an intervention that provides the greatest benefit and least risk (4) d.) Determine the probability of intervention-related complications (3) <I am sure, it goes (a) to (b), but I am uncertain whether it is (d) first or © first, what do you guys think?> 15. A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern about his future. Which of the following is therapeutic response by the nurse? a.) “You‟re concerned about what will happen when you leave the hospital?” b.) “If you work hard on your physical therapy, you won‟t need to worry” c.) “You shouldn‟t worry about the future so you can concentrate on getting well” d.) “Why are you concerned even though everyone is here to help you?” 16. A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take? a.) Follow a systematic pattern from side-to-side moving down the client‟s chest b.) Ask the client to breathe in deeply through his nose c.) Instruct the client to sit erect with his head tilted slightly backward d.) Place the bell of the stethoscope on the client‟s chest 17. A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select ALL) a.) “I need to set my hot water heater to 140 degrees Fahrenheit” b.) “I will use the grab bars when getting in and out of the bathtub” c.) “I will apply tape over frayed areas of electrical cords” d.) “I need to have a fire escape plan with my family” e.) “I need to check my medications for expiration dates” 18. A nurse is caring for a client preoperatively who has given informed consent for an appendectomy. Which of the following statements by the client should the nurse address first? a.) “I am afraid to walk if it hurts too much” b.) “I don‟t understand why I need this surgery” c.) “I don‟t want my family helping me after the surgery” d.) “I am afraid the scar will make me look disfigured” 19. A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take? a.) Place the shallow end of the fracture pan under the client‟s buttocks b.) Encourage the client to try to defecate for 20 min while on the fracture pan c.) Keep the bed flat while the client is on the fracture pan d.) Hyperextend the client‟s back while the fracture pan is in place <fundamentals pg. 240;; head of the bed to 30, never leave a client lying flat on bedpan,... 20. A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a.) “I should roll the NPH vial between my hands before drawing it up” b.) “I should draw up the NPH insulin before the regular insulin” c.) “I should inject air into the vial of regular insulin first” d.) “I should wait 10 minutes after mixing the insulin to inject it” <NPH - regular - regular - NPH> 21. A nurse is caring for a client who is confused and pulling at the tubing of her IV. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider? a.) Place the client in a room away from the nurses‟ station b.) Limit the client‟s visitors c.) Give the client washcloths to fold d.) Close the door of the client‟s room 22. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report? a.) Where the client ate his breakfast b.) The times for routine vital sign measurements c.) The exact times the client had visitors d.) The type of transmission-based precautions in place 23. A nurse on a med-surg unit is teaching newly licensed nurse about tasks to delegate to AP. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a.) “An AP may take orthostatic blood pressure measurements from a client who reports dizziness” - RNs job since this requires ASESSMENT due to episode of adverse effect. b.) “An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids”- monitoring is part of assessment since it is using judgment c.) “An AP may perform a central line dressing change for a client who is ready for discharge” d.) “An AP may count the respirations of a client who is going to have surgery later the same day”- the client has surgery LATER that day, so this should mean that the patients condition is not that urgent 24. A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a.) A surgeon who removed the wrong kidney during a surgical procedures refuses to take responsibility of her actions- please double check anyone b.) A client who has a new colostomy refuses to take instructions from the ostomy therapist because she “doesn‟t like him” c.) The family of a client who has a terminal illness asks that the provider not tell the client the diagnosis d.) A client who has Crohn‟s disease reports that his prescription drug plan will not pay for his medications 25. A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client‟s continuity of care? a.) Plan to assign a different nurse to the client each shift b.) Limit the number of interdisciplinary team members managing the client‟s care c.) Request that the client complete a satisfaction survey at discharge d.) Start discharge planning on the day of admission 26. A nurse is caring for a client who begins to experience a generalized seizure while standing in her room. Which of the following actions should the nurse take? a.) Place a pad under the client‟s head b.) Hold the client‟s limbs tightly to prevent injury c.) Lift the client into bed with the help of other staff members (You assist them to fall) d.) Insert a bite block into the client‟s mouth <DOUBLE-CHECK this> Rationale: PDF p 58: Advise all caregivers and family not to restrain the client during a seizure but to lower him to the floor or bed, protect his head, remove nearby furniture, provide privacy, put him on his side with his head flexed slightly forward if possible, and loosen his clothing. 27. A nurse is caring for a client who is grieving the loss of her partner. The client states, “I don‟t see the point of living anymore.” Which of the following actions should the nurse take? a.) Recommend that the client seek spiritual guidance b.) Request that the client‟s family provide additional support c.) Tell the client that this is a normal response to grief d.) Ask the client if she plans to harm herself 28. A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan? a.) Empty the drainage bag at least every 8 hr b.) Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Tape the catheter to the lower abdomen 29. A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include? a.) “Keep a nightlight on the bathroom” b.) “Set room temperature to 68 degrees Fahrenheit” c.) “Place throw rugs over electrical cords” d.) “Use chairs without arm rests” 30. A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care” (select ALL) a.) Secure restrains to allow three fingers to slide under the restrains (1-2 fingers) b.) Ensure that the bed is in the lowest position c.) Tie each restraint with a quick-release knot d.) Attach the client‟s restraints to the bed rail (to the bed frame) e.) Remove the client‟s restraints every 2 hr 31. A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client‟s son tells the nurse, “I don‟t know what to tell my dad if he asks how he is going to die.” Which of the following is an appropriate response by the nurse? a.) “Let‟s talk more about your dad‟s condition” <???????? I think this is more for the physician b.) “The social worker will help you answer those questions” c.) “I think that you should discuss this with the hospice nurse” d.) “Try to help your dad enjoy this time as much as he can” 32. A nurse is caring for a client who will receive intermittent enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? (select ALL) a.) Keep the client sitting upright for 15 min following administration b.) Instill the formula over a period of 30 to 45 min c.) Heat the formula to 80F prior to administration d.) Check for residual volumes by aspirating stomach contents e.) Place the client into the Fowler‟s position 33. A nurse is preparing to administer metoprolol 25 mg PO every 12 hr. Available is metoprolol 50 mg/scored tablet. How many tablets should the nurse administer with each dose? (nearest tenth) -> Answer;; 25mg x (1 tablet/50mg) = 0.5 tablet 34. A nurse is assessing a client who is receiving tube feedings via NG tube. Which of the following findings should the nurse report to the provider? a.) Potassium 5.5 mEq/L b.) Irritation of nasal mucosa c.) Sodium 144 mEq/L d.) Loose stools 35. A nurse is caring for a client who consumed 4 oz of juice, 16 oz of milk, 8 oz of coffee, and 200 mL of water over an 8-hr period. Calculate the client‟s intake for that 8-hr period using millilters. (nearest whole number) 1oz=30mL -> Answer;; 120mL (juice) + 480mL (milk) + 240mL (coffee) + 200mL (water) = 1,040mL 36. A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? a.) Use proper medical terms when giving instructions to the client. b.) Offer written instructions in the client‟s language c.) Direct verbal discharge instructions to the interpreter (No, supposed to address the pt) d.) Request that an assistive personnel interpret that instructions for the client <DOUBLE-CHECK it for me, confused between B&C> Rationale PDF p175: Address the client directly when the interpreter is present, Provide educational materials and instructions in the client‟s language. 37. A nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? a.) Don sterile gloves prior to opening sterile dressing supplies b.) Set up the sterile field above waist level c.) Consider 5.08cm (2 in) of the sterile field‟s border to be contaminated d.) Place the cap of a sterile solution inside the sterile field 38. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a.) Assess the client for a gag reflex b.) Measure the pH of the gastric aspirate c.) Place the end of the NG tube in water to observe for bubbling d.) Auscultate 2.5cm (1 in) above the umbilicus while injecting 15 mL of sterile water 39. A nurse is documenting in a client‟s medical record. Which of the following entries should the nurse record? a.) “Incision without redness or drainage” b.) “Drank adequate amounts of fluid with meals” c.) “Administered pain medication” d.) “Oral temperature slightly elevated at 0800” 2013 - Folder 2 40. A nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following images indicates the proper method of cleaning a wound site. PDF p 330: Perform wound cleansing. - For clean wounds, such as a surgical incision, cleanse from the least contaminated (the incision) toward the most contaminated (the surrounding skin). - Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound. - Although the provider might prescribe other mild cleansing agents, isotonic solutions remain the preferred cleansing agents. -Never use the same gauze to cleanse across an incision or wound more than once. -Do not use cotton balls and other products that shed fibers. - If irrigating, use a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5 to 8 psi of pressure. A 30 to 60 mL syringe with a 19‑gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer‟s, or an antibiotic/antimicrobial solution -Remove sutures and staples. - Administer analgesics and monitor for effective pain management. - Administer antimicrobials (topical, systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count). -Document the location and type of wound and incision, the status of the wound and type of drainage, the type of dressing and materials, client teaching, and how the client tolerated the procedure. 41. A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take? a. Press straight down on the container to create a vacuum b. Wear sterile gloves when emptying the container c. Reset the container with the drainage port closed d. Maintain the drain in a dependent position to facilitate drainage 42. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corn And calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching? a. I can place an oval corn pad over toes that have corns as long asi remove the pad weekly b. I should soak my feet in warm water daily to soften corns and calluses c. I can apply lotion to soften calluses as long asidont put lotion between my toes d. I should use an over the counter liquid medication to remove corns Rationale PDF p205: A qualified professional should perform foot care for clients who have diabetes mellitus to evaluate the feet and prevent injury. Instruct clients at risk for injury to do the following: inspect the feet daily, paying specific attention to the area between the toes; Use lukewarm water, and dry the feet thoroughly; Apply moisturizer to the feet, but avoid applying it between the toes; Avoid over‑the‑counter products that contain alcohol or other strong chemicals; Avoid self‑treating corns or calluses; Do not apply heat unless prescribed. 43. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include? a. Remove clocks from the clients room b. Use full length side rails on the clients bed (considered a restraint) c. Check on the client frequently while he is in the restroom (safety) d. Encourage physical activity throughout the day to expend energy 44. A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? a. Contact b. Droplets c. Airborne d. Protective environment 45. A nurse is planning to use nonpharmacological pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan? a. Encourage the client to apply a heating pad for 2 hours at a time b. Apply an ice pack to the clients back for 1 hour c. Remove distractions from the client‟s room (distraction is good for the pt to get mind off of pain) d. Instruct the client to take deep, rhythmic breaths Rationale PDF p 223: Avoid long applications of either heat or cold because this can result in tissue damage, burns, and reflex vasodilation (with cold therapy). PDF p.233: Breathwork: Reduces stress and increases relaxation through various breathing patterns 46. A nurse is teaching a client how to use an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. I will try not to cough after using the spirometer (it‟s good to cough up sputum) b. I will use the spirometer three times a day (3-5x an hour) c. I will initially hold my breath for 15 seconds (for inhalers) d. I will seal my lips around the mouthpiece 47. A nurse is preparing to provide foot care for a client. Identify the order in which the nurse should perform the steps of foot care - Test the temperature of the water - Soak the client's feet in warm water - Use an orange stick to clean under the nails - Apply lotion to the client's feet 48. A charge nurse is assigning tasks to nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP? a. Report ABG results to the provider b. Instruct a client about how to use an incentive spirometer c. Administer an enteral feeding to a client who has an established gastrostomy tube d. Monitor the color of a client‟s urinary output 49. A nurse is interviewing a family as part of a family assessment. The nurse identifies the family unit as a husband, a wife, and three children. One child is biological from this marriage and the other two are from the wife‟s previous marriage. The nurse should identify this as which of the following family forms? Extended Blended Nuclear Alternative 50. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? a. Obtain a replacement pump b. Notify the biomedical department to fix the pump c. Label the pump with a defective equipment sticker d. Unplug the pump- unplugging will remove the source of potential fire started . 51. A nurse is preparing to insert IV catheter for an adult client. Which of the following actions should the nurse take? a. Choose the most proximal site on the extremity selected (distal first) b. Apply a cool compress for several minutes before insertion of the IV catheter (warm it) c. Stroke the extremity for several minutes before insertion of the IV catheter d. Place the tourniquet below the proposed insertion site (above it) 52. A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching a. I will place the bed in the lowest position (place at your hip level) b. I will tighten my abdominal muscles prior to moving c. I will keep my legs straight to provide more power in the lift (bend) d. I will twist at the waist while pulling the draw sheet (avoid) Rationale PDF p71: Avoid twisting your thoracic spine and bending your back while your hips and knees are straight; When lifting an object from the floor, flex your hips, knees, and back; tighten the abdominal muscles to increase support to the back muscles 53. A nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report? a. Frequency of previous vital sign measurement b. Number of family members who have visited c. Time of the clients last bath d. Effectiveness of the last dose of pain medication Rational PDF p39: Transfer documentation: -Medical diagnosis and care providers - Demographic information -Overview of health status, plan of care, and recent progress - Alterations that can precipitate an immediate concern -Notification of assessments or care essential within the next few hours -Most recent vital signs and medications, including PRN - Allergies - Diet and activity orders -Specific equipment or adaptive devices (oxygen, suction, wheelchair) -Advance directives and emergency code status - Family involvement in care and health care proxy, if applicable 54. A nurse is assessing a client‟s bowel sounds. Which of the following actions should the nurse take? a. Listen to the bowel sounds after performing abdominal palpation (inspect, auscultate, percuss palpate) b. Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes) c. Place the diaphragm of the stethoscope over each quadrant d. Ask the client to cough upon auscultation (for lung assessment) 55. A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate? A. Evaluating healing of an incision B. Inserting a NG Tube C. Performing a simple dressing change. D. Changing IV tubing. 56. A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care? A. HR 105/min B. BMI 25 kg/m2 C. BP 148/92 D. Glucose 45mg/dl 57. A nurse is assessing a client‟s extraocular eye movements. Which of the following actions should the nurse take? A. Position the client 6.1m(20ft) away from the Snellen chart. B. Instruct the client to follow finger through the six cardinal position of gaze, C. Ask the client to cover her right eye during assessment of her left eye. D. Hold a finger 46cm (18inch) in front of the client‟s eye. 58.A nurse is planning care for a client who has prescription of knee-length antibolic stockings. Which of the following actions should the nurse take? A. Remove the client‟s stockings at least once each shift. B. Roll the top of the client‟s stocking down to just below the knee. C. Seat the client in a chair for 30min prior to applying stockings D. Measure the length of the client‟s leg from the heel to gluteal fold. 59. A nurse is assessing a client‟s oculomotor nerve functions. Which of the following actions should the nurse take? A. Check the client‟s pupillary reaction to light B. Ask the client to read print from the Snellen chart C. Ask the client to identify diff scents D. Use cotton to touch the client‟s cornea lightly. 60. A nurse is planning to perform ear irrigation on an adult client who has impacted cerumen. Whichof the following should the nurse plan to take? A. Wear sterile gloves while performing irrigation B. Position the client with the affected side down following irrigation C. Use cool fluid to irrigate the ear canal. D. Pull the pinna downward during irrigation. 61. A nurse is preparing to administer gentamicin 2mg/kg via IV bolus to a client who weighs 220lb. How many mg should the nurse administer? 200mg 62. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication are not option for managing pain. Which of the following is an appropriate response by the nurse? A. Im sure it will work if you just give it a chance? B. You may take any herbal remedies you bring from home C. Why do you think pain medication is not going to help you D. Would you like me to give you a back massage? 63. A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first? A. Provide the client with contact number for diabetes education specialist. B. Obtain printed information on insulin self-administration C. Make a copy of the medication reconciliation from for the client D. Determine whether the client can afford the insulin administration supplies 64. A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take? A. Allow the client to slide down his outstretched leg. B. Place his arms around the client to prevent her fall. C. Remain upright as the client falls toward him D. Move quickly to a position in front of the client. 65. A nurse is preparing to use the Z-track method to administer iron dextran to a client who has iron-deficiency anemia. The client asks why this method of injection is necessary. Which of the following responses should the nurse make? A. It decreases the risk of injecting medication into a blood vessel. B. It delays medication absorption C. It minimizes tissue irrigation D. It accelerates medication excretion 66. A nurse is conducting a health assessment for a client who take herbal supplements. Which of the following statement by the client indicates an understand of the use of the supplements? A. I use garlic for my menopausal symptoms. B. I use ginger when I get car sick C. I take ginkgo biloba for headache 11 Proven Ginkgo Biloba Benefits - Increases Concentration. ... - Reduces Risk for Dementia and Alzheimer's. ... - Helps Fight Anxiety and Depression. ... - Fights Symptoms of PMS. ... - Helps Maintain Vision and Eye Health. ... - Helps Prevent or Treat ADHD. ... - Improves Libido. ... - Helps Treat Headaches and Migraines. D. I take echinacae to control cholesterol 67. A nurse is caring for a client who has C-diff infection Which of the following actions should the nurse take? A. Give the client chlorhexidine gluconate for hand hygiene. B. Remove the protective gown first when exiting the client's room C. Use alcohol-based hand rub when caring for the client D. Initiate contact precautions when providing client care 68. A nurse is caring for a client who is scheduled for hip surgery in hr. Which of the following actions is the nurse‟s priority? A. Ensure that the client has signed the consent form. B. Lock the client‟s valuable in a safe location C. Verify that the client‟s lab values are in the medical record. D. Administer the prescribed preoperative sedative. 69. A nurse is caring for a client who has prescription for morphine 5mg IM accidentally administers the whole 10mg from the single dose vial. Which of the following actions should the nurse take first? A. Complete an incident report B. Measure the client‟s respiratory rate C. Report the incident to the pharmacy. D. Notify the client's provider ATI FUNDAMENTALS 1. A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after excessive as I get older." 2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Absent bowel sounds with distention 3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority? Temperature 4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Administe analgesics to the child on a routine schedule throughout the day and night. 5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Pericardial friction rub 6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than alcohol based hand rub to clean my hands." 7. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Discontinue the machine, and measure the blood pressure manually every 15 min. 8. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change 9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Temporal 10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The signature on the preoperative consent form is the client's 11. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? Assessment 12. A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? The nurse washes with her hands held higher than her elbows 13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Second intercostal space to the right of the sternum 14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart 15. A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? "What worries you about being without your teeth?" 16. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Encourage the client to express his thoughts about death and dying 17. A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? "Tell me what I can do to help you overcome your fear of giving yourself injections." 18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Confirm unresponsiveness 19. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Screening groups of older adults in nursing care facilities for early influenza manifestations 20. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Perform hand hygiene 21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Place the bladder of the cuff over the posterior aspect of the thigh 22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Identify the client using two identifiers 23. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back 24. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Sit on the toilet 30 minutes after eating a meal." 25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Obtain client information 26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Place the wheelchair at a 45 degree angle to the bed 27. A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation 28. A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Remove the restraints one at a time 29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Sit and hold the client's hand 30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "I keep having nightmares about my upcoming surgery." 31. A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Inspect, Auscultate, Percuss, Palpate 32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining cotton balls for the tracheostomy care 33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses 34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take? Notify the provider about the client's decision 35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? Donate autologous blood before the surgery 36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client reports severe pain 37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "Using a cuff that is too small will result in an inaccurately high reading." 38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Carefully remove the gloves and follow with hand hygiene 39. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? Lock the wheels on the bed and stretcher 40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Raise the level of the bed 41. A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action? Check the client's perineum 42. A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as: Purulent 43. A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of: Solutes in the urine 44. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should: Cleanse the entry port priot to withdrawing urine. 45. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance diet as tolerated." Which of the following is appropriate for the nurse to tell the patient? I am going to listen to your abdomen 46. A nurse is caring for a client who is post-op following a partial colectomy. THe patient has a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and asks the nurse when the NG tube will be taken out. Which of the following responses by the nurse is appropriate at this time? When the GI tract is working again, in about three to five days, the tube can be removed. 47. A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces? Oil Retention 48. When a nurse makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with 10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed. Which of the following actions should the nurse take? Notify the surgeon. 49. A nurse takes an older adult lient who has dysphagia following a CVA to the dining room for dinner. When assisting the client at mealtime, the nurse should: Offer the client tart or sour foods. (This makes it easier for them to swallow) 50. A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to: Establish an airway 51. A nurse is caring for several clients who are receiving O2 therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity? 100% oxygen via partial rebreathing mask 52. A client is hospitalized for an infection of a surgical wound following abd surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of: Vitamin C and Zinc 53. When communicating with a client who is hearing impaired, the nurse should Face the client and speak slowly 54. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take Examine the elbow 55. A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client: Is unable to swallow foods by mouth 56. CPR has been initiated for the client in the ER. The nurse understands that a critical concept related to effective cardiac chest compressions is the need to: Push hard and deep on the chest 57. A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device? Collapsing the device whenever its 1/2-2/3 full of air. 58. A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan? Demonstration of appropriate hand hygeine 59. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should Weight the client upon rising. 60. A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse: Refrigerates the collected specimen 61. When replacing a client's surgical dressing, the nurse should: Don clean gloves to remove the old dressing 62. A nurse is preparing to instert a NG tube for a client admitted with bowel obstruction. Which of the following should the nurse do first? Explain the procedure to the client. 63. A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to Ask if the patient is choking 64. Which nursing action prevents injury to a client's eye during the administration of eye drops Holding the tip of the container above the conjunctival sac 65. When ambulating a frail, older adult client, the nurse should Use the transfer belt if the client is unsteady 66. A client is recovering fromgallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour? 4-5 times per hour 67. A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon? A halo of erythemia on the surrounding skin 68. While changing the linen on the client's bed, the nurse should Hold the linen away from his body and clothing. 69. A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site? The area around the injection site feels warm when touched. 70. A post-op nurse has an indwelling catheter in place to gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse shoudl take is to: Check to see if the tubing was kinked. 71. A client's provider has ordered that sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen... In the morning upon rising. 72. The mother of a toddler calls the nurse "Help! My baby is choking on his food!" The nurse determines that the heimlich maneuver is necessary based on which finding: Inability of the toddler to cry or speak 73. A client returns from surgery with two penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site? Montgomery straps 74. A client who is post-op following laparotomy is reporting pain and dry mouth. The client has morphine sulfate ordered to control the pain. Before administrering the morphine sulfate prescribed for the client the nurse should first Measure the client's vital signs. 75. A nurse is teaching a lient with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client Positions the irrigating solution bag 30 inchees above the stoma 76. A nurse is performing an eye irrigation for the client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation? Wearing gloves during the procedure. 77. In planning care for a client with surgical wound helating by secondary intention, the nurse can anticipate that the client will Be at an increased susceptibility for infection. 78. A nurse is assessing a client admitted with sudden onset of severe back pain of unknow origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain? Tell me how you are feeling right now. 79. A nurse has inserted an indwelling catheter for a male patient. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction? Lower abdomen 80. A nurse is in a public building when someone cries out "Help! I think he is having a heart attack!" The nurse responds to the scene and finds the unconcious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after making certain someone has called for EMS, should be to Administer cardiac compressions. 81. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? Assessment 82. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Washing dishes 83. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Tachycardia 84. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? Inspection 85. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? A 10-month-old infant can pull up to a standing position. 86. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Observe the rate, depth, and character of the client's respirations. 87. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? "I can see that this is upsetting you." 88. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? The AP hangs the collection bag at the level of the bladder. 89. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A client who has a prescription for a transfusion of packed red blood cells. 90. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Provide a protein intake of 1.5 g/kg of body weight per day. 91. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? Tie the restraint with a quick-release knot. 92. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? Romberg test 93. A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Oil retention 94. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight 95. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? Impaired peristalsis of the intestines 96. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Cough deeply after each use. 97. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Bear weight on both of your legs." 98. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? Fidelity 99. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? Remove the safety pin from the extinguisher. 100. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic 101. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? Consult the medication reference book available on the unit. 102. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing. 103. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? Position the client on his left side. 104. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "It must be difficult to care for someone who is confined to bed." 105. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in Trendelenburg's position. 106. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Edema at the infusion site 107. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? Lower the client the floor and place a pad under the client's head. 108. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? Ventrogluteal 109. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client. 110. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss 111. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? People who practice Judaism status with the body of the deceased until burial. 112. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? Liver damage 113. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? Cold extremities 114. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? PC for after meals 115. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium 116. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? WBC 15,000 mm3 117. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? Airway 118. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? Repeat each joint motion five times during each session. 119. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown. 120. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? Educating clients about the recommended immunization schedule for adults 121. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? Have the client demonstrate the procedure. 122. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? Wear cotton clothing to avoid static electricity. 123. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? Bounding pulse 124. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? "All of this equipment can be frightening." 125. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? Place the client in a lateral position with the head turned to the side before beginning the procedure. 126. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? "Tell me more about how your friends discourage you." 127. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? Fill the bag two-thirds full with ice. 128. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? When lifting an object, spread your feet apart to provide a wide base of support. 129. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? Gelatin 130. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply) 1. Provide oral hygiene frequently 2. Measure the drainage from the NG tube every shift 3. Secure the NG tube to the client's gown ATI Fundamentals 1. 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. Decrease in heart rate b. Fluid volume deficit causes tachycardia 2. 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 signatures may the nurse legally witness? a. A 16 y/o client who is married b. A 27 y/o who has schizophrenia c. An adoptive parent who brings in his 8 yo son d. A 17 year old mother who brings in her toddler. 3. 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. Appy intermittent suction when withdrawing the catheter 4. 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. Avocados b. Avocados contain no cholesterol 5. 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. Assess the client for orthostatic hypotension b. The first action should be to assess the patient and determine if the patient is at risk for falling or fainting during the transfer. 6. A nurse is caring for a group of clients. Which of the following should the nurse take to prevent the spread of infection. a. Place a client who has TB in a room with negative pressure airflow b. A client who has TB requires airborne precautions 7. 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. 8. 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. Bladder scan shows 525 mL or urine b. A client who has an indwelling catheter should have continuous urine flow w/o an accumulation of urine in the bladder 9. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? a. Wash her hands before and after contact with the client b. Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria 10. 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. Compare prescriptions with medications the client received during hospitalization. b. When performing reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. 11. 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 catheter up to the hub reduces the risk of contamination along the length of the catheter. b. Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter 12. 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. Cheddar cheese b. Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are good sources of complete protein. 13. 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? a. Check the cord routinely for frays or tearing b. Consider purchasing a generator for power backup c. Observe for signs of hypoxia d. Clothing and bedding should not be made from synthetic fabric b/c it can generate static electricity, the client should wear cotton instead. Oxygen equipment should be at least 10 feet away from open flames (gas stove, fireplace). 14. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first? a. Check the IV tubing for obstruction 15. 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. Evaluate electrolytes b. Assess the client’s electrolytes first/lab results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances. You should not restrict intake of oral fluids first. 16. 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 w/o using a tourniquet. b. The nurse should use the tourniquet minimally or not at all to avoid injury to f \ragile skin or veins. 17. 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 18. 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. Elevate the head of the client's bed 19. 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? a. "We can talk about advance directives, and I can also give you some brochures about them." 20. 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 sharp or dull? b. Asking this type of question helps determine the quality of the pain. 21. 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. Breath sounds 22. 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 level of 3 g/dL b. An albumin level below 3.5 indicates protein deficiency, placing the client at risk for pressure ulcer formation and poor wound healing. The braden scale measures the patient’s risk for developing a pressure ulcer. 23. 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. Bruised on the arms in various stages of healing. 24. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next? a. Notify the nursing manager. b. The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore the nurse should activate the chain of command to ensure proper patient care. 25. 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. Swelling and coolness are observed at the IV site. 26. A client who is non-ambulatory 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. Evacuate the client b. RACE mnemonic (Rescue first) 27. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client? a. "We need to document the exact medication you were taking because you might be allergic to it." b. If there is any possibility that the client is allergic to a medication, it is imperative that the provider does not prescribe the same medication again. 28. 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 asthma. 29. 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. Restraints w/o padding can abrade the client’s skin. The nurse should remove the restraints at least every 2 hours to reposition the client and assess his need for hygiene and toileting. 30. 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? a. Make sure two fingers can fit under the sleeves. 31. 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? a. 107 ml/hr 32. 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 wears a mask when outside her room if there is construction in the area. b. An allogeneic stem cell transplant compromises the client’s immune system, putting her at risk for infection. 33. 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 degree angle. 34. 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. The nurse should examine her own personal values about the issue to help her provide care that is w/o bias. 35. 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? a. 8 oz of ice chips 36. 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. Practice sessions 37. 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? a. Use tracheostomy covers when outdoors. b. Tracheostomy covers protect the client’s airway from cold air, dust, and other airborne particles. In the home environment, medical asepsis with clean technique is appropriate. 38. 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 apply oxygen through a tube in your nose.” b. Oxygen can provide comfort and is not resuscitative when the nurse delivers it via nasal cannula. 39. 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 oxygen via nasal cannula at a flow rate no more than 6l/min 40. 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)? a. Assist the client with a partial bed bath b. Measure the client's BP after the nurse administers an antihypertensive medication c. Use a communication board to ask what the client wants for lunch 41. 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. 42. 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. An uneven shape 43. 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 am available to talk if you should change your mind.” 44. 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. 45. A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect? a. Abdominal cramping b. The client has hyponatremia, manifestations include abdominal cramping, weakness, headache, and nausea. 46. 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 responded affirmatively. b. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. 47. A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds. a. Normal breath sounds 48. 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 family member washes out the feeding bag with warm water once every 24 hours. b. You should wash out the feeding bag at each refilling throughout the day (every 4-8 hours) and replace it with a new feeding bag every 24 hours to prevent bacterial contamination. 49. 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. An x-ray shows the end of the tube above the pylorus. 50. A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next? a. Clean sutures along the incision site. 51. 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. a. Obtain the pronouncement of death from the provider b. Remove tubes and indwelling lines c. Wash the client's body d. Ask the client's family members if they would like to view the body e. Place a name tag on the body 52. 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? a. Tap just below the knee 53. 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? a. Administer pain meds 45 minutes before changing the client’s dressing. b. The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet the client’s physiological need for comfort and pain relief. 54. 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 stair, I will first shift my weight to my right (unaffected) leg." 55. 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? a. "It might help me to listen to music while I'm lying in bed." b. Listening to music is an effective non-pharmacological intervention for the management of mild pain. 56. A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? a. Droplet 57. 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 58. 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. "People in middle adulthood often find satisfaction in nurturing and guiding young people." b. According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people. 59. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client fell out of bed. Which of the following statements should the nurse document? a. “Client found lying on the floor.” 60. 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 assistive devices? a. “I will be sure to remove my hearing aid before taking a shower.” ATI Fundamentals 1. A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after excessive as I get older." 2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Absent bowel sounds with distention 3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority? Temperature 4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Administer analgesics to the child on a routine schedule throughout the day and night. 5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Pericardial friction rub 6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than alcohol based hand rub to clean my hands." 7. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Discontinue the machine, and measure the blood pressure manually every 15 min. 8. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change 9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Temporal 10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The signature on the preoperative consent form is the client’s 11. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first? Assessment 12. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques? The nurse washes with her hands held higher than her elbows. 13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Second intercostal space to the right of the sternum 14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. 15. A nurse is caring for an older adult client who becomes agitated when the nurse requests the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make? “What worries you about being without your teeth?” 16. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. Which of the following actions should the nurse take? Encourage the client to express his thoughts about death and dying 17. A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? “Tell me what I can do to help you overcome your fear of giving yourself injections.” 18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Confirm unresponsiveness. 19. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Screening groups of older adults in nursing care facilities for early influenza manifestations 20. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Perform hand hygiene 21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Place the bladder of the cuff over the posterior aspect of the thigh 22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Identify the client using two identifiers 23. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back 24. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Sit on the toilet 30 minutes after eating a meal." 25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Obtain client information 26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Place the wheelchair at a 45 degree angle to the bed 27. A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation 28. A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Remove the restraints one at a time 29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Sit and hold the client's hand 30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "I keep having nightmares about my upcoming surgery." 31. A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Inspect, Auscultate, Percuss, Palpate 32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining cotton balls for the tracheostomy care 33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses 34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take? Notify the provider about the client's decision 35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? Donate autologous blood before the surgery 36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client reports severe pain 37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "Using a cuff that is too small will result in an inaccurately high reading." 38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Carefully remove the gloves and follow with hand hygiene 39. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? Lock the wheels on the bed and stretcher 40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Raise the level of the bed ATI FUNDAMENTALS 1. Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of had hygiene is the amount of friction 2. A nurse is demonstrating postoperative deep breathing and coughing exercise to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client  reports severe pain 3. A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client‟s skin turgor, the nurse should  grasp a fold of the skin on the chest under the clavicle, release it, and not the depth of the impression 4. A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long-term goal of weight loss?  attempt to develop the client‟s self-motivation 5. When admitting a client, the nurse records which information in the client‟s record first?  assessment of the client 6. A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following is an appropriate nursing response?  Is there something about this procedure that concerns you? 7. A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client‟s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action? --> Disconnect the machine, and measure the blood pressure manually every 15 min. 8. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statements?  Tell me what I can do to help you overcome your fear of giving yourself injections. 9. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?  It is very upsetting to see an adult client regress. 10. A nurse‟s neighbor is scheduled for elective surgery. The neighbor‟s provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?  donating autologous blood before the surgery 11. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location? Second intercostals space to the right of the sternum 12. A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?  evaluate the pedal pulses 13. A nurse is caring for a client who requires rectal temperature monitoring. Available at the client‟s bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take? obtain a thermometer with a short, blunt insertion end. 14. A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the  involvement of the client in planning the change 15. A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is an nursing action?  firmly tell the client not to grab 16. An assistive personnel tells the nurse, “I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?” The nruse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is  high 17. Which of the following should the nurse do first when preparing to provide tracheostomy care? --> perform hand hygenie 18. A 3-year old child has had multiple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake, from the recovery room. Which approach is likely to be successful?  Examine the mouth last 19. A nruse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. The client‟s surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that  the signature on the preoperative consent form is the client‟s. 20. To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should  place the bed in a high horizontal position 21. Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases? --> elimination of the exposure 22. When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment findings prior to beginning chest compression?  absence of pulse 23. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?  bend at the knees while maintaining a wide stance and a straight back, with the client‟s hands on the nurse‟s shoulders, and the nurse‟s hands under the client‟s axillae. 24. An older adult client appears agitated when the nurse requests that the client‟s dentures be removed prior to surgery and states, “I never go anywhere without my teeth.” Which of the following is an appropriate nursing response?  You seem worried. Are you concerned someone may see you without your teeth? 25. To use the nursing process correctly, the nurse must first  obtain information about the client 26. A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client‟s abdomen, the nurse expects the bowel sounds to be  absent 27. While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?  Remove the gloves carefully and follow with hand hygiene 28. A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheotomy care. The nurse should intervene if the equipment the preceptee gathered included  cotton balls 29. A nurse is caring for a client diagnosed with a terminal illness. The client asks several questions about the nurse‟s religious beliefs related to death and dying/ An appropriate nursing response is to  encourage the client to express his thoughts about death and dying 30. When assessing a client‟s heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a pericardial friction rub 31. A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client‟s temperature is 39.2C (102.6F), her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority attention?  The client‟s menses is overdue 32. At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing  with her hands held higher than her elbows 33. A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?  ask the client why she has changed her mind. 34. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should  lock the wheels on the bed and stretcher 35. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client‟s room to administer medications and finds the client crying/ The appropriate nursing is to  sit and hold the client‟s hand. 36. Steps used for abdominal assessment  inspection, auscultation, percussion, palpation 37. While measuring a client‟s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?  count the apical pulse rate for 1 full min, and describe the rhythm in the chart. 38. A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the client‟s blood pressure?  obtain the blood pressure under the same conditions each time. 39. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client‟s room, the priority action is to  check the client‟s identification bracelet. 40. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?  help the client write down the questions to ask the provider, so that the client doesn‟t forget. ATI Fundamentals Chapter 1 1. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) a. Home health care b. Rehabilitation facilities c. Diagnostic centers d. Skilled nursing facilities e. Oncology centers 2. A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) a. Preferred provider organization (PPO) b. Medicare c. Long-term care insurance d. Exclusive provider organization (EPO) e. Medicaid 3. A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? a. Collaborating with providers to perform obesity screenings during routine office visits. b. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity. c. Providing specialized intraoperative training in surgical treatments for obesity. d. Educating acute care nurses about postoperative complications related to obesity. 4. A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? a. Monitoring evidence-based practice for clients who have a specific diagnosis. b. Ensuring that health care providers comply with regulations. c. Setting quality standards for accreditation of health care facilities. d. Determining whether medications are safe for administration to clients. 5. A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) a. Intensive care unit b. Oncology treatment center c. Burn center d. Cardiac rehabilitation e. Home health care Chapter 2 1. A nurse is caring for a group of clients on a medical surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) a. A client who has terminal cancer requests hospice care in the home. b. A client asks about community resources available for older adults. c. A client states, “I would like to have my child baptized before surgery.” d. A client requests an electric wheelchair for use after discharge. e. A client states, “I do not understand how to use a nebulizer.” 2. A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? a. Social worker b. Certified nursing assistant c. Registered dietitian d. Occupational therapist 3. A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain managements. Which of the following members of the interprofessional care team can assist the client in understanding the medication‟s effects? (Select all that apply.) a. Provider b. Certified nursing assistant c. Pharmacist d. Registered nurse e. Respiratory therapist 4. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? a. Social worker b. Certified nursing assistant c. Occupational therapist d. Speech-language pathologist 5. A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks CNAs can perform, which of the following client activities should the nurse include? (Select all that apply.) a. Bathing b. Ambulating c. Toileting d. Determining pain level e. Measuring vital signs Chapter 3 1. A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client‟s choice is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence 2. A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Beneficence 3. A nurse is instructing a group of newly license nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence 4. A nurse questions a medication prescription as too extreme in light of the client‟s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence 5. A nurse is instructing a group of newly licensed nurses how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? a. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. b. A nurse overhears another nurse telling an older adult client that if he doesn‟t stay in bed, she will have to apply restraints. c. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. d. A client who is terminally ill hesitates to name their partner on their durable power of attorney form. Chapter 4 1. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? a. Assault b. Battery c. False imprisonment d. Invasion of privacy 2. A nurse is caring for a competent adult client who tells the nurse, “I am leaving the hospital this morning whether the doctor discharges me or not.” The nurse believes that this is not in the client‟s best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning 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 3. 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 “I plan to prepare my advance directives before I come to the hospital.” Which of the following statements mad 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 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 at the hospital.” 4. 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 alternatives to having the surgery. 5. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. 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. Chapter 5 1. A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift b. Blood pressure from the previous day c. Bone scan scheduled for today. d. Medication routine from the medication administration record 2. A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) a. A single electronic record passwords is provided for nurse 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 copy of their medical record. e. A nurse can photocopy a client‟s medical record for transfer to another facility. 3. A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines sold be followed when documenting in a client‟s record? (Select all that apply.) a. Cover errors with correction fluid and write in the correct information. b. Put the date 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. 4. A nurse is discussing occurrences that require completion 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. Needlesticks c. Conflict with provider and nursing staff d. Omission of prescription e. Missed specimen collection of a prescribed laboratory test 5. 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 proscription within 24 hr. 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. Chapter 6 1. A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? a. Updating the plan of care for a client who is postoperative 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 injury 2. A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? a. Charge nurse b. Registered nurse (RN) c. Practical nurse (PN) d. Assistive personnel (AP) 3. 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 wearing slippers over antiembolic stockings. c. The client uses a front-wheeled walker when ambulating. d. The client had pain medication 30 min ago. e. The client is allergic to codeine. 4. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? a. Creating a plan of care for a client who is recovering following a stroke. b. Assessing a pressure injury on a client who is on bed rest. c. Providing nasopharyngeal suctioning for a client who has pneumonia. d. Teaching a client who has asthma to use a metered-dose inhaler. 5. A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) a. Right place b. Right supervision and evaluation c. Right direction and communication d. Right documentation e. Right circumstances Chapter 7 1. 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 hr. c. Change the plan of care to provide different pain relief interventions. d. Teach the client about the plan of care for managing the pain. 2. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client‟s MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation 3. 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, “They said they hurt after walking about 10 minutes.” c. The client‟s pain rating is 3 on a scale of 0 to 10 d. The client‟s skin is pink, warm, and dry. e. The assistive personnel reports that the client walked with a limp. 4. 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 interventions should the charge nurse include? a. Writing a prescription for morphine sulfate as needed for pain b. Inserting a nasogastric (NG) tube to relieve gastric distention 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 hr to reduce pressure injury risk 5. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed 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 carry out the new prescriptions from the provider.” d. “I will ask the client if their nausea has resolved.” Chapter 8 1. A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquid well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client “I will call the surgeon and ask for a change in diet.” 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 2. A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client‟s medical record, discovers that the client is allergic to the antibiotic, and call 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 3. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) a. Find a mentor. b. Use a journal to write about the outcomes of clinical judgments. c. Review articles about evidence-based practice. d. Limit consultations with other professionals involved in a client‟s care. e. Make quick decisions when unsure about a client‟s needs. 4. 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 this 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 5. 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 did the nurse demonstrate? a. Confidence b. Perseverance c. Integrity d. Discipline Chapter 9 1. A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review od systems, which of the following actions is a priority for the nurse? a. Orient the client to their room. b. Conduct a client care conference. c. Review medical prescriptions. d. Develop a plan of care. 2. A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply.) a. Explain the roles of other care delivery staff. b. Begin discharge planning. c. Inform the client that advance directives are required for hospital admission. d. Document the client‟s wishes about organ donation. e. Introduce the client to their roommate. 3. A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.) a. Ensure that the client has possession of their valuables. b. Confirm that the rehabilitation center has a room available at the time of transfer. c. Assess how the client tolerates the transfer. d. Give a verbal transfer report via telephone. e. Complete a transfer form for the receiving facility. 4. A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.) a. Advance directive status. b. Follow-up care. c. Instructions for diet and medications. d. Most recent vital sign data. e. Contact information for the home health care agency. 5. As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client‟s family? a. Body mass index b. Usual times for meals and snacks c. Favorite foods d. Any difficulty swallowing Chapter 10 1. 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 ft 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 microorganisms into the surgical wound. d. Keep a box of facial tissue for the client to use during the dressing change. 2. A nurse as 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 farthest from the body 3. 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 a 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 4. 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 handwashing? (Select all that apply.) a. Apply 3 to 5 mL of liquid soap to dry hands. b. Wash the hands with soap and water for at least 15 seconds. c. Rinse the hands with hot water. d. Use a clean paper towel to turn off hand faucets. e. Allow the hands to air dry after washing. 5. 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 hr because the provider receives an emergency call. d. The nurse turns and speak to someone who enters through the door behind the nurse. e. The client‟s hand brushes against the outer edge of the sterile field. Chapter 11 1. A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows 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. 2. A nurse is caring for a client who has a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? a. Allergic reaction b. Ringworm c. Systemic lupus erythematosus d. Tuberculosis 3. A nurse is caring for a client who reports 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 4. A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. 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 5. 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? (Select all that apply.) a. Place the client in a room that as a negative air pressure of at least six exchanges per hour. b. Wear a mask when providing care within 3 ft 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. Chapter 12 1. 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 they are sitting on 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. 2. A nurse manager is reviewing with nurses on the unit in 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 their side.” b. “I will go to the nurses‟ station for assistance.” c. “I will note the time that the seizure begins.” d. “I will prepare to insert an airway.” 3. 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 open doors on the unit. 4. 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 their possession. 5. A nurse discovers a small paper fire in a trash can in a client‟s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? a. Open the windows in the client‟s room to allow smoke to escape. b. Obtain a class C fire extinguisher to extinguish the fire. c. Remove all electrical equipment from the client‟s room. d. Place wet towels along the base of the door to the client‟s room. Chapter 13 1. 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? (Select all that apply.) a. Family members who smoke must be at least 10 ft 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” signs 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. 2. A nurse educator is presenting module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? a. Hypotension b. Bradycardia c. Clammy skin d. Bradypnea 3. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding? a. “I will set my water heater at 130oF.” b. “Once my baby can sit up, they should be safe in the bathtub.” c. “I will place my baby on their stomach to sleep.” d. “Once my infant starts to push up, I will remove the mobile from over the crib.” 4. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include? 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. 5. A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (Select all that apply.) a. Most food poisoning is caused by a virus. b. Immunocompromised individuals are at increased 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. Chapter 14 1. A nurse is caring for a client who is receiving enteral feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? a. Supine b. Semi-Fowler‟s c. Semi-prone d. Trendelenburg 2. 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 to transfer back to bed. b. Call for additional staff to assist with the transfer. c. Use a transfer belt to assist the client back into bed. d. Determine the client‟s ability to help with transfer. 3. A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? a. “Lie on your back with our head and shoulders supported by a pillow.” b. “Have your head turned to the side while you lie on your stomach.” c. “Have a table beside your bed so you can sit on the bedside and rest your arms on the table.” d. “Lie on your side with your top arm resting on the bed and your weight on your hip.” 4. 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 to 3 hr to flex and stretch your joints and muscles. 5. 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.” Chapter 15 1. A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse‟s 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 and full-thickness burns to his face, neck and chest. d. A client who has a fractured fibula and tibia. 2. A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (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 the windows. d. Draw shades and close drapes. e. Instruct ambulatory clients in the hallways to return to their rooms. 3. 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. 4. 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 understanding? 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 as any questions and just let the caller talk.” d. “I will listen for background noises.” 5. A nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) a. A client who is dehydrated and receiving IV fluid and 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. Chapter 16 1. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? a. Give the client information about immunization against meningitis. b. Tell the client to have a TB skin test every 2 years. c. Determine the client‟s health risks. d. Teach the client about exercise recommendations. 2. A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) a. Help the client see the benefits of their actions. b. Identify the client‟s support systems. c. Suggest and recommend community resources. d. Devise and set goals for the client. e. Teach stress management strategies. 3. A nurse in a health clinic is caring for a 210year client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? a. Testicular examination b. Blood glucose c. Fecal occult blood d. Prostate-specific antigen 4. A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? a. Providing cholesterol screening b. Teaching about a healthy diet c. Providing information about antihypertensive medications d. Developing a list of cardiac rehabilitation programs 5. A nurse at a provider‟s office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? a. “So I don‟t need the colon cancer procedure for another 2 or 3 years.” b. “For now, I should continue to have a mammogram each year.” c. “Because the doctor just did a Pap smear, I‟ll come back next year for another one.” d. “I had my glucose test last year, so I won‟t need it again for 4 years.” Chapter 17 1. 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 an understanding of the process. d. The client is able to write the steps on a piece of paper. 2. A nurse in a provider‟s office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? a. Cognitive b. Affective c. Psychomotor d. Kinesthetic 3. 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.” 4. A nurse is preparing an instructional session for a client 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. c. Identify goals the nurse and the client agree are reasonable. d. Determine what the client knows about stress incontinence. 5. A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. 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 about how the nurse presented the information. d. Ask whether the client has resources for further instruction on this topic. Chapter 18 1. A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply.) a. Rolls from back to front b. Bears weight on legs c. Walks holding onto furniture d. Sits unsupported e. Sits down from standing position 2. A nurse is reviewing safety measures with the parent of an 8-month-old infant. Which of the following statements by the parent indicates an understanding of safety for the infant? a. “My baby loved to play with the crib gym, but I took it out of the crib.” b. “I just bought a soft mattress so my baby will sleep better.” c. “My baby really likes sleeping on the fluffy pillow we just got.” d. “”I put the baby‟s car seat out of the way on the table after I put him in it.” 3. A nurse is reviewing car seat safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include? a. Use a car seat that has a three-point harness system. b. Position the car seat so that the infant is rear-facing. c. Secure the car seat in the front passenger seat of the vehicle. d. Convert to a booster seat after 12 months. 4. A nurse is assessing a 2-week-old newborn during a routine checkup. Which of the following findings should the nurse expect? a. Sleeps 14 to 16 hr each day. b. Posterior fontanel closed. c. Pincer grasp present. d. Hands remain in a closed position. e. Current weight same as birth weight. 5. The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? (Select all that apply.) a. “It might be good to add bananas, as they can help with loose stools.” b. “Let‟s make a list of the foods your baby is eating so we can spot any problems.” c. “Did the changes begin after you started one particular food?” d. “Has your baby been vomiting since starting these new foods?” e. “Most babies react with a little indigestion when you start new foods.” Chapter 19 1. A nurse is giving a presentation about accident to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply.) a. Store toxic agents in locked cabinets. b. Keep toilet seats up. c. Turn pot handles toward the back of the stove. d. Place safety gates across stairways. e. Make sure balloons are fully inflated. 2. A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply.) a. Building models. b. Working with clay. c. Filling and emptying containers. d. Playing with blocks. e. Looking at books. 3. A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? a. Establish consistent boundaries for the toddler. b. Place the toddler in a room with the door closed. c. Inform the toddler how you feel when he misbehaves. d. Use favorite snack to reward the toddler. 4. A mother tells the nurse that her 2-year-old toddler has temper tantrums and says “no” every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development? a. Trying to increase her independence. b. Developing a sense of trust. c. Establishing a new identity. d. Attempting to master a skill. 5. A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? a. “I should keep feeding my son whole milk until he is 3 years old.” b. “It‟s okay for me to give my son a cup of apple juice with each meal.” c. “I‟ll give my son about 2 tablespoons of each food at mealtimes.” d. “My son loves popcorn, and I know it is better for him than sweets.” Chapter 20 1. A nurse is talking with the guardian of a 4-year-old child who reports that the child is waking up with nightmares. Which of the following interventions should the nurse suggest? a. Offer the child a large snack before bedtime. b. Allow the child to watch an extra 30 min of TV in the evening. c. Have the child go to bed at a consistent time every day. d. Increase physical activity before bedtime. 2. A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) a. Assembling puzzles. b. Pulling wheeled toys. c. Using musical toys. d. Playing with puppets. e. Coloring with crayons. 3. A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child‟s cooperation in taking medications? (Select all that apply.) a. Reassure the child an injection will not hurt. b. Mix oral medications in a large glass of milk. c. Offer the child choices when possible. d. Have the guardians bring in a favorite toy from home. e. Engage the child in pretend play with a toy medical kit. 4. A nurse is reviewing the Centers for Disease Control and Prevention‟s (CDC) immunization recommendations with the guardian of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply.) a. Heamophilus influenzae type B b. Varicella c. Polio d. Hepatitis A e. Seasonal influenza 5. A nurse is talking with guardians who are concerned about several issues with their preschooler. Which of the following issues should the nurse identify as the priority? a. “My child mimics the way my partner and I dress.” b. “My child has temper tantrums every time we tell them to do something they don‟t want to do.” c. “I think my child truly believes that toys have personalities and can talk.” d. “I feel bad when I see my child trying so hard to button their shirt.” Chapter 21 1. A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority? a. “We just don‟t understand why our child can‟t keep up with the other kids in simple activities like running and jumping.” b. “Our child keeps trying to find ways around our household rules. They always want to make deals with us.” c. “We think our child is trying too hard to excel in math just to get the top grades in the class.” d. “Our child likes to sing and worries it will make the other kids want to laugh.” 2. A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) a. Building models. b. Playing video games. c. Reading books. d. Using toy carpentry tools. e. Playing board games. 3. A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? a. “Our child wants to eat as much as we do, but we‟re afraid It will lead to becoming overweight.” b. “Our child skips lunch sometimes, but we figure it‟s okay as long as we eat a healthy breakfast and dinner.” c. “We limit fast-food restaurant meals to three times a week now.” d. “We reward school achievements with a point system instead of pizza or ice cream.” 4. A nurse is talking with the caregivers of a 10-yeaar-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the nurse make? a. “Perhaps you should try to find out what is happening behind those closed doors.” b. “Suggest that the door be left ajar for safety reasons.” c. “At this age, children tend to become modest and value their privacy.” d. “You should establish a disciplinary plan to stop this behavior.” 5. A nurse is planning a health promotion and primary prevention class for the caregivers of school-age children. Which of the following actions should the nurse plan to take? (Select all that apply.) a. Provide information about the risk of childhood obesity. b. Discuss the danger of substance use disorder. c. Promote discussion about sexual issues. d. Recommend the school-age child sit in the front seat of the car. e. Reinforce stranger awareness. Chapter 22 1. A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occur first? a. Appearance of downy hair on the upper lip b. Hair growth in the axillae c. Enlargement of the testes and scrotum d. Deepening of the voice 2. A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply.) a. Suggest that the guardians bring in video games to play. b. Provide a television and movies for the adolescent to watch. c. Limit visitors to the adolescent‟s immediate family. d. Involve the adolescent in treatment decisions when possible. e. Allow the adolescent to perform morning self-care. 3. A nurse is reviewing CDC‟s immunization recommendations with the guardians of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) a. Rotavirus b. Varicella c. Herpes zoster d. Human papilloma virus e. Seasonal influenza 4. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? a. “I kind of like this boy in my class, but he doesn‟t like me back.” b. “I want to hang out with the kids in the science club, but the jocks pick on them.” c. “I am so fat, I skip meals to try to lose weight.” d. “My dad wants me to be a lawyer like him, but I just want to dance.” 5. A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply.) a. Obtain a periodic mental evaluation. b. Discuss prevention of sexually transmitted infections. c. Regularly screen for tuberculosis. d. Provide education about drug and alcohol use. e. Teach monthly breast examination. Chapter 23 1. A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding? a. “I already had my immunizations as a child, so I‟m protected in that area.” b. “It is important to schedule routine health care visits even if I a feeling well.” c. “I will just go to an urgent care center for my routine medical care.” d. “There‟s no reason to seek help if I am feeling stressed because it‟s just part of life.” 2. A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply.) a. Influenza b. Measles, mumps, rubella c. Pertussis d. Tetanus e. Polio 3. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? a. Becoming actively involved in providing guidance to the next generation. b. Adjusting to major changes in roles and relationships due to losses. c. Devoting time to establishing an occupation. d. Finding oneself “sandwiched” between and being responsible for two generations. 4. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further? a. “I have my own apartment not, but it‟s not easy living away from my guardians.” b. “It‟s been so stressful for me to even think about having my own family.” c. “I don‟t even know who I am yet, and now I‟m supposed to know what to do.” d. “My partner is pregnant, and I don‟t think I have what it takes to be a good parent.” 5. A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply.) a. Install bath rails and grab bars in bathrooms. b. Wear a helmet while skiing. c. Install a carbon monoxide detector. d. Secure firearms in a safe location. e. Remove throw rugs from the home. Chapter 24 1. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? a. The client evaluates their behavior after a social interaction. b. The client states they are learning to trust others. c. The client wishes to find meaningful friendships. d. The client expresses concerns about the next generations. 2. A nurse is collecting data to evaluate a middle adult‟s psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply.) a. Develop an acceptance of diminished strength and increased dependence on others. b. Spend time focusing on improving job performance. c. Welcome opportunities to be creative and productive. d. Commit to finding friendship and companionship. e. Become involved with community issues and activities. 3. A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) a. Metabolism b. Ability to hear low-pitched sounds. c. Gastric secretions d. Far vision e. Glomerular filtration 4. A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply.) a. Eye examination every 1 to 3 years b. Decrease intake of calcium supplements c. DXA screening for osteoporosis d. Increase intake of carbohydrate in the diet e. Screening for depressive disorders 5. A nurse is counselling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? a. “I am struggling to accept that my parents are aging and need so much help.” b. “It‟s been so stressful for me to think about having intimate relationships.” c. “I know I should volunteer my time for a good cause, but maybe I‟m just selfish.” d. “I love my grandchildren, but my child expects me to relive my parenting days.” Chapter 25 1. A nurse is counselling an older adult who describes having difficulty 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 I had my job back.” b. “It‟s been so stressful for me to have to depend on my child 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.” 2. A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the 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.” 3. 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. HPV immunization b. Pneumococcal immunization c. Yearly eye examination d. Periodic mental health screening e. Annual fecal occult blood 4. A nurse is talking with an older adult client about improving 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. 5. 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 Chapter 26 1. A nurse provides and introduction to a client as the first step of comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) a. Address the client with the appropriate title and their last name. b. Use a mix of open- and closed-ended questions. c. Reduce environmental noise. d. Have the client complete a printed history form. e. Perform the general survey before the examination. 2. A nurse is a provider‟s office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.) a. Posture b. Skin lesions c. Speech d. Allergies e. Immunization status 3. A nurse is collecting data for a client‟s comprehensive physical examination. After inspecting the client‟s abdomen, which of the following skill of the physical examination process should the nurse perform next? a. Olfaction b. Auscultation c. Palpation d. Percussion 4. A nurse is preparing to perform a comprehensive physical examinations of an older adult client. Which of the following interventions should the nurse use in consideration of the client‟s age? (Select all that apply.) a. Expect the session to be shorter than for a younger client. b. Plan to allow plenty of time for position changes. c. Make sure the client has any essential sensory aids in place. d. Tell the client to take their time answering questions. e. Invite the client to use the bathroom before beginning the examination. 5. A nurse in a provider‟s office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? a. Palmar surface b. Fingertips c. Dorsal surface d. Base of the fingers Chapter 27 1. A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3oC (101oF), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) a. Obtain culture 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. 2. A nurse is instructing an AP about caring for a client who has a low platelet count. 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 their respirations.” d. “Let the client rest for 5 minutes before you measure their BP.” 3. A nurse is instructing a group of assistive personnel 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 sec if it is irregular. e. Count and report any sighs the client demonstrates. 4. A nurse is measuring BP of a client who has a fractured femur. BP is 140/94 mmHg, and the client denies any history of HTN. Which of the following actions should the nurse take first? a. Request a prescription for an antihypertensive medication. b. Ask the client if they are having pain. c. Request a prescription for an antianxiety medication. d. Return in 30 min to recheck the client‟s BP. 5. A nurse is performing an admission assessment on a client. The nurse determines the client‟s radial pulse rate is 68/min and the simultaneous apical pulse is 84/min. what is the client‟s pulse deficit (per minutes)? 16 Chapter 28 1. A nurse is a provider‟s office is preparing to test a client‟s cranial nerve function. Which of the following should the nurse include when testing cranial nerve V? (Select all that apply.) a. “Close your eyes.” b. “Tell me what you can taste.” c. “Clench your teeth.” d. “Raise your eyebrows.” e. “Tell me when you feel a touch.” 2. A nurse is assessing a client‟s thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Palpating the thyroid in the lower half of the neck. b. Visualizing the thyroid on inspection of the neck. c. Hearing a bruit when auscultating the thyroid. d. Feeling the thyroid ascend as the client swallows. e. Finding symmetric extension off the traches on both sides of the midline. 3. A nurse is assessing an adult client‟s internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) a. Pull the auricle down and back. b. Insert the speculum slightly down and forward. c. Insert the speculum 2 to 2.5 cm (0.8 to 1 in) d. Make sure the speculum does not touch the ear canal. e. Use the light to visualize the tympanic membrane in a cone shape. 4. A nurse is caring for a client who asks what their Snellen eye test results mean. The client‟s visual acuity is 20/30. Which of the following responses should the nurse make? a. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.” b. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.” c. “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.” d. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.” 5. A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) a. Reddened gums b. Lowered vocal pitch c. Tooth loss d. Glare intolerance e. Thickened eardrums Chapter 29 1. A nurse in a provider‟s office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) a. Smaller nipples b. Less adipose tissue c. Nipple discharge d. More pendulous e. Nipple inversion 2. A nurse in a provider‟s office is preparing to auscultate and percuss a client‟s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Rhonchi b. Crackles c. Resonance d. Tactile fremitus e. Bronchovesicular sounds 3. During an abdominal examination, a nurse in a provider‟s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? a. Fat b. Fluid c. Flatus d. Hernias 4. During a cardiovascular examination, a nurse in a provider‟s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) a. Ventricular gallop b. Closure of the mitral valve c. Closure of the pulmonic valve d. Apical heart rate e. Murmur 5. A nurse in a provider‟s office is preparing to auscultate and percuss a client‟s abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Tympany b. High-pitched clicks c. Borborygmi d. Friction rubs e. Bruits Chapter 30 1. A nurse in a provider‟s office is preparing to assess a client‟s skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Capillary refill less than 3 seconds b. 1+ pitting edema in both feet c. Pale nail beds in both hands d. Thick skin on the soles of the feet e. Numerous macules on the face darker than the surrounding skin color 2. A nurse is assessing an older adult client who has significant tenting of the skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) a. Thin, parchment-like skin b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity e. Excessive wrinkling 3. A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test which of the following? (Select all that apply.) a. Range of motion b. Skin color c. Edema d. Skin lesions e. Skin temperature 4. A nurse is performing skin assessment on a group of clients. Which of the following lesions should the nurse identify as vesicles (Select all that apply.) a. Acne b. Warts c. Psoriasis d. Herpes simplex e. Varicella 5. A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? a. Pallor b. Cyanosis c. Jaundice d. Erythema Chapter 31 1. A nurse in a provider‟s office is preparing to assess a young adult client‟s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Concave thoracic spine posteriorly b. Exaggerated lumbar curvature c. Concave lumbar spine posteriorly d. Exaggerated thoracic curvature e. Muscle slightly larger on the dominant side 2. A nurse, who is assessing a client‟s neurologic system, should ask the client to close their eyes and identify which of the following items? a. A word the nurse whispers 30cm from the ear b. A number the nurse traces on the palm of the hand c. The vibration of a tuning fork the nurse places on the foot d. A familiar object the nurse places in the hand 3. A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client‟s ability to perform which of the following activities? a. Exercising the deltoid muscle when using hand weights b. Brushing the hair on the back of the head c. Fastening or zipping closures on the back while dressing d. Reaching into cabinet above the sink 4. A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client‟s balance? (Select all that apply.) a. Romberg test b. Heel-to-toe walk c. Snellen test d. Spinal accessory function e. Rosenbaum test 5. A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) a. Slower light touch sensation b. Some vision and hearing decline c. Slower fine finger movement d. Some short-term memory decline e. Decreased risk of depression Chapter 32 1. A nurse is caring for a client who states, “I have to check with my partner and see if they think 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 2. Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (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. Sit facing the client. 3. A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being 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 the support system you‟ll have after you leave the hospital.” e. “It sounds like you are not sure how to having a colostomy will affect swimming.‟ 4. Which of the following strategies should a nurse use to establish a helping relationship with a client? a. Make sure the communication is equally distributed between the nurse‟s and client‟s desires. b. Encourage the client to communicate their thoughts and feelings. c. Give the nurse-client relationship communication no time limits. d. Allow communication to occur spontaneously throughout the nurse-client relationship. 5. 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. Chapter 33 1. A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of DM. the client is tearful and states, “How could you possibly understand what I am going through?” Which of the following responses should the nurse make? a. “It takes time to get over the loss of a loved one.” b. “You are right. I cannot really understand. Perhaps you‟d like to tell me more about what you‟re feeling.” c. “Why don‟t you try something to take your mind off your troubles, like watching a funny movie.” d. “I might not share your exact situation, but I do know what people go through when they deal with a loss.” 2. A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client‟s vital signs and notes an elevation in BP and HR. the nurse should recognize this response as which part of general adaptation syndrome (GAS)? a. Exhaustion stage b. Resistance stage c. Alarm stage d. Recovery stage 3. A nurse is caring for a client who has left-sided hemiplegia resulting from a CVA accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client‟s role problem? a. Role conflict b. Role overload c. Role ambiguity d. Role strain 4. A nurse is caring for a client who has a new diagnosis of type 2 DM. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) a. Suggest coping skills for the client to use in this situation. b. Allow the client to provide input in the treatment plan. c. Assist the client with time management, and address the client‟s priorities. d. Provide extensive instructions on the client‟s treatment regimen. e. Encourage the client in the expression of feelings and concerns. 5. A nurse is caring for a family who is experiencing crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? a. Prescribing tasks unilaterally. b. Delegating care to one member c. Speaking to the primary client privately d. Convening a family meeting Chapter 34 1. 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 there has been a decreased desire for sexual relations since the 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 bod feels to you.” c. “Consider an afternoon at a spa. A facial will make you feel more attractive.” d. “It‟s still too soon to expect to feel normal. Give it a little more time.” 2. A nurse is caring for a group of clients on a medical surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply.) a. A client who had a laparoscopic appendectomy. b. A client who had a mastectomy. c. A client who had a left above-the-knee amputation. d. A client who had a cardiac catheterization. e. A client who had a stroke with right-sided hemiplegia. 3. 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 statements indicates 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 a leg.” d. “I don‟t even want to look at my leg. You can check the dressing.” 4. A nurse is caring for a client who is recovering from a MI and a cardiac catheterization. The client states: “I am concerned that things might be a little, you know, „different‟ with my partner when I got home.” Which of the following statements should the nurse make? a. “Sounds like something you should discuss with them when you get home.” b. “It sounds like your are concerned about sexual functioning. Let‟s discuss your concerns.” c. “Oh, I wouldn‟t be too concerned. Things will be fine as soon as we get you home.” d. “Just make sure you take your medication as directed, and you should be fine.” 5. A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates as issue with self-concept? a. “I was having difficulty with attaching the appliance at first, but my partner 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 they taught me a few things.” d. “It can take me a while to get the hang of things. I have to admit, I am pretty nervous.” Chapter 35 1. 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 family member? (Select all that apply.) a. Talk to the interpreter about the family while the family is in the room. b. Determine client understanding several times during the conversation. 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. 2. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? a. Members of the same religion share similar feelings about their religion. b. A shared religion 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. 3. A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? a. Contact the hospital‟s spiritual services. b. Ask what is making the client cry. c. Ensure no visitors or staff enter the room for a short time period. d. Turn on the television for a distraction. 4. A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? a. “I will make sure the menu includes kosher options.” b. “I will ask the client if the want to schedule some times to pray during the day.” c. “I will avoid discussing care when the client‟s family is around.” d. “I will make sure daily communion is available for this client.” 5. A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not acceptable treatment option. Which of the following responses should the nurse make? a. “I believe in this case you should make an exception and accept the blood transfusion.” b. “I know your family would approve of your decision to have a blood transfusion.” c. “Why does your religion mandate that you cannot receive any blood transfusions?” d. “Let‟s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.” Chapter 36 1. 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 the family? a. Allowing the client to function independently will strengthen muscles and promote healing. b. The client needs privacy at times for self-reflecting and organizing life. c. The client‟s sense of loss can be lessened through retaining control of some areas of life. d. Performing ADLs is a requirement prior to discharge from an acute care facility. 2. 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 attend my child‟s wedding.” Based on the Kubler-Ross model, which stage of grief is the client experiencing? a. Anger b. Denial c. Bargaining d. Acceptance 3. A nurse is consoling the partner of a client who just died after a long battle liver cancer. The grieving partner states, “I hate them for leaving me.” Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) a. “Would you like to contact the chaplain to come and speak with you?” b. “You will feel better soon. You have been expecting 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 loved one at this time.” e. “Tell me more about how are you feeling.” 4. A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client‟s family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? a. Regular breathing pattern. b. Warm extremities. c. Increased urine output. d. Decreased muscle tone. 5. A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) a. Remove the dentures from the body. b. Make sure the body is lying completely flat. c. Apply fresh linens and place a clean gown on the body. d. Remove all equipment from the bedside. e. Dim the lights in the room. Chapter 37 1. 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 it. c. Brush the client‟s teeth once per day. d. Inject a mouth rinse into the center of the client‟s mouth. 2. A nurse is instructing a client who has DM about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) a. Inspect the feet daily. b. Use moisturizing on the feet. c. Wash the feet with warm water and left them air dry. d. Use OTC products to treat abrasions. e. Wear cotton socks. 3. A nurse is planning care for a client who develops dyspnea and feels tired after completing 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. 4. A nurse is beginning a complete bed bath for a client. After removing the client‟s gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? a. Face b. Feet c. Chest d. Arms 5. 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 dentures 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. Chapter 38 1. A nurse in a provider‟s office is caring for a client who states that, for the past week, “I have felt tired during the day and cannot sleep at night.” Which of the following responses should the nurse ask when collecting data about the client‟s difficulty sleeping? (Select all that apply.) a. “Have your working hours changed recently?” b. “Do you feel confused in the late afternoon?” c. “Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?” d. “Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?” e. “Tell me about you personal stress you are experiencing.” 2. A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.) a. Practice muscle relaxation techniques. b. Exercise each morning. c. Take an afternoon nap. d. Alter the sleep environment for comfort. e. Limit fluid intake at least 2 hr before bedtime. 3. A nurse is caring for a client who has been following the facility‟s routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? a. Rub the client‟s back for 15 min before bedtime. b. Offer the client warm milk and crackers at 2100. c. Allow the client to take a bath in the evening. d. Ask the provider for a sleeping medication. 4. A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining REM sleep, which of the following characteristics should the nurse include? (Select all that apply.) a. REM sleep provides cognitive restoration. b. REM sleep lasts about 90 min. c. It is difficult to awaken a person in REM sleep. d. Sleepwalking occurs during REM sleep. e. Vivid dreams are common during REM sleep. 5. A nurse is instructing a client who has a narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. “I‟ll add plenty of carbohydrates to my meals.” b. “I‟ll take a short nap whenever I feel a little sleepy.” c. “I‟ll make sure I stay warm when I am at my desk at work.” d. “It‟s okay to drink alcohol as long as I limit it to one drink per day.” Chapter 39 1. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? a. Give the client thing liquids. b. Instruct the client to tuck their chin when swallowing. c. Have the client use a straw. d. Encourage the client to lie down and rest after meals. 2. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? a. Fat b. Protein c. Glycogen d. Carbohydrates 3. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client‟s meal tray? a. Cooked barley b. Pureed broccoli c. Vanilla custard d. Lentil soup 4. A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the BMI and determine whether the client‟s BMI indicates a healthy weight, underweight, overweight, or obese. 5. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) a. Older adults are more prone to dehydration that younger adults are. b. Older adults need the same amount of most vitamins and minerals as younger adults do. c. Many older men and women need calcium supplementation. d. Older adults need more calories that they did when they were younger. e. Older adults should consume a diet low in carbohydrates. Chapter 40 1. A nurse is caring for a client who has been sitting in a chair for 1 hr. which of the following complications is the greatest risk to the client? a. Decreased subcutaneous fat b. Muscle atrophy c. Pressure injury d. Fecal impaction 2. A nurse is caring for client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) a. Instruct the client not to perform the Valsalva maneuver. b. Apply elastic stockings. c. Review laboratory values for total protein level. d. Place pillows under the client‟s knees and lower extremities. e. Assist the client to change positions often. 3. A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? a. Encourage the client to perform antiembolic exercises every 2 hr. b. Instruct the client to cough and deep breathe every 4 hr. c. Restrict the client‟s fluid intake. d. Reposition the client every 4 hr. 4. A nurse is evaluating a client‟s understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? a. “This device will keep me from getting sores on my skin.” b. “This device will keep the blood pumping through my leg.” c. “With this device on, my leg muscles won‟t get weak.” d. “This device is going to keep my joints in good shape.” 5. A nurse is instructing a client, who has an injury of the left lower extremity, about the use of cane. Which of the following instructions should the nurse include? (Select all that apply.) a. Hold the cane on the right side. b. Keep two points of support on the floor. c. Place the cane 38 cm (15 in) in front of the feet before advancing. d. After advancing the cane, move the weaker leg forward. e. Advance the stronger leg so that it aligns evenly with the cane. Chapter 41 1. A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? a. Presence of associated manifestations. b. Location of the pain c. Pain quality d. Aggravating and relieving factors 2. A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client‟s pain? a. Ask the client what precipitates the pain. b. Question the client about the location of the pain. c. Offer the client a pain scale to measure their pain. d. Use open-ended questions to identify the client‟s pain sensations. 3. A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. A client who has a broken femur and reports hip pain. b. A client who has incisional pain 72 hr following pacemaker insertion. c. A client who has food poisoning and reports abdominal cramping. d. A client who has episodic back pain following a fall 2 years ago. 4. A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) a. Urinary incontinence b. Diarrhea c. Bradypnea d. Orthostatic hypotension e. Nausea 5. A nurse is caring for a client who is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? a. “I‟ll wait to use the device until it‟s absolutely necessary.” b. “I‟ll be careful about pushing the button too much so I don‟t get an overdose.” c. “I should tell the nurse if the pain doesn‟t stop while I am using this device.” d. “I will ask my adult child to push the dose button when I am sleeping.” Chapter 42 1. A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? a. Offer information on a relaxation technique and ask if they are interested in trying it. b. Request a social worker to see the client to discuss meditation. c. Attempt to use biofeedback techniques with the client. d. Tell the client many people feel the same way before surgery and to think of something else. 2. A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? a. Chamomile b. Ginseng c. Ginger d. Echinacea 3. A nurse is reviewing complementary and alternative therapies with a group of a newly licensed nurses. Which of the following interventions are mind-body therapies? (Select all that apply.) a. Art therapy b. Acupressure c. Yoga d. Therapeutic touch e. Biofeedback 4. A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (Select all that apply.) a. Guided imagery b. Massage therapy c. Meditation d. Music therapy e. Therapeutic touch 5. A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body intervention? a. Tell the cli3nt the goal of therapy is to promote healing. b. Ask whether the client is comfortable with using prayer. c. Encourage the client to participate actively for best results. d. Instruct the client to relax during the therapy. Chapter 43 1. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? a. Eating more protein is optimal prior to testing. b. One stool specimen is sufficient for testing. c. A red color change indicates a positive test. d. The specimen cannot be contaminated with urine. 2. A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? a. Macaroni and cheese b. One medium apple with skin c. One cup of plain yogurt d. Roast chicken and white rice 3. A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply.) a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema 4. While a nurse is administering a cleansing edema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Have the client hold their breath briefly and bear down. b. Clamp the enema tubing. c. Remind the client that cramping is common at this time. d. Raise the level of the enema fluid container. 5. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.) a. Warm the enema solution prior to instillation. b. Position the client on the left side with the right leg flexed forward. c. Lubricate the rectal tube or nozzle. d. Slowly insert the rectal tube about 5 cm (2 in). e. Hang the enema container 61 cm (24 in) above the client‟s anus. Chapter 44 1. A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.) a. Limit total daily fluid intake. b. Decrease or avoid caffeine. c. Take calcium supplements. d. Avoid drinking alcohol. e. Used the Cred maneuver. 2. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is patent. b. Reassure the client that it is not possible for them to urinate. c. Re-catheterize the bladder with a larger-gauge catheter. d. Collect a urine specimen for analysis. 3. A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? a. Discard the first voiding b. Keep the urine in a single container at room temperature. c. Dispose of the last voiding. d. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. 4. A nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) a. Frequent sexual intercourse b. Lowering of testosterone levels c. Wiping from front to back to clean the perineum d. Location of the urethra closer to the anus e. Frequent catheterization 5. A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) a. Restrict the client‟s intake of fluids during the daytime. b. Have the client record urination time. c. Gradually increase the urination intervals. d. Remind the client to hold urine until the next scheduled urination time. e. Provide a sterile container for urine. Chapter 45 1. A nurse is caring for a client who has a stroke and has aphasia. Which of the following interventions should the nurse use to promote communications with this client? (Select all that apply.) a. Speak at a higher volume to the client. b. Make sure only one person speaks at a time. c. Avoid discouraging the client by indicating that they cannot be understood. d. Allow plenty of time for the client to respond. e. Use brief sentences with simple words. 2. A nurse is caring for a client who has an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? a. Immediately complete a thorough assessment. b. Encourage visitors to distract the client. c. Provide a private room, and limit stimulation. d. Speak at a higher volume to the client. 3. A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) a. Weber test showing lateralization to the right ear b. Light reflex at 10 o‟clock in the left ear c. Indications of obstruction in the left ear canal d. Rinne tests showing less time for air and bone conduction e. Rinne test showing air conduction less than bone conduction in the left ear 4. A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) a. Furosemide b. Ibuprofen c. Cimetidine d. Simvastatin e. Amiodarone 5. A nurse is reviewing instructions with a client who has a searing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. “I use the damp cloth to clean the outside part of my hearing aids.” b. “I clean the ear molds of my hearing aids with rubbing alcohol.” c. “I keep the volume of my hearing aids turned up so I can hear better.” d. “I take the batteries out of my hearing aids when I take them off at night.: Chapter 46 1. A nurse is caring for a client who is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client‟s medication administration record, which of the following medications should the nurse administer? a. Meperidine 75 mg IM b. Fentanyl 50 mcg/hr transdermal patch c. Morphine 2 mg IV d. Oxycodone 10 mg PO 2. A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. “I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal.” b. “If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding.” c. “I can crush the enteric coated pill, if needed.” d. “I will eat two crackers with the pain pills.” 3. A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? a. “Flush the tube before and after each medication.” b. “Mix your medications with your enteral feeding.” c. “Push tablets through the tube slowly.” d. “Mix all the crushed medications prior to dissolving them in water.” 4. A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? a. Use a 22-gauge needle. b. Select a site on the client‟s abdomen. c. Use the Z-track technique to displace the skin on the injection site. d. Observe for bleb formation to confirm proper placement. 5. A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands? a. “I will straighten my ear canal by pulling my ear down and back.” b. “I will gently apply pressure with my finger to the front part of my ear after putting in the drops.” c. “I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.” d. “After the drops are in, I will place a cotton ball all the way into my ear canal.” Chapter 47 1. A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take? a. Offer to assist the client who needs the bedpan. b. Administer the injection the other nurse prepared. c. Prepare another syringe and administer the injection. d. Tell the client who needs the bedpan to wait while the nurse gives someone else medication. 2. A nurse is reviewing a client‟s prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply.) a. A once-daily multivitamin b. Eye drops prescribed every 3 hr c. An antibiotic prescribed every 8 hr d. A blood pressure pill prescribed twice daily e. A subcutaneous injection prescribed once weekly 3. A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? a. “A second nurse enters the prescription into the client‟s medical record.” b. “Another nurse should listen to the phone call.” c. “The provider can clarify the prescription when they sign the health record.” d. “I should omit the „read back‟ if this is a one-time prescription.” 4. A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply.) a. “I will observe for adverse effects.” b. “I will monitor for therapeutic effects.” c. “I will prescribe the appropriate dose.” d. “I will change the dose if adverse effects occur.” e. “I will refuse to give a medication if I believe it is unsafe.” 5. A nurse reviewing a client‟s health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescription? a. Single b. Stat c. Routine d. Now Chapter 48 1. A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero.) 0.3mL 2. A nurse is preparing to administer lactated Ringer‟s (LR) IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do not use a trailing zero.) 400mL/hr 3. A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.) 83 gtt/min 4. A nurse is preparing to administer metoprolol 200-mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Do not use a trailing zero.) 2 tablets 5. A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30-mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 mL 6. A nurse is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do not use a trailing zero.) 100 mL/hr 7. A nurse is preparing to administer acetaminophen 320 mg PO every 4-hr PRN for pain. The amount available is acetaminophen liquid 160-mg/5-mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 10 mL 8. A nurse is preparing to administer dextrose 5% in lactated Ringer‟s (D5LR) 1,000 mL to infuse over 6-hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.) 42 gtt/min Chapter 49 1. A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? a. “I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood.” b. “I will insert the needle into the client‟s skin at an angle of 10 to 30 degrees with the bevel up.” c. “I will apply pressure approximately 1.2-inches below the insertion site prior to removing the needle.” d. “I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location.” 2. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and “not feeling well.” The nurse notes warmth, edema, induration, and red streaking on the client‟s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? a. Obtain a specimen for culture. b. Apply a warm compress. c. Administer analgesics. d. Discontinue the infusion. 3. During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? a. “I will leave the IV catheter in place after the client completes the course of IV antibiotics.” b. “As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt.” c. “If my client needs to use the rest room, it would be safer to disconnect their IV infusion as long as I clean the injection port thoroughly with an antiseptic swab.” d. “I will replace any IV catheter when I suspect contamination during insertion.” 4. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.) a. “The temperature around the IV site is cooler.” b. “The rate of the infusion increases.” c. “The skin at the IV site is red.” d. “The IV dressing is damp.” e. “The tissue around the venipuncture site is swollen.” 5. A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) a. “I feel lightheaded.” b. “I feel as though my heart is racing.” c. “I feel a little short of breath.” d. “The nurse technician told me that my blood pressure was 150 over 90.” e. “I think my ankles are less swollen.” Chapter 50 1. A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply.) a. Orthostatic hypotension b. Tremors c. Acute dystonia d. Decreased level of consciousness e. Restlessness 2. A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication‟s anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply.) a. Take sips of water frequently. b. Wear sunglasses when outdoors in sunlight. c. Use a soft toothbrush when brushing teeth. d. Take the medication with an antacid. e. Urinate prior to taking the medication. 3. A nurse is reviewing a client‟s medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? a. Decreased therapeutic effects of cimetidine b. Increased risk of imipramine toxicity c. Decreased risk of adverse effects of cimetidine d. Increased therapeutic effects of imipramine 4. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? a. “Get up and change positions slowly.” b. “Avoid eating aged cheese and smoked meat.” c. “Report any usual bruising or bleeding to the doctor immediately.” d. “Eat the same amount of foods that contain vitamin K every day.” 5. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse‟s priority? a. Teaching the client about the purpose of the medication b. Giving the medication at the administration time the provider prescribed c. Identifying the client‟s medication allergies d. Documenting the client‟s anxiety level Chapter 51 1. To promote adherence with medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply.) a. Adjust dosages according to daily weight. b. Place pills in daily pill holders. c. Ask for liquid forms if the client has difficulty swallowing pills. d. Ask a relative to assist periodically. e. Request child-resistant caps on medication containers. 2. A client in a provider‟s office tells the nurse that “I fast for several days each week to help control my weight.” The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? a. Increasing the metabolism of the medications over time b. Increasing the protein-binding response c. Increasing medications‟ transit time through the intestines d. Decreasing the excretion of medications 3. A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply.) a. Increased gastric acid production b. Immature liver c. Higher body water content d. Increased absorption of topical medications e. Increased gastric emptying time 4. A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? a. Drink 8 oz of milk with each dose of medication. b. Use medications that have an extended half-life. c. Take each dose right after breastfeeding. d. Pump breast milk and freeze it prior to feeding to the newborn. 5. A nurse in an outpatient clinic is teaching a client who is in the first trimester of pregnancy. Which of the following statements should the nurse make? a. “You will need to get a rubella immunization if you haven‟t had one prior to pregnancy.” b. “You can safely take over-the-counter medications.” c. “You should avoid any vitamin preparations containing iron.” d. “Your provider can prescribe medication for nausea if you need it.” Chapter 52 1. A nurse is reviewing the medical record of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply.) a. Diuretics b. Corticosteroids c. Oral anticoagulants d. Opioid analgesics e. Antipsychotics 2. A nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? a. Smear the blood onto the strip. b. Squeeze the blood onto the strip. c. Touch the puncture to stimulate bleeding. d. Hold the test strip next to the blood on the fingertip. 3. A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? a. Puncture another finger to obtain a capillary specimen. b. Test the urine with a urine reagent strip. c. Wrap the hand in a warm, moist cloth. d. Perform a venipuncture to obtain a venous sample. 4. A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) a. Perform SMBG once daily at bedtime. b. Wipe the hand with an alcohol swab. c. Hold the hand in a dependent position prior to the puncture. d. Place the puncturing device perpendicular to the site. e. Prick the outer edge of the fingertip for the blood sample Chapter 53 1. A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) a. Restlessness b. Tachypnea c. Bradycardia d. Confusion e. Hypertension 2. A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) a. Apply petroleum jelly around and inside the nares. b. Remove the nasal cannula during mealtimes. c. Check the position of the cannula frequently. d. Report any nausea or difficulty breathing. e. Post “No Smoking” signs in prominent locations. 3. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse‟s priority? a. Increase the oxygen flow. b. Assist the client to Fowler‟s position. c. Promote removal of pulmonary secretions. d. Obtain a specimen for arterial blood gases. 4. A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) a. Apply suction while withdrawing the catheter. b. Perform suctioning on a routine basis every 2 to 3 hr. c. Maintain medical asepsis during suctioning. d. Use a new catheter for each suctioning attempt. e. Apply suction for 10 to 15 seconds. 5. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) a. Apply the oxygen source loosely if the SpO2 decreases during the procedure. b. Use surgical asepsis to remove and clean the inner cannula. c. Clean the outer cannula surfaces in a circular motion from the stoma site outward. d. Replace the tracheostomy ties with new ties. e. Cut a slit in gauze squares to place beneath the tube holder. Chapter 54 1. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? a. “Water helps clear the tube so it doesn‟t get clogged.” b. “Flushing helps make sure the tube stays in place.” c. “This will help you get enough fluids.” d. “Adding water makes the formula less concentrated.” 2. A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? a. Auscultate breath sounds. b. Stop the feeding. c. Obtain a chest x-ray. d. Initiate oxygen therapy. 3. A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse‟s highest assessment priority before performing this procedure? a. Check how long the feeding container has been open. b. Verify the placement of the NG tube. c. Confirm that the client does not have diarrhea. d. Make sure the client is alert and oriented. 4. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) a. Auscultate bowel sounds. b. Assist the client to an upright position. c. Test the pH of gastric aspirate. d. Warm the formula to body temperature. e. Discard any residual gastric contents. 5. A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) a. Review a signal the client can use if feeling any distress. b. Lay a towel across the client‟s chest. c. Administer oral pain medication. d. Obtain a Dobhoff tube for insertion. e. Have a petroleum-based lubricant available. Chapter 55 1. A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) a. Extremes in age b. Chronic illness c. Low hemoglobin d. Malnutrition e. Poor wound care 2. A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) a. Increase in incisional pain b. Fever and chills c. Reddened wound edges d. Increase in serosanguineous drainage e. Decrease in thirst 3. A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) a. Stage 3 pressure injury b. Sutured surgical incision c. Casted bone fracture d. Laceration sealed with adhesive e. Open burn area 4. A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) a. Cover the area with saline-soaked sterile dressings. b. Apply an abdominal binder snugly around the abdomen. c. Use sterile gauze to apply gentle pressure to the exposed tissues. d. Position the client supine with the hips and knees bent. e. Offer the client a warm beverage (herbal tea). 5. A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client‟s skin? (Select all that apply.) a. Keep the head of the bed elevated 30°. b. Massage the client‟s bony prominences frequently. c. Apply cornstarch liberally to the skin after bathing. d. Have the client sit on a gel cushion when in a chair. e. Reposition the client at least every 3 hr while in bed. Chapter 56 1. A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents should the nurse include as examples of the direct mode of transmission? (Select all that apply.) a. Blood spurting from an arterial wound splashes into a nurse‟s eye. b. A nurse has a needlestick injury. c. A mosquito bites a hiker in the woods. d. A nurse finds a hole in their glove while handling a soiled dressing. e. A person fails to wash their hands after using the bathroom and touches a client. 2. A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? (Select all that apply.) a. Urinary incontinence b. Malaise c. Acute confusion d. Fever e. Agitation 3. A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? a. Implement airborne precautions. b. Obtain a sputum culture. c. Administer antituberculosis medications. d. Recommend a screening test for family members. 4. A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia? a. Linear clusters of vesicles on the right shoulder b. Purulent drainage from both eyes c. Decreased white blood cell count d. Report of continued pain following resolution of the rash 5. A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? a. “I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial.” b. “MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed.” c. “I will protect others from exposure when I transport the client outside the room.” d. “To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile.” Chapter 57 1. A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) a. Distended neck veins b. Hyperthermia c. Tachycardia d. Syncope e. Decreased skin turgor 2. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? a. A client who has nasogastric suctioning b. A client who has chronic constipation c. A client who has syndrome of inappropriate antidiuretic hormone d. A client who took an toxic dose of sodium bicarbonate antacids 3. A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.) a. Hct 55% b. Blood osmolarity 260 mOsm/kg c. Blood sodium 150 mEq/L d. Urine specific gravity 1.035 e. Blood creatinine 0.6 mg/dL 4. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? a. A client who has a new diagnosis of adrenal insufficiency b. A client who has heart failure c. A client who is receiving treatment for diabetic ketoacidosis d. A client who has abdominal ascites 5. A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? a. Administer antihypertensive on schedule. b. Check the client‟s weight each morning. c. Notify the provider of a urine output greater than 30 mL/hr. d. Encourage independent ambulation four times a day. Chapter 58 1. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? a. Infuse hypotonic IV fluids. b. Implement a fluid restriction. c. Increase sodium intake. d. Administer sodium polystyrene sulfonate. 2. A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? a. Crohn‟s disease b. Postoperative following appendectomy c. History of bone cancer d. Hyperthyroidism 3. A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? a. Starting an IV infusion of 0.9% sodium chloride b. Consulting with dietitian to increase intake of potassium c. Initiating continuous cardiac monitoring d. Preparing the client for gastric lavage 4. A nurse is collecting data from a client who has hypercalcemia as a result of long- term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) a. Hyperreflexia b. Confusion c. Positive Chvostek‟s sign d. Bone pain e. Nausea and vomiting 5. A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? a. “Avoid green, leafy vegetables while taking this medication.” b. “You should receive a prescription for a thiazide diuretic to take with the magnesium.” c. “You should eliminate whole grains from your diet until your magnesium level increases.” d. “Report diarrhea while taking this medication.” ATI Fundamentals Terms in this set (106) Always correct You've answered all of these correctly! +1 Home safety: -remove items that could cause Teaching anolder the client to trip (rugs, cords, adult client about carpets) home safety -place electrical/extension cords against a wall behind furniture -monitor gait/balance, provide aids PRN -makesuresteps/sidewalksarein good condition -grabbars near toilet, tub, shower -stool riser, toilet cushion -nonskid bath mats/shower mats -shower chair or bedside commode PRN -ensure adequate lighting -water heater 120 -no smoking if on oxygen, cotton stuffonly, no heating oil ornail polish remover -cook meat and fish fully, handle properly +1 Safe Medication Administration & Error Reduction: Appropriate Actions Following a Medication Error -assess client -inform charge nurse -complete incident report Normallevelfor WBC's 4,500 - 11,000 Normal lab values for Hbg male 13.5-17.5 g/dL Normal lab values for Hbgfemale 12-16 g/dL Normal lab values for Na 135-145 mEq/L Normal lab values for K 3.5-5 mEq/L Normal lab values for Cl 95-105 mEq/L Normal lab values for HCO3 22-29 mEq/L NormalBUN lab values 7-18 mg/dL Normal Creatine lab values 0.6- 1.2 mg/dL Normal Glucose lab values 70-110 mg/dL Normal Calciumlab values 8.5-10.5 mg/dL Normal total protein lab values 6-8 g/dL NormalAlb lab values 3.5-6 g/dL Normal total Bili 0-1 mg/dL How many grams are in 1oz 28.35 How many mL are in 1 oz 29.57 Howmanyozare in 1 cup? 8 oz How many liters are in 1 gallon? 3.8 What are normal values of pH for ABG 7.35-7.45 Whatarenormal valuesofPaCO2? 35-45 mmHg What are normal values of PaO2? 80-100 mmHg What are normal values of HCO3 24-30 mEq/L What are the steps in removing an artificial eye? pulldown thelowerlip with index finger & exert slight pressure, allowing to slide over lower lid and grab with free hand -store artificial eye in labeled container filled with tap water or saline What are the steps in inserting an artificial eye? lift upperand lowerlidto insert and blink until sets How do youwash an artificialeye? Wash with warm, normal saline, with soft gauze or clean tap water How do you properly irrigate an ear -Haveptsit or lie on side with the affected ear UP. -Using a bulb-irrigating syringe orWalterPikseton No 2, gently washear with warm solution, directing flow toward the superior aspect of the ear canal. Nonblanchable erythema indicates the skin hasbeen damaged by what? Pressure Explain what is happening in the S1 sound "Lub" sound- tricuspid and mitral valves snap shut @ beginning of systole.It is loudestattheapex of theheart. Explain what is happening in the S2 sound "Dub" sound- Aortic and Pulmonic valves shutatbeginning ofdiastole.This is heard best at the base of the <3 What does a split S2 mean? Electrical conduction may be delayedononeside soventricles might not close at the same time - may sound like a "stutter" S3 is heard in pt's with what? CHF. Itfollows S2 S4 is heard in pt's with what? HTN, CAD, MI. Whatisamurmur? occurs between S1 and S2. It shouldbesilentthere,butwitha murmur there is a whooshing sound . this typically happens if a valve isn't open wide enough (Stenotic) orifa valvedoesn't close tightly enough and blood leaks back Grade 1 murmurs difficult aretypically _ to hear Grade 6 murmurs are typically to hear easy to hear Grade 4 and above murmurs are considered and are accompanied bya loud murmurs. palpable thrill Pericardial friction rub pericardium (membrane around the heart) becomesinflamed. It causeshigh pitched, scratchy sound. It is loaded at apex Whatisthe Valsalva maneuver? holding breath and bearing down. Usually done to check for hernia's When suctioning a trach, do you apply suction before or after insertion?Do you use a rotation method? After insertion.Yes Do not insert into artificial airway because it increases the risk of infection normal saline. insert artificial airway until feel resistance or patient starts coughing. If pt needs more suctioning, repeat procedure only more times & wait at least minute 1-2. 1 Torinse catheter, use mL of 5-10 mL. Normal saline Elderlypeopleand children needa gauge forIV's larger # Everytime access port you should clean it NEVER infuse potassium chloride Change IV sites every 72 hours Change tubing every 96 hours Fluids should not hangmorethan 24 hours Infiltration in IV Fluidgoesinto interstitial skinand pt's extremities look cool and swollen Phlebitis inflammation ofvein. Pt is redand warm nearsite Signs and symptoms offluid overloadare SOB, cracklesin lung, increased urine output Steps for inserting an IV -place pt in dependent position -apply tourniquetabovethe antecubital fossa or approximately 4-6 inches from anticipated site if pt has fragile skin or excessive hair,where doyou oversle eve ofgown to protect skin place the tourniquet? Ifa pthasfragile skin and the tourniquet is not available, use , Inflate just below pt'snormal . blood pressure cuff. Diastolic pressure If you are having trouble finding a well dilated vein, what do you do? stroke the extremity below intended IV site from distal to proximal or place a warm blanket/towel over extremity for a couple of minutes. AVOID rubbing vigorously or flicking vein as it can cause vein to constrict or a hematoma If pt is not receiving a continuous infusion, what do you initiate? A saline lock. Saline locks must be flushed with what and when? They mustbeflushedwith 1-3mLof normal saline before and afteryou administer each medication Whatdoyouclean site with prior to Chlorhexidine 2% initiating IV access? IVinsertions on older adults - Usetourniquet sparingly to avoid tearing or bruising of the skin -be sure to pull skill below the insertion site taut to stabilize the vein -use lower angle of insertion to avoid puncturing posterior wall of vein -to secure, use minimal tape-use mesh dressinginstead Hypertonic solutions used for pt's who have severe hyponatremia. cardiac or renal disease. -most risky, -pull fluid into vascular space by osmosisresultinginanincreased vascular vL that can result in pulmonary edema, Discharge teaching for a client with diabetes mellitus: DIET: -limit calories & decrease total fat intake to 30% of total calories/day -eat omega 3 fatty acids and fiber -low sat fats -use artificialsweetners WHEN SICK: -monitor glucose Q 3-4 hr -take DM meds as prescribed -increase fluids -test urine for ketones -encourage rest -report persistent fever above 101, confusion, rapid breathing, persistent N/V,etc. -assess supportsystems -assess ability to self-admin insulin -check glucose before meals and at bedtime -return demonstrations on self admin -store test strips in dry closed container -hand hygiene -continuous pump needles need to be changed Q 2-3 days -rotate injection sites -record I&Os and daily weights -hypoglycemia warrants immediate evaluation of glucose FOOT CARE: -inspectfeetdaily,wash w/mild soap& warm water-test temp first -avoid lotions -use mild foot powders -NO home corn/callous remedies -nail care after bath/shower -avoid open toe or open heel shoes -leather shoesbetter -no barefoot -cotton or wool socks -water heater should be no more than 120 Client safety: fall riskprecautions -complete fall risk assessment upon admission -show client how to use call light, make sure it is within reach -ensure adequate lighting -orient the client to the setting, make sure they know how to use allassistive devices -place fall risk clients near nurses station -bedside tables, overbed tables, and frequently used items should be within reach -bed in lowestposition -sedated/unconscious clients bed rails up, bed in lowest position -avoid use of full side bed rails forclients who get out of bed or attempt to w/outassistance -nonskidfootwear& nonskid bathmats -keep floor free from clutter (no rugs, cords,furniture) -educate family & client on fall risk status/prevention -lock wheels on beds, wheelchairs, & cartss -use chair & bed sensors Client safety: alternatives to restraints fora client who is confused -one to one care -keep close to nurse's station -low to the floorbeds with mattress on the floors -bed alarms -rocking chair in the room -relaxation techniques -family stay with the patient Hygiene: Bathing a client who has dementia -assess client's ability to help -collect equipment & explain procedure, reassure, maintain their dignity -apply gloves -lock wheels on beds -wash face first -keep them covered -shave in direction of hair -brush teeth and hairoften and gently -donotneedto bathe daily as their skin cannot take it -reorient often thorax, heart, and abdomen: appropriate technique for abdominal assessment: 1. Inspection 2. Auscultation 3. Percussion 4. Palpation -urinate before abd assessment -supine, knees slightly bent Self-concept and sexuality: Providing client support following a mastectomy: -monitor anger,emotions -encourage client to participate in care -arrangesupport group orvisit from someone in similar situation -counseling -discuss alternative means of sexual expression (hugging, cuddling) -therapeutic communication Mobility & Immobility: Appropriate use of crutches: -do not alter crutches after fitting -follow prescribed crutchgait -support body weight at the hand grips w/theelbowsflexed at 30 degrees -position crutches on the unaffected side when sitting or rising from a chair -keep crutches 6 inches to the frontand to the side of client when walking -don't let crutchesfit underthe armpit - allow some space to avoid damage to skin or nerves in axillae Urinary elimination: preventing skin breakdown -keep skin dry and clean -assess for signs of breakdown -apply protective barrier creams -implement bladder retraining programs Mobility & Immobility: Preventing thrombus formation: -avoid pillows under knees or lower extremities -avoid crossing legs -avoid wearing tight clothes -avoidsitting forlong periodsof time -avoid massaging the legs -use elastic stockings -use compression devices (SCD, IPC) -increase fluid intake -avoid valsalvamaneuver -change positions often -encourage ROM & leg exercises Fluid imbalances: hypersomolar imbalance -aka dehydration -fluids: isotonic solutions such as LR or 0.9% sodium chloride NaCl -blood transfusions -encourage oral rehydration as tolerated this results in: -increased Hct -increased serum elecs -increased urine specific gravity -antidiuretic hormone release -aldosterone release -increased thirst Nasogastric Intubation & Enteral feedings: Unexpected findings -excoriation of nares & stomach -coffee-ground or blood streaked drainage -distention (caused byocclusion of tube) -gastric residual exceeds 250 ml for each of two consecutive assessments -diarrhea 3 or more times in 24 hrs -N/V -aspiration of formula -skin irritation around site Nutrition & Oral Hydration: Calculating intake 1. 1oz= 30mL 2. 1 cup=240mL 3. 1 tsp=5mL 4. 1 tbsp=15mL 5. CONVERT to mL then add Rest & Sleep: Interventions to promote sleep: -establish routine -limit waking during the night -help w/personal hygiene needs or a back rub prior to sleep to increase comfort -exercise regularly at least 2 hr before bedtime -limit fluids 2-4 hr before bed -engage in muscle relaxation techniques -pharm agents Pharmacokinetics & Routes of Admin: Administering Intradermal Tuberculin Test -use smallamounts ofsolution (0.01to 0.1mL) inatuberculin syringe -fine-gauge needle (26-27 gauge) -inject in lightly pigmented, thin- skinned, hairless sites (inner surface of mid-forearm or scapular area of the back) -10 to 15 degree angle Pharmacokinetics & Routes of Admin: Enteral Administration of Medications Contraindications include: -vomiting -decreased GI motility -absence of gag reflex -difficulty swallowing -decreased LOC -have client seated at 90 degree angle -admin irritating meds w/small amounts offood -do not mix w/large amounts of food or beverages in case the client is unable to consume the entire quantity -avoid grapefruit juice ormilk w/iron etc -admin oralmedson an empty stomach (30-1 hr before mealsor2 hr after meals) -enteric-coated meds or time- release must be swallowed whole -use a liquid form of med to facilitate swallowingwhenever possible Intravenous therapy: catheter insertion procedure -don't use tourniquet on older adults, use BP cuff -cleanse the skin prior w/betadine or alcohol-wait to dry,inwardthen movingout -pull skin taut and hold it -warn client of sharp stick -insertat10-30 degreeanglewith bevel up -advance catheter, look for flashback ofblood -thread catheter in vein about 0.25 in -retract needle -stabilize catheter withhandand release tourniquet -attach tubing andstabilize with tape/dressing -document Intravenous therapy: Initiating IVtherapyforan older adult client -don't use tie, use BP cuff (4-6 inchesaboveproposedsite) -do not slap the extremity to visualize veins -avoid rigorous friction while cleaning the site -assess for allergies prior -assess for bleeding disorders prior Airway management: Monitoring oxygen saturation -pulse ox (normal 95-100%) -acceptable levels range from 91- 100%, some illness states may even allow85-89% -readings below 90% reflect hypoxemia -readings can be impaired in older clients, darker skinned clients, clientsw/hypothermia, edema, and nail polish -place client in semi-fowler's or fowlers -encourage deepbreathing Nasogastric intubation & enteral feedings: preparing to administer feeding 1. introduce, explain, establish signs to show distress, clean 2. set up equipment & provide privacy -NG tube -tape -clean gloves -water soluble lubricant -cup of water & straw -basin -catheter tip syringe (30-60 mL) -pH test strip or meter -stethescope -towel -clamp or plug -suction -gauze square 3. Auscultate bowelsounds, then palpate -raise HOB -highfowlers -assess nares 4. check placement -aspirate, test pH (4 orless is expected) -confirm placement w/x ray -feed slowly 5. document Sensory perception: Performing ear irrigation: MEDS: -use medical aseptic technique -sit upright or maintain side-lying -straighten ear canal by pulling auricle upward& outward for adults -down and back for children -holddropper1 cm abovethe ear canal, instill med, then gently apply pressure w/finger to tragus of ear unless contraindicated due to pain -donotpresscotton ballinto ear, place in outermost area if needed -remain in side lying position if possible for 2-3 min after installation of ear drops -use warm water UP & BACK adults DOWN& BACKkids Sensory perception: Teaching about care of an artificial eye -wash hands before and after touching eye -keep blood pressure, blood glucose, and cholesterol under control -eatfoodsrichinantioxidants, such as leafy vegetables -use warm water& mild non scented soap to wash it REMOVAL: -place towelbelowhead in case it pops out -pulldown onlower lid until you can see edge -put extractor under & pull gently out Airway management: teaching incentive spirometry use -used to see total breath intake and output -place lips around mouthpiece and make surethere is a good seal around it -inhale as much as you can -once you have inhaled enough, hold your breath for three seconds -exhale normally Airway management: performing Nasopharyngeal suctioning -don correct PPE -semi or high fowlers -encourage coughing & deep breathing -hyperoxigenate prior -obtain baselines prior -use a flexible catheter & lubricate the distal 6-8 cm with water solublelubricant -suction pressure nohigher than 120-150 -limit duration of 10-15 seconds, 2-3 attempts -no suction while inserting -measure tube insertion correctly(end of nose, to ear, to sternum) -apply intermittent suctioning by doing thumb on/off 10-15 seconds & rotating on slowly removing Pressure ulcers, wounds, and wound management: dressings for pressure ulcers -saline or occlusive for stage 2 -nonadherent for stage IV -debridement & skin grafts for stage IV -antimicrobials for stage 3 -clean from least contaminated to the most contaminated -use gentle friction -do not use cotton balls orother products that shed fibers -document the location and type of wound and incision, the status of the wound, type ofdressing andmaterials, client teaching, and howthe client handled the procedure DO NOTUSE: -alcohol -dakin's solution -acetic acid -providone-iodine -hydrogen peroxide -cytotoxic cleansers Legal responsibilities: completing an informed consent -witness -parents may sign for minors -clientmustunderstand& have no further questions -have them sign -document the questions the clienthad, if used an interpreter, reinforcementofteaching, etc Medical & Surgical Asepsis: Planning care for a client who has a latex allergy -check before any procedure -ensurelatexfreeeverything is used by staff, client, and team Older Adult (65 & PHYSICAL: up): identify expected changes indevelopment: -decrease in skin turgor -decrease in subcutaneous fat & connective tissue -thinning & grayingofhair, sparser distribution -thicker fingernails & toenails -slower reactiontime -decrease in touch, smell, taste -decline in vision -decrease in muscle tone & height -joint degeneration -decrease in GI motility -decalcification of bones -decrease in bladder capacity -decline in estrogen & testosterone -dental problems COGNITIVE: -dementia, delirium,depression PSYCHOSOCIAL: -face death -deal with family losses -integrity vs despair Urinary elimination: Effects of Aging on Urinary Infections -increasing risk of UTIs with age -residual urine from insufficient bladder emptying -poortone fromaging leads to frequency Adverse Effects, Interactions, -decreased respirations (morphine, opioids) Contraindications: Priority Assessment Findings (pain management) -EPS symptoms -seizures -LOC changes Specimen Collection for Glucose Monitoring: Obtaining a Capillary Blood Glucose Sample -check meds, gather stuff -outer edge of fingertip most common site -alternate sites -warm site prior -cleanse w/warm water & soap or an antiseptic swab -pierce skin w/lancet, hold perpendicular to skin -wipe away first drop of blood -milk finger if needed -don't smear blood on strip Intravenous therapy: Recognizing Phlebitis -edema -throbbing -burning -pain at site -erythema -redline upthearm w/a palpable band at the vein site Breast self- examination -inspect in front of mirror -palpate in the shower -do it 2-3 days after period ends -postpartum clients should do BSE on the same day each month -areola should be darker than nipple& roundor ovalshaped -nipples should be everted -one slightly larger than other Ergonomic principles: Safely Transferring a Client from the Bed to the Chair -use 2 or more people to help -use assistive equipment -assess client's ability to help -avoid twisting or bending at the waist caringforaclient with c-diff -contact precautions -wash hands with soap and water -keep one stethoscope in room -use PPE Identifying an intentional tort: -assault (threatens to place catheter) -battery (restrains client & admins med against will) -false imprisonment (all side rails) Performing Romberg assessment: ask client to stand w/his feet together, armsatside, eyes closed expected finding: minimal swaying for at least 5 seconds Implementing isolation precautions: -change PPE after every client -provide stimulation to client in isolation -assist client & family in understanding why precautions are implemented YoungAdults (20- 25): teaching appropriatehealth promotion guidelines: -immunizations (hep A & B, diptheria, tetanus, pertussis, MMR, influenza, HPV, & pneumococcal & meningococcal) -monitor calciumintakefor women -avoid drugs & alcohol -car safety -helmets -smoke & carbon monoxide detectors -securing firearms in safe location Normal BP systolic= systolic=less than 120 diastolic=less than 80 Pre-HTN BP systolic=120-139 diastolic=80-89 stage 1 HTN BP systolic=140-159 diastolic=90-99 stage 2 HTNBP ... ... systolic=greater than 160 diastolic=greaterthan 100 A.T.I FUNDAMENTALS 7. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard? a) An assistive personnel places a weight-sensitive sensor mat on the mattress beneath the client’s buttocks. b) An assistive personnel raises all four side rails of a client’s bed before leaving the room. c) A client who has bilateral wrist restraints has a capillary refill less than 2 seconds. d) A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site. 8. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss? a) “I stay awake at night because I keep thinking about my leg.” b) “I need to learn how to perform a dressing change on my leg.” c) “I know my family means well, but I don’t want visitors seeing my leg right now.” d) “I am going to have to find someone who can take care of my leg at home.” 9. A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse make? a) Measure the client’s BP in the other arm. b) Use a narrower cuff to repeat the BP measurement. c) Deflate the cuff faster when repeating the bp measurement. d) Request a prescription for an antihypertension medication. 10. A nurse is assisting with the admission of a client who has streptococcal pharyngitis. Which of the following precautions should the nurse make? a) Have the client’s visitors put on a gown before entering the room. b) Escort the client to a room with a negative airglow. c) Prohibit fresh flowers and plants in the client’s room. d) Wear a surgical mask when giving the client direct care. 11. A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following images indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration? 12. A nurse working in a rehabilitation unit is caring for a client who has dysphagia and has difficulty swallowing during meals. Which of the following actions should the nurse take to prevent the client from aspiration while eating? a) Add liquid to foods to thin consistency. b) Tilt the clients head slightly backward. c) Offer verbal support while the client is eating. d) Encourage socialization with others during meals. 13. A nurse in a provider’s office performs a fecal occult blood test with a positive result on a client. Which of the following clients may have a false positive result? a) A client who has a venous stasis ulcer. b) A client who takes an iron supplement. c) A client who has peripheral hematomas. d) A client who underwent a barium swallow study. 14. A nurse is caring for a client who is flushed and has temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? a) Give the client an alcohol sponge bath. b) Place cold packs on the client’s axillae. c) Place a fan to blow air across the client. d) Remove blankets from the client. 15. A nurse is caring for a client who has a hip fracture and plans to administer a pain medication prior to turning the client. Which of the following ethical principles is the nurse implementing? a) Beneficence. b) Fidelity. c) Autonomy. d) Veracity. 16. A nurse is caring for a client who was recently admitted to hospice care and tells the nurse “I am going to die, and my family is hoping for a cure. I am mad that they behave like everything will be fine.” Which of the following responses should the nurse make? a) “It sounds like you have given up and you want to stay mad at your family.” b) “Why do you think they don’t know what’s happening?” c) “You are feeling angry that your family continues to wish for a cure?” d) “I think you and I need to talk about your anger with your family.” 17. A nurse in a provider’s office is reviewing the medical record of an older adult who report’s having nausea and vomiting for the last 48 hrs. Which of the following findings indicate fluid volume deficit? (Select all that apply.) a) Dry mucous membranes. b) Decreased skin turgor. c) Heart rate 72/min. d) Distended neck veins. e) Blood pressure 88/62 mm Hg. 18. A nurse is caring for a client who refuses a prescribed medical procedure. Which of the following actions should the nurse take to act as the client’s advocate? a) Evaluate the client’s concerns and communicate them to the provider. b) Ask the client’s partner to find out why the client has refused the procedure. c) Explain the necessity of the procedure to the client. d) Contact the unit’s social worker to report the client’s refusal. 19. A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis? a) Expansion of the upper intercostal spaces. b) Increased convex curve of the cervical spine. c) Increased concave curve of the thoracic spine. d) Unequal height of the shoulders. 20. A nurse is disinfecting the room of a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use? a) Isopropyl alcohol. b) Triclosan. c) Chlorhexidine. d) Chlorine bleach. 21. A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/ 10 mL. How many mL should the nurse administer per dose? (Round to the nearest whole number.) mL (80x35÷1*1000 x10) /4 =7 mL 22. A nurse is reinforcing teaching with a client who follows a vegan diet and is interested in ways to increase protein to promote healing after a recent surgery. Which of the following suggestions is appropriate? a) Scrambled eggs. b) Baked eggs. c) Grilled salmon. d) Cottage cheese. 23. A home health nurse is reinforcing teaching about dietary needs with the son of a client. The son states, “I don’t know what to do because he’s not eating.” Which of the following responses should the nurse make? a) “I’m sure it’s nothing serious and his appetite will return soon.” b) “Why do you think he is not eating?” c) “He may need a feeding tube.” d) “Tell me more about what happens at mealtime.” 24. A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? a) Assess the pain level of a client who has received acetaminophen. b) Measure the intake and output of a client who has received furosemide. c) Check a client’s peripheral IV site for redness or swelling. d) Reinforce teaching with a client about crutch-gait walking. 25. A nurse is preparing to insert an indwelling urinary catheter and is verifying the client’s express consent for the procedure. Which of the following actions should the nurse take? a) Witness the client’s signature on a consent form. b) Check the medical record for the client’s signature on a previous consent form. c) Have another nurse co-sign the client’s consent. d) Obtain verbal consent from the client. 26. A nurse is planning to place a client into the Sims’ position. Which of the following actions should the nurse plan to take? a) Position the client’s arms at his side. b) Raise the head of the client’s head to a 30-degree angle. c) Place a pillow under the client’s flexed leg. d) Evaluate the client’s feet with two pillows. 27. A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include? a) Avoid placing the toilet tissue in the bedpan after defecation. b) Urinate after the specimen collection. c) Place 1.3 cm (0.5 in) of formed stool into a culture tube. d) Keep the specimen in a warm area. 28. A nurse is planning to apply a belt restraint to a client who is confused and at risk for falls. Which of the following actions should the nurse make? a) Apply the belt under the client’s gown. b) Allow four finger widths between the restraint and the client. c) Place the belt across the client’s chest. d) Fasten the client’s restraint using a quick-release tie. 29. A nurse is collecting data from a client following lumbar puncture. For which of the following adverse effects of the procedure should the nurse monitor the client? a) Headache. b) Fluid overload. c) Difficulty voiding. d) Diarrhea. 30. A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider? a) Bradycardia. b) Calf swelling. c) Tortuous veins. d) Clammy skin. 31. A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following interventions should the nurse give the client to prevent orthostatic hypotension? a) “Perform regular isometric exercise.” b) “Increase your intake of protein.” c) “use your incentive spirometer.” d) “dangle your legs over the side of the bed.” 32. A nurse is caring for a client who speaks a different language than the nurse and is 6 hrs postoperative. Which of the following actions should the nurse take to determine the client’s level of pain? a) Use a communication board to interact with the client. b) Ask an assistive personnel who speaks the same language as the client to interpret. c) Use the FACES pain scale to gauge the client’s level pf pain. d) Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client’s pain level. 33. A nurse is performing a wound irrigation for a client who has methicillin-resistant. Staphylococcus aureus. When removing personal equipment, which of the following pieces should the nurse remove first? a) Goggles. b) Mask. c) Gown. d) Gloves. 34. While performing hygiene care for a client, a nurse notices a frayed electrical cord on the clients electronic BP monitor. Which of the following actions should the nurse take first? a) Report the defective equipment. b) Remove the device from the room. c) Request a replacement deice. d) Access the facility’s maintenance protocol. 35. A nurse is reinforcing teaching with a male client about collecting a mid-stream urine specimen. Which of the following interactions should the nurse include? a) Begin by urinating a small amount into the toilet, stop the stream of urine, and then urinate into the cup. b) Urinate a small amount into the cup, discard the urine, and then urinate into the cup for the sample. c) Begin by urinating into the cup and then finish urinating in the toilet. d) Urinate into the toilet and then place the cup into the stream to collect urine. 36. A nurse is reinforcing teaching with a client who has a new ileostomy about nutrition therapy. Which of the following food choices by the client demonstrates an understanding of the teaching? a) Mushrooms. b) Popcorn. c) Bananas. d) Broccoli. 37. A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk? a) The client has removed the wheels from rolling chairs. b) The client’s mattress is directly on the floor. c) A stool riser is in place on the bathroom toilet. d) Throw rugs over electrical cords on the floor. 38. A nurse is collecting data from a client who had a stroke and is unable to name common items. The nurse should recognize that the client’s experiencing which of the following types of aphasia? a) Global aphasia. b) Expressive aphasia. c) Receptive aphasia. d) Sensory aphasia. 39. A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect? a) Hyperkalemia. b) Hypermagnesemia. c) Hyponatremia. d) Hypocalcemia. 40. A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider? a) Greenish-yellow drainage. b) Report of hunger. c) Gastric contents are present in the air vent. d) Abdominal distention. 41. A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious which of the following actions by the AP requires intervention by the nurses? a) Using an oral care sponge swab moistened with cool water to clean the client’s mouth b) Wearing clean gloves to perform mouth care for the client c) Lowering the side rail on the side of the bed where they will stand to perform mouth care d) Using two gloved fingers to open the client’s mouth for cleaning 42. A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute unit. Which of the following actions should the nurse include in the plan? a) Restrict the number of visitors for clients b) Assign different nurses to provide care for clients each day c) Turn on loud music in client care areas d) Offer the clients many choices regarding care 43. A nurse is reinforcing teaching with a client who is learning to use a walker and his left- leg weakness. Which of the following instructions should the nurse include in the teaching? a) “Move your right leg forward as you advance the walker” b) “Keep your eyes on your feet when ambulating with the walker” c) “Support yourself with the walker when rising from a chair” d) “Maintain your arms in a slightly fixed position when using the walker” 44. A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique? a) “I’ll think about my grandfather’s farm to reduce pain” b) “I’ll use focused breathing to control my pain” c) “I’ll learn to notice the sensation of muscle tension” d) “I’ll listen to my favorite music to take my mind off the pain” 45. A nurse is assisting a client who is 4hr postoperative to get out of bed. The client states, “Do not touch me! I can get up by myself.” Which of the following response should the nurse make? a) “I will be next to you and will help if you need to” b) “I think you need some pain medication before getting out of bed c) “We can talk about this after you have gotten out of bed” d) “Why don’t you want to be touched?” 46. A nurse is reinforcing teaching with a newly hired nurse about cultural sensitivity during death and dying. Which of the following information should the nurse include? a) Devout practitioners of Hinduism prefer to be buried after death and not cremated b) Devout practitioners of Judaism prefer to be buried 5 days after death c) Devout practitioners of Islam prefer to have their heads turned toward Mecca at death d) Devout practitioners of Buddhism prefer a ritual bath prior to burial 47. A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend? a) Passive range-of-motion exercise b) Walking c) Bowling d) Jogging 48. A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to promote commucation? a) Use short phrases b) Speak in a loud voice c) Decrease background noise d) Talk at a rapid rate 49. A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur? a) The sterile solution is poured with the bottle held over the field b) A pair of sterile forceps is allowed to rest in a container of sterile water on the field c) The handle of a pair of sterile scissors is resting 5cm ҁ2in҂from the field’s edge d) Unnecessary sterile items are place on the field 50. A nurse is reinforcing teaching with the adult children of a client who is receiving palliative care. Which of the following statements by one of the adult children indicates an understanding of the teaching? a) “We will receive emotional support during our mother’s illness” b) “We won’t allow her spiritual advisor to visit during this time” c) “We won’t discuss the illness in the presence of our mother” d) “We will provide resuscitation to our mother if necessary” 51. A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? 1) Separate the labia with the nondominant hand 2) Clean around the urinary meatus from front to back 3) Insert the catheter into the urethral meatus 4) Inflate the catheter balloon 5) Secure the catheter to the client’s thigh 52. A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take? a) Instruct the partner not to touch the client’s body b) Place the client’s personal belongings in a safe location in the facility c) Ask the partner about any rituals they would like to be performed d) Direct the partner to leave and return once postmortem care is complete 53. A nurse is reinforcing teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object? a) Bend at the waist b) Tighten the abdominal muscles c) Keep legs straight d) Hold object away from the body 54. A nurse in a provider’s office receives a telephone call from a client’s sibling requesting current information about the client’s condition. Which of the following actions should the nurse take? a) Provide the caller with a brief update about the client’s condition b) Gather additional information from the caller to verify their identity c) Ask the caller to contact the client directly for information d) Request that the caller contact the client’s provider directly for information 55. A nurse is caring for a client who is experiencing fecal incontinence. Which of the following actions should the nurse take? a) Decrease the client’s fluid intake b) Increase the client’s intake of raw fruits and vegetables c) Cleanse the client’s perianal area with an alcohol-based solution d) Apply barrier ointment to the client’s perianal area 56. A nurse is caring for a client who has difficulty swallowing following a stroke. Which following actions should nurse take when administering an oral medication to this client? a) Instruct the client to use a straw to take liquid medications b) Place the client in high-Fowler’s position c) Tilt the client’s head backward while swallowing d) Dissolve medications in water prior to administration 57. A nurse is caring for a group of clients. For which of the following situatuons should the nurse complete an incident report? (Select all that apply) 1) A client is unable to afford the physical therapy that the provider recommends 2) A client becomes disoriented and falls out of bed 3) A client reports being dissatisfied with the temperature of the meals provided 4) A client’s visitor becomes dizzy and faints in the client’s room 5) A client receives burns from a heating pad 58. A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take? a) Have the client sign an against medical advice form b) Tell the client that the surgeon will prescribe restraints if they try to leave c) Administer a sedative medication to the client d) Explain to client that they cannot leave until the surgeon discharges them 59. A nurse is caring for a client who has experienced a cerebrovascular accident with resulting dysphagia. Which of the following therapists assists clients to learn to eat with less risk of aspiration? a) Speech b) Physical c) Occupational d) Respiratory 60. A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client’s health record? a) Client drank adequate amounts of fluid with meals b) Episiotomy approximated, 3 cm (1.18 in) in length c) Client instructed on self-care needs d) Oral temperature elevated at 0800 61. A nurse is in a long-term care facility is transcribing a prescription for a client. Which of the following abbreviations is appropriate? a) sub q b) mcg c) qhs d) qod 62. A nurse is assisting with the admission of a client. Which of the following statements should the nurse make to demonstrate the principle of advocacy? a) “I will do my best to fulfill my promises to you” b) “I will keep your personal information private” c) “I will speak with your provider on your behalf” d) “I will let you make decisions about your health care” 63. A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include? a) Standing with the crutch tips against the feet b) Bear weight on the unaffected leg c) Keep the crutches at the level of the axillae d) Hold the arms straight when walking 64. A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake? a) Restrict visitors during meals b) Provide the client with finger foods for meals c) Limit snacks between meals d) Provide the client with three large meals each day 65. A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take? a) Reposition the sensor probe b) Apply a cooling blanket to the client c) Ambulate the client d) Place the client in a side-lying position 66. A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to promote wound healing. Which of the following foods should the nurse recommend as the best source of vitamin C? a) 1 small banana b) 1 small pink grapefruit c) 1 small apple with the skin d) 1 medium fresh green pear 67. A nurse in an acute care center is caring for a client who just died. The client’s family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make? a) “You will have to sign a release form to perform the care yourself” b) “I will assist you in any way I can during this process” c) “A licensed health care worker must perform postmortem care.” d) “This care takes place after the client leaves the facility” 68. A nurse is wearing sterile gloves in preparation for assisting with a client’s sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands? a) Interlock her fingers and hold her hand away from her body above her waist b) Keep her arms at the sides of her body with her hands in a relaxed position c) Place one hand over the other against the part of the gown covering her upper body d) Clasp her hands together in a relaxed position behind her body at her waist 69. A nurse is assisting in the transfer of a client who has left-side weakness from a bed to chair. Which of the following actions should the nurse take? a) Flex hips and knees when assisting the client to a standing position b) Pivot on the foot farthest from the bed when assisting the client into the chair c) Raise the bed to waist level before moving the client d) Stand on the client’s stronger side when moving the client into the chair 70. A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates understanding of this assistive device? (missing answers) Stuvia.com - The Marketplace to Buy and Sell your Study Material A.T.I FUNDAMENTALS 1. A nurse is reaching a client and his family how to care for the client’s tracheostomy at home. Which of the following should the nurse include in the teaching? a. Use tracheostomy covers when outdoors 2. A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? a. The client’s care giver washed out the feeding bag once every 24 hours with warm water 3. A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the following responses should the nurse make? a. Let’s talk about how the change in your hob status will affect you. 4. A nurse is assessing a client who reports increased pain following pt. Which of the following questions should t15he nurse ask hen assessing the quality of the client’s pain? a. Sharp & dull 5. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. Reassure the client that this is an expected response to grief. 6. 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 7. A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. The client uses no acetone nail polish remover. 8. Nurse caring for a client who has a respiratory infection. What technique should she use when preforming nasotracheal suctioning? a. Apply intermittent suction when withdrawing the catheter. 9. Nurse is preparing for change of shift. Which document or tools should the nurse use to communicate? a. SBAR 10. Nurse is planning care for a client who had a stroke. What should be assigned to the assistive personal? (SATA) a. -Assist the client with a partial bed bath. b. -Measure the client’s BP after the nurse administers antihypertensive meds. c. -Use a communication board to ask what the client wants for lunch. 11. Nurse caring for a client who has dementia. What interventions should be taken to minimize risk for injury? a. Use bed exit alarm system 12. Nurse performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy? a. A mole with an asymmetrical appearance Stuvia.com - The Marketplace to Buy and Sell your Study Material 13. Nurse is administering optic ear medication on an adult client. Which action should be done to ensure the medication reached the inner ear? a. Press gently on the tragus of the client’s ear. 14. Nurse is planning strategies to manage time effectively for client care. What should the nurse implement? a. Use the planning step of the nursing process to prioritize client care delivery. 15. Nurse caring for a client who has a sodium level of 125. What findings should the nurse expect? a. Abdominal cramping 16. Nurse is preparing an education program for staff about advocacy. What information should the nurse include? a. Advocacy ensures clients’ safety, health, and rights. 17. Nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take? a. Administer the medication with the needle at a 45-degree angle. 18. A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which precaution should the nurse plan for this client? a. Make sure the client wears a mask when outside her room if there is construction in the area. 19. Nurse providing discharge instructions for client who will be using a walker. Which statement indicates an understanding of the teaching? a. I will hire someone to trim the tree that hands low over the stairs of my front porch. 20. Nurse planning to insert IV for an older adult client. What actions should the nurse plan to take? a. Place the client’s arm in a dependent position. 21. 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 22. A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the ED and I had a difficulty breathing?” Which of the following responses should the nurse make? a. We would give you oxygen through a tube in your nose. 23. 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. Help the client take sips of water to promote insertion of the NG tube 24. Nurse auscultating anterior chest who is newly admitted. Listen a. Normal breathing sounds 25. Caring for a client who died 1. Obtain order 2. Remove tubes 3. Wash client 4. Ask family 5. Place the tags 26. A nurse is providing discharge teaching to a client about self-administering heparin. a. Administer medication in abdomen Stuvia.com - The Marketplace to Buy and Sell your Study Material 27. A nurse caring for a client who asks about the purpose of advance directives a. Indicate form of treatment a client is willing to accept 28. Nurse is assessing an older adult for risk for falls (SATA) a. Pupil clarity, visual fields, visual acuity 29. Nurse assessing a client who is on bed rest for past month. Indication of thrombophlebitis a. Calf Swelling 30. Deep tendon reflex -- patellar reflex a. Knee picture 31. Postop client with fluid volume deficit. Changes indicate successful treatment a. Decrease in heart rate 32. Nurse is reviewing EBP about administration of O2 therapy a. Regulate O2 via nasal canula no more than 6L 33. Nurse responding to call light and finds client on bathroom floor. FIRST a. Check client for injuries 34. Nurse caring for client prescribed blood transfusion. Parents refuse due to religious beliefs. What should the nurse do? a. Examine personal values about the issues. 35. Nurse caring for client approaching death. SOB, noisy respirations. What should they do? a. Turn client 2 hours 36. Nurse is assessing readiness to learn about insulin self-administration. What indicates the client is ready to learn? a. I can concentrate best in morning. 37. Nurse receives report about a client getting IV fluids infusing 125ml/hr but notes he has only gotten 80 mL over the last 2 hours. What should nurse do first? a. Check IV tubing for obstruction 38. A nurse is preparing an injection for opioid medication. Draws 1mL from 2mL vial, what should the nurse do? a. Ask another nurse to observe medication waste? 39. Nurse caring for a group of clients. Prevent spread of infection a. Place a client with TB in negative pressure room. 40. Nurse caring for client at end of life. Which statement by client’s partner is effective coping? a. I am relying on support from out family during this time 41. Nurse caring for postop client following knee arthroplasty and requires thigh high compression sleeves. What should the nurse do? a. Make sure two fingers can fit under the sleeve. 42. Nurse using an open irrigation technique for client’s catheter. What action should nurse take? a. Subtract amount of irritant used from client’s urine output. 43. Nurse is caring for a client who has pharyngeal diphtheria. Transmission precautions? a. Droplet 44. Postop, signs of hemorrhagic shack. Nurse notifies surgeon and he said to continue to monitor vitals every 15 minutes and report in one hour. What should the nurse do next? a. Notify nurse manager 45. Reviewing client’s fluid and electrolytes status. What should nurse report to provider? a. Potassium 5.4 Stuvia.com - The Marketplace to Buy and Sell your Study Material 46. Nurse caring for client postop. When nurse prepares to change dressing, client says it hurts. Which intervention is the nurse’s priority action? a. Administer pain meds 45 minutes prior to dressing change. 47. Nurse admitting new client. Medication reconciliation? a. Compare the client’s home medications to the providers prescriptions 48. Nurse admitting client with abdominal wound. Which precaution? a. Contact precaution 49. Nurse lifting bedside cabinet. Prevent self-injury by? a. Standing close to cabinet when lifting 50. Preparing to apply dressing to stage 2 pressure injury. Which type of dressing should the nurse use? a. Hydrocolloid 51. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this? a. Role overload 52. Nurse is evaluating a client’s use of cane. What is the correct use? a. Client holds the cane on the stronger side of the body. 53. Math Question – 7 hours a. 107 mL/hr. 54. Nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching? a. Use the complete name of the medication magnesium sulfate. 55. Nurse caring for client who has herpes zoster. Client asks about complementary and alternative therapies for pain control. Nurse should inform client that this condition is a contraindication for which of the following therapies? a. Acupuncture 56. Nurse caring for a client who has the poops due to shigella. Precautions to implement? a. Wear a gown when caring for the client. 57. Nurse caring for client postop refuses to use incentive spirometer following major abdominal surgery. Nurse’s priority? a. Determine the reason why the client is refusing to use IS. 58. Client postop is verbalizing pain at a 2 on a scale from 0-10. Indication that client understands pain management? a. It might help me to listen to music while lying in bed. 59. A nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use? a. Ensure the bladder of the BP cuff surrounds 80% of their arm. 60. Nurse caring for client who has prostate cancer. Provider discusses treatment options and leaves room. Client declines to talk about concerns. Which of the following statements should the nurse make? a. I am available to talk if you should change your mind. Stuvia.com - The Marketplace to Buy and Sell your Study Material 5/3/19 ATI FUNDAMENTALS EXAM Key: Most likely on test Motivational quotes 1. CHAPTER 1: HEALTH CARE DELIVERY SYSTEMS A. Components of Health care systems a. Participants 1. Consumers- clients 2. Providers a. Licensed providers: registered nurses, license practical (or vocational) nurses (LPN), advanced practice nurses (APN), medical doctors, pharmacists, dentists, dietitians, physical/respiratory/occupational therapists, etc b. Unlicensed providers: assistive personal b. Settings 1. Hospitals, homes, skilled nursing, assisted living, schools, etc c. Regulatory Agencies 1. US department of Health and Human Services 2. US Food and Drug Administration (FDA) 3. State and local public health agencies 4. State licensing boards a. Determines laws/regulations that govern nursing in their state b. ensure health care providers and agencies comply with state regulations c. Issue/revoke nursing license i. Nurses need a license in every state they practice in 5. Joint Commission (JCAHO) a. Set quality standards for accreditation of health care facilities 6. Professional Standards Review Organizations- monitor health care services provided d. Healthcare financing Mechanisms 1. Public federally funded programs a. Affordable Care Act (Obamacare) i. Increases access to healthcare for all individuals ii. Decreasing healthcare costs iii. Providing opportunities for uninsured to become insured at an affordable cost b. States Children’s Health Insurance i. Covers uninsured children up to 19 years old at a low cost to parents Stuvia.com - The Marketplace to Buy and Sell your Study Material Don’t stop until you are proud c. MEDICARE MEDICAID Eligibility: >65 years old OR on disability for more than 2 years OR have ALS OR on dialysis Part A: inpatient hospital, limited skilled nursing care, home health care (hospital insurance) Part B: outpatient care, diagnostic services, OT/PT (medical insurance) Part C: combination of parts A and B, optional private insurance (Medicare advantage plan) Part D: prescription drugs (medications) Eligibility: low socioeconomic status, no insurance Federally and state funded Individual states determine eligibility requirements e. Levels of Health Care 2. CHAPTER 2: THE INTERPROFESSIONAL TEAM A. Interprofessional Personnel (non-nursing) Spiritual Support Staff Provides spiritual care (pastors, rabbis, priests) Registered Dietitian Assess/plans for/educates regarding nutrition needs Laboratory technician Obtains specimens of body fluids, and performs diagnostic tests Occupational therapist Focuses on patient’s independence and regain activities of daily living (ADL) skills 2 Stay Positive, work hard, make it happen Stuvia.com - The Marketplace to Buy and Sell your Study Material Radiologic technologist Positions client and performs x rays and other imaging procedures for providers to review for diagnosis of disorders of various body parts Respiratory therapist Evaluates respiratory status and provides respiratory treatments including oxygen including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation Social worker Works with clients and families by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and discharge Speech-language pathologist Evaluates and makes recommendations regarding the impact of disorders or injuries on speech, languages, and swallowing Ex: patient with dysphagia call speech pathologist for consult 3. CHAPTER 3: ETHICAL RESPONSIBILITIES A. Ethical Decision Making In Nursing a. Basic principles of ethics 1. Advocacy- support of client’s health, wellness, safety, privacy, and personal rights 2. Responsibility- willingness to respect obligations and follow through on promises 3. Accountability- ability to answer for one’s own actions 4. Confidentiality- protection of privacy without diminishing access to high-quality care b. Ethical Principles for client care c. Ethical Dilemma 1. Problems that involve more than one choice and stem from differences in values and beliefs of the decision maker a. A problem is an ethical dilemma when: i. There is not enough scientific data to solve it ii. It conflicts between 2 moral imperatives 3 Stuvia.com - The Marketplace to Buy and Sell your Study Material iii. Answer will have a profound effect on the situation and the client 2. When making an ethical decision: a. Identify if the issue is an ethical dilemma, gather as much relevant info as possible, reflect on own values, list and analyze all possible options, select correct option, apply it to situation Don’t stress. Do your best. Forget the rest. 4. LEGAL RESPONSIBILITIES A. Sources of Law a. Federal regulations 1. Health Insurance Portability and Accountability Act (HIPPA) 2. Americans with Disabilities Act (ADA) 3. Mental Health Parity Act (MHPA) 4. Patient Self-Determination Act (PSDA) b. Criminal and civil laws 1. Criminal law- relates to the relationship between an individual and the government 2. Civil law- protect individual rights (ex: tort law) c. State laws d. Licensure B. Types of Torts a. Unintentional torts 1. Negligence a. nurse fails to implements safety measured for a client at risk for falls (ex: bed alarm) b. 5 elements necessary to prove negligence i. Duty to provide care as defined by a standard ii. Breach of duty by failure to meet standard iii. Foreseeability of harm iv. Breach of duty has potential to cause harm v. Harm occurs 2. malpractice 4 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. nurse admins a large dose of meds due to a calculation error and client gets hurt b. Intentional torts 1. Assault- threat 2. Battery- acting on the threat 3. False imprisonment a. A person is confined or restrained against his will; inappropriate use of restraints and sedatives C. Informed consent a. Legal process by which a client or the client legally appointed designee has given written permission for a procedure or treatment b. Provide should explain (needs to be in clients primary language- interpreter may be needed): 1. Reason the patient needs procedure or treatment 2. How the procedure/treatment will benefit the client 3. The risks involved if the client receives the procedure/treatment 4. Other options to treat the problem c. Nurses role: 1. Witness patient’s informed consent signature 2. Notify provider if they have more questions d. Individuals may grant consent for another person if they are: 1. Parent of a minor 2. legal guardian 3. court specified representative 4. individual has durable power of attorney authority for health care e. Refusal of treatment 1. Notify provider, patient signs a document indicating understanding of risks D. Advanced Directives a. Living will- legal document that expresses client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end of life issues Durable power of attorney for health care- document in which clients designates health care proxy to make health care decisions for them if they are unable to do so c. Providers orders- unless there is DNR or AND in the clients medical record, the nurse will initiate CPR 5 Stuvia.com - The Marketplace to Buy and Sell your Study Material E. Mandatory reporting a. Abuse- nurses must report any suspicion of abuse (child, elderly, or domestic abuse) b. Communicable disease c. Impaired coworker (drinking, drugs) 1. Do not talk directly to them 2. Do not gather more information 3. Report the suspicion 5. INFORMATION TECHNOLOGY A. Documentation a. Elements of documentation 1. Subjective data- direct quotes or summarize information as the client’s statement 2. Objective data- what the nurse sees, hears, feels, and smells; NO OPINIONS b. Legal guidelines 1. Begin with date and time; write legibly, do not leave blank spaces; do not use correction fluid, erase, scratch out or blacken out errors, sign all documents with name and title B. Reporting formats a. Change of shift report b. Telephone reports 1. Try to have another RN there to listen in on phone call 2. Read back order to the provider 3. Provider signs order off within 24 hours c. Transfer (hand off) reports d. Incident reports 1. Document facts without judgement or opinion 2. Do not refer to an incident report in a client’s medical record C. Information security a. HIPPA (health insurance portability and accountability act of 1996 6 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Only health care team members directly responsible for a client’s care may access that client’s record 2. Clients have a right to read and obtain a copy of their medical record 3. Staff must keep medical records in a secure area to prevent inappropriate access to the info 4. Electronic records are password-protected 5. Nurses must not disclose unauthorized individuals or family members 6. Nurses must not disclose client’s info to unauthorized individuals or family members a. Many hospitals use a code system 6. DELEGATION AND SUPERVISION A. Delegation a. RN cannot delegate 1. Patient education 2. task that needs nursing judgement 3. Nursing assessment RN to LPN RN to CNA Monitoring findings Reinforce patient teaching Tracheostomy care Suctioning Checking NG tube patency Administering enteral feedings Inserting a urinary catheter Administering medication Activities of Daily Living (ADLs) - Bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning Routine tasks - Bed making, specimen collection, intake and output, vital signs (for stable clients) b. 5 rights of delegation 1. Right task a. Right task is repetitive, requires little supervision, and is noninvasive for the client 2. Right circumstance a. Determine the health status and complexity of care the client requires 3. Right person a. Task is within the delegatee’s scope of practice 4. Right direction and communication a. Provide a method and timeline for reporting b. Communicate specific tasks and detail expected results. Timeline, and expectations for follow-up communication 5. Right supervision and evaluation a. Provide supervision and provide feedback 7 Stuvia.com - The Marketplace to Buy and Sell your Study Material 7. NURSING PROCESS A. Assessment/Data collection a. Subjective data (symptoms)- during nursing history 1. client’s feelings, perceptions, and descriptions of health status b. Objective data (signs)- during physical examination 1. Feel, see, hear, and smell objective data through observation or physical assessment of the client c. Sources of data collection 1. Primary sources a. Subjective: what the client tells the nurse b. Objective: data the nurse obtains through observation and examination 2. Secondary sources a. Subjective: what others tell the nurse (family, friends) b. Objective: data the nurse collects from their sources B. Analysis/Data collection a. Requires nurses to look at the data and 1. Recognize patterns or trends 2. Compare the data with expected standards or reference ranges C. Planning a. Prioritize outcomes of care they can readily measure and evaluate D. Implementation a. Nurses base the care they provide on assessment data, analyses and then E. Evaluation a. Nurses evaluate the client’s responses to nursing interventions and form a clinical judgement about the extent to which clients have met the goals and outcomes 8. CRITICAL THINKING A. Don’t know specifics and know how to use critical thinking skills 9. ADMISSIONS, TRANSFERS, AND DISCHARGE A. Admission process 8 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Document client’s advance directive status (DNR, full code, etc), Base line data (vital signs, height, weight, allergies), Health history, swallowing problems (get evaluation from speech pathologist), spiritual health/quality of life concerns, safety assessments (risk for falls) b. Discharge planning starts at admission c. Inventory personal items 1. Assistive items: glasses, hearing aids, dentures 2. Medications 3. Discourage keeping valuables at the bedside B. Transfer a. Best thing to use: 1. Situation 2. Background 3. Assessment 4. Recommendation C. Discharge Education a. Review symptoms of potential complications and when to contact provider b. Provide names and numbers of community resources c. Step by step instructions for continuing treatments (dressing changes, etc) d. Dietary restrictions and guidelines e. Directions how to take medications f. Follow up appointments 10. MEDICAL AND SURGICAL ASEPSIS A. Hand Hygiene a. Hand wash with antimicrobial or alcohol-based products 1. Antimicrobial: wash for 15 seconds, dry hands with clean paper towel before turning off faucet a. Use antimicrobial soap over alcohol based when: i. Hands are visibly soiled 9 Stuvia.com - The Marketplace to Buy and Sell your Study Material ii. Before eating a meal iii. After using the bathroom iv. After contact with any bodily fluids 2. Alcohol based: use 3-5 mL, continue to rub until both hands are completely dry B. Physical environment a. Cover mouth and nose when coughing or sneezing, using and disposing of facial tissues 1. Ensure 3 spatial separation of 3 ft from a cough b. Keep nails short, clean, and no artificial nails; remove jewelry from hands and wrists c. Do not put items on flood, do not shake linens C. Sterile Field a. Do not cough, sneeze, talk over the sterile field b. Outer 1 inch wrapping of package is not sterile c. Objects below waist/above chest contaminated d. Do not reach across/above sterile field, turn back on sterile field 1. To add item drop form 6 inches above the field e. Any sterile, nonwaterproofed wrapper that encounters moisture becomes nonsterile 11. INFECTION CONTROL A. Immune Defenses a. Nonspecific innate- barriers respond immediately to all antigens 1. Ex: skin, mucus membrane, stomach acid Specific adaptive immunity – allows the body to make antibodies in response to a foreign organism (antigen) 1. Involves B ant T lymphocytes; takes more time c. Types of immunity 1. Active natural immunity- body produces antibodies in response to exposure to a live pathogen 2. Active artificial immunity- body produces antibodies in response to a vaccine 10 Stuvia.com - The Marketplace to Buy and Sell your Study Material 3. Passive natural immunity- antibodies passed down form a mom to a baby through breastmilk or the placenta 4. Passive artificial immunity- patient’s immunoglobins administered to them after exposure to pathogen B. Infection Processes a. Chain of infection 1. Causative agent (bacteria, virus, fungus, prion, parasites) 2. Reservoir- where it lives (human, animal, food, organic matter on inanimate surfaces, water, soil, insects) 3. Portal of exit- where it leaves the host (respiratory tract, gastrointestinal trac, etc) 4. Mode of transmission a. Contact- direct physical contact (person to person) b. Droplet- sneezing, coughing, and talking c. Airborne- sneezing and coughing 5. Portal of entry- how it enters the host (may be the same as the portal of exit) 6. Susceptible host- compromised defense mechanisms (immunocompromised, breaks in skin) leave the host more susceptible to infections b. Stages of infection 1. Incubation- pathogen enters the body to first symptom 2. Prodromal stage- onset of general symptoms to more distinct symptoms 3. Illness stage- specific symptoms to infection occur 4. Convalescence- acute symptoms disappear to total recovery c. Virulence- ability of pathogen to produce disease C. Assessment/Data collection a. Risk factors: 1. Inadequate hand hygiene, compromised health/defense, chronic or acute disease, poor personal hygiene, crowded environment, use of IV drugs, unprotected sex, poor sanitation b. Inflammation 1. Body’s local response to injury or infection 2. First stage: redness, edema, pain 3. Second stage: fluid containing dead tissue cells and WBCs accumulates and exudate appears at the site a. Types of exudate i. Serious (clear), sanguineous (blood), serosanguineous (pinkish tint), Purulent (leukocytes and bacteria) 11 Stuvia.com - The Marketplace to Buy and Sell your Study Material 4. Third stage: scar tissue D. Laboratory tests a. Leukocytosis- WBC level greater than 10,000/uL indicates infection 1. Normal range: 5,000-10,000/uL 2. Left shift: increase in neutrophils b. Elevated erythrocyte sedimentation rate (ESR)- over 20 mm/hr indicates infection c. Presence of micro-organisms on culture of the specific fluid/area d. Diagnostic procedures 1. Gallium scan, radioactive gallium citrate 2. X rays, CT scan, MRI E. Isolation Guidelines a. Standard precautions- for everyone 1. Hand hygiene- use alcohol based waterless product when hands are not visibly soiled 2. Masks, eye protection, face shields when splashing or spraying of bodily fluids may occur 3. Clean gloves b. Airborne precautions 1. Used for measles, varicella, pulmonary, or laryngeal tuberculosis 2. Private room 3. N95 masks for visitors and caregivers 4. Negative air flow in the room c. Droplet Precautions 1. Used for pneumonia, influenza, rubella, mumps, sepsis 2. Private room or room with someone with the same thing 3. Masks for providers and visitors d. Contact Precautions 1. Used for respiratory syncytial virus (RSV), shigella, wound infections, scabies 2. Private room or room with other patient that has the same infection 3. Gloves and gowns worn by caregivers F. Herpes Zoster (shingles) a. Chickenpox shingles 12 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Risk factors 1. Concurrent illness, stress, compromise immune system, fatigue, poor nutritional status c. Symptoms: paresthesia, unilateral rash, low grade fever 1. Rash is erythematous, vesicular, pustular, or crusting d. Nursing care 1. Isolate the client until the vesicles have crusted 2. Avoid exposing to infants, pregnant women, and those who not had the chicken pox e. Medications: 1. analgesics- enhance client comfort 2. Antiviral agents- acyclovir f. Complications 1. Postherpetic neuralgia- pain more than 1 month after shingles is gone g. Prevention: Zoster vaccine and chicken pox vaccine 12. CLIENT SAFETY A. Preventing falls a. Patient with orthostatic hypotension should avoid getting up too quickly 1. Sit on side of bed for few seconds, stand up for a few seconds, then walk b. Provide regular toileting c. Place clients at risk for falls close to nurses’ station d. Provide hourly rounding e. Keep bed in low position and lock breaks f. Avoid using all side rails g. Provide nonskid footwear h. Use gait belts 13 Stuvia.com - The Marketplace to Buy and Sell your Study Material B. Seizures a. Sudden surge of electrical activity in the brain b. Do not restrain c. Lower them to the floor put them on their side don’t put anything in their mouth C. Fire Safety 13. HOME SAFETY A. Infants and Toddlers a. Do not feed the infant ad hard foods that could be choking hazard b. Always place infants on their back to rest c. Keep plastic bags to reach d. Make sure crib slats are no more than 2 3/8 inches apart e. Do not place anything in the crib with the infant f. Place toddlers in rear facing car seat in the back seat until 2 years old g. Use car seat with 5-point harness for infants and children h. Place pots on back burner and turn handle away from front of stove B. Preschool age children a. Place locked fences around pools and provide supervision around pools or water 14 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Use booster seats for children who are less than 4 feet 9 in tall and weigh less than 40 lbs c. If passenger seat has an air bag, place children under 12 years in the back seat d. Use of protective equipment in sports e. Keep firearms unloaded, locked up, and out of reach 1. Store bullets in different location f. Reduce setting on water heater to no higher than 120 degrees F C. Adolescents a. Educate on the hazards of smoking, alcohol, legal, and illegal drugs, and unprotected sex b. Educate on the hazards of driving while distracted c. Be alert ot signs of depression, anxiety, or other behavioral changes D. Older adults a. Remove items that could cause the client to trip, such as throw rugs and loose carpets b. Place electrical cords and extension cords against a wall behind furniture c. Place grab bars near the toilet and in the tub or shower, and install a stool riser d. Use nonskid mat in the tub or shower e. Place shower chair in the shower E. Fire Safety a. use and store oxygen equipment according to the manufacturer’s recommendation b. place a no smoking sign near front of the door c. ensure that electrical equipment is in a good repair and well grounded d. replace bedding that can generate static electricity (wool, nylon, synthetics) with items made from cotton. 15 Stuvia.com - The Marketplace to Buy and Sell your Study Material e. Keep flammable materials such as heating oil and nail polish remover away from the client when oxygen is in use F. Carbon Monoxide a. Very dangerous gas because it binds with hemoglobin and reduces the oxygen supplied to the tissues in the body b. Carbon monoxide cannot be seen, smelled, or tasted c. Symptoms: nausea, vomiting, headache, weakness, unconsciousness d. Gas burning furnaces, water heaters, and appliances should be inspected annually e. Carbon monoxide detectors should be installed and inspected regularly G. Food Poisoning a. Young, old, immunocompromised, and pregnant women are at risk complications b. Perform hand hygiene c. Ensure meet and fish are cooked at correct temperature d. Handling raw and fresh food separately to avoid cross contamination, refrigerated perishable items H. ABCDE principle a. Airway/cervical spine- need patent airway, stabilize cervical spine b. Breathing 1. Exception: COPD patients- O2 saturation is low 90s—expected a. NOT PRIORITY c. Circulation- assess BP, HR, capillary refill d. Disability- determine level of consciousness e. Exposure I. First Aid 16 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Bleeding 1. Direct pressure to wound site 2. Do not remove impaling objects- instead stabilize them b. Fractures 1. Apply a splint 2. Reassess neurovascular status below the injury c. Sprains 1. RICE a. Rest, ice, compression, elevate d. Frostbite 1. Warm the affected area to 37-42 degrees C (98.6-108 F) water bath 2. Admin tetanus vaccine e. Burns 1. Remove burning agent 2. Elevate clients extremity 3. Admin fluids and tetanus toxoid 14. ERGONOMIC PRINCIPLES A. Body Mechanics a. Spread feet apart to lower center of gravity and broaden base of support 1. Results in greater balance b. Use the major muscle groups to prevent back strain c. Distribute weight between the large muscles of arms and legs d. Hold object as close as possible e. Have a staff member help with positioning clients f. Use smooth movements g. Gurnee bed 17 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Bed should be slightly lower 2. Patient’s arms crossed, chin tilted in 3. Put board against feet to prevent foot drop B. Client positions a. Semi-Fowlers- head of the bed elevated 15-45 degrees 1. Prevents regurgitation and aspiration 2. Promotes lung expansion and ventilation b. Fowlers- head of bed elevated 45-60 degrees 1. Useful during nasogastric tube insertion and suctioning 2. Promotes lung expansion and ventilation c. High Fowlers- head of bed elevated 60-90 degrees 1. Promotes lung expansion and ventilation 2. Relieves severe dyspnea 3. Prevents aspiration during meals d. Supine- client lies on back e. Prone- client lies on abdomen 1. Helps prevent hip flexion contractures after a lower extremity amputation f. Sims- client lays on left side and both legs in flexion 1. comfortable sleeping position for many clients 2. used for enema or rectal exams g. Orthopneic- sits at the side of bed with arms on bedside table 1. Promotes lung expansion and ventilation 2. Beneficial for COPD patients h. Trendelenburg- head of bed lower than the foot of the bed i. Reverse Trendelenburg- foot of the bed lower than the head of the bed 1. Promotes gastric emptying for GERD j. Modified Trendelenburg- flat with legs about the level of the heart 1. Prevent and treat hypovolemia or hypovolemic shock 18 Stuvia.com - The Marketplace to Buy and Sell your Study Material 15. SECURITY AND DISASTER PLANS A. Triage a. Class 1: Emergent category (red tag) 1. Highest priority- life threatening injuries b. Class 2: Urgent Category (Yellow tag) 1. Second highest priority- major injuries (ex: bone fracture) c. Class 3: Nonurgent Category (Green tag) 1. Minor injuries (ex: sprain, cut) d. Class 4: Expectant category (black tag) 1. Not expected to live and allowed to die naturally (ex: chest is crushed) B. Tornado a. Close drapes, lower bed to lowest position and move away from windows, place blanket over clients who are confined to bed C. Chemical Incident a. Undress the client b. Irrigate skin with running water 1. Except dry chemicals- then brush the agent off clothes and skin D. Hazardous material a. Identify hazardous material b. Use water E. Bomb threat a. Extend conversation for as long as possible b. Listen for distinguishing background noises to help police 16. HEALTH PROMOTION AND DISEASE PREVENTION A. Tests 19 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Colorectal screening 1. Every year beginning at age 50 for fecal occult blood testing 2. sigmoidoscopy every 5 years 3. colonoscopy ever 10 years b. Pap Smear (Papanicolaou test) 1. Every 3 years starting at age 21 c. Mammogram 1. Every year starting at age 40 d. Testicular Examination 1. Starting at age 20 e. Prostate exam 1. Starting at age 50 B. Prevention a. Primary Prevention 1. Helps prevent initial occurrence of disease a. Ex: immunization programs, client teaching b. Secondary Prevention 1. Early detection of illness, limiting severity a. Ex: screening c. Tertiary Prevention 1. Maximizing recovery after illness a. Ex: support groups, rehab 17. CLIENT EDUCATION A. Domains of Learning a. Cognitive Learning 1. Thinking, knowledge, comprehension b. Affective learning 1. Feelings, beliefs, values 20 Stuvia.com - The Marketplace to Buy and Sell your Study Material c. Psychomotor learning 1. mental and physical activity B. Assessment a. Assess learning needs b. identifying learning style (auditory, visual, kinesthetic) c. identify available resources C. Planning a. Identify mutually agreeable outcomes D. Implementation a. No medical jargon b. 6th grade level or lower E. Evaluation a. Observe demonstrations 18. SKIP 19. SKIP 20. SKIP 21. SKIP 22. SKIP 23. SKIP 21 Stuvia.com - The Marketplace to Buy and Sell your Study Material 24. SKIP 25. SKIP 26. DATA COLLECTION AND GENERAL SURVEY A. Therapeutic communication a. Don’t do one long assessment try to break it up b. Allow more time for responses for older adults c. Make sure client is comfortable d. Reduce environmental noises 1. Ex: tv, visitors B. Assessments a. Normal order: Inspection, palpation, percussion, auscultation 1. *Exception is abdomen: inspection, auscultation, percussion, palpation b. Inspection 1. Size, shape, color, symmetry, position c. Palpation 1. Size, consistency, texture, temperature, location, tenderness a. Palpate tender areas last 2. Dorsal surface: most sensitive to temperature 3. Palmar surface: sensitive to vibration d. Percussion 1. Size, location, tenderness, density e. Auscultation 1. Amplitude/intensity, pitch/frequency, duration, quality 2. Used for heart sounds, bowel sounds, lung sounds C. General Survey Physical Appearance 22 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Age, gender race, level of consciousness, signs of distress, signs of substance abuse b. Body structure 1. Height and weight, Nutritional status, posture, abnormalities (amputation, skin lesions) c. Mobility 1. Gait, movements, range of motion d. Behavior 1. Mood, speech e. Vital signs 1. Temperature, pulse, respiration, blood pressure, oxygen saturation 27. VITAL SIGNS A. Temperature a. Ways to take temp 1. Oral: 36-38 C or 96.8 to 100.4 F 2. Rectal: 0.5 C or 0.9 F higher than oral a. 36.5-38.5 or 97.7- 101.1 F b. Patient in sim’s position, lubricate thermometer, place in about 1-1.5 in for adult 3. Axillary: 0.5 C or 0.9 F lower than oral a. 35.5-37.5 C or 95.9-99.3 F 4. Temporal: 0.5 C or 0.9 F higher than oral a. 36.5-38.5 or 97.7- 101.1 F b. Move gently from forehead over the temporal artery and then to skin behind earlobe 5. Tympanic a. Adult: pull ear up and back b. Child younger than 3: pull down and back b. Considerations 1. Newborns: 36.5-37.5 C or 97.7 and 99.5 F 2. Older adults: average temp: 36 C (96.8 F) 3. Hormonal Changes- temp rises with ovulation, menses, and menopause 4. Exercise, activity, and dehydration: development of hyperthermia 5. Recent food, drink, or smoking: wait 20-30 min to take temp c. Complications 23 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Hyperthermia- greater than 39 C a. Obtain specimens b. Admin antibiotics c. Provide fluids d. Provide antipyretics e. Prevent shivering- offer blankets 2. Hypothermia- less than 35 C a. Provide warm environmental temperature i. Warming blanket, warmed IV fluids b. Keep head covered B. Pulse a. Rate 1. Normal adult: 60-100 bpm 2. Normal infant: 120-160 bpm b. Rhythm- regularity c. Strength (amplitude) 1. 0= absent 2. 1+= diminished 3. 2+= normal, expected 4. 3+= increased, strong 5. 4+= bounding d. Locate radial pulse 1. If pulse is regular: count rate for 30 sec and multiply by 2 2. If pulse is irregular: count for full min and compare to apical pulse e. Locate apical pulse 1. Fifth intercostal space, left midclavicular line f. Tachycardia- greater than 100 bpm g. Bradycardia- less than 60 bpm C. Respirations a. Physiological responses 1. Chemoreceptors in carotid arteries and the aorta monitor CO2 levels of the blood 24 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Rising CO2 levels trigger respiratory centers of the brain to increase respiratory rate b. Process of respiration 1. Ventilation- exchange of CO2 between environment and lungs 2. Diffusion- exchange of O2 and CO2 between alveoli and RBC 3. Perfusion- flow of RBC to and from pulmonary capillaries (tissues) c. Assessment 1. Rate a. Normal rate: i. adults= 12-20/min ii. infants= 35-40/min iii. school age kids= 20-30 2. Depth- deep or shallow 3. Rhythm d. Pulse Oximetry 1. Normal 95-100% 2. COPD normal: 91-100% e. Considerations 1. Increased respiratory rate a. Anxiety, smoking, illnesses, anemia, high altitude 2. Decreased respiratory rate a. Opioids, sedative meds, increasing old age D. Blood Pressure a. hypertension b. Hypotension- Systolic is less than 90 mmHg c. Pulse pressure=systolic- diastolic 25 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Increase pulse pressure can indicate cardiovascular disease d. Orthostatic hypertension- blood pressure that decreases when a client changes position from lying to sitting/standing 1. Take clients BP and HR while lying in supine 2. Then have them sit, wait 1-3 min, take BP again 3. The client has orthostatic hypotension if the Systolic decreases more than 20 mmHg and/or Diastolic decreases more than 10 mmHg with a 10-20% increase in HR e. Auscultatory method 1. Width of a cuff should be 40% of arm circumference 2. The inside of the cuff should surround 80% of the arm circumference a. Too large of cuff: falsely low readings b. Too small of cuff: falsely high readings f. Nursing implications 1. Don’t measure BP: a. in an arm with IV infusion in progress b. side where the client has had a mastectomy 28. HEAD AND NECK A. Cranial Nerves Nu mbe r Name Function How to test 26 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1 Olfactory Sensory: Smell 2 Optic Sensory: vision Snellen chart 3 Oculomotor Motor: pupil constriction, eye movements Follow the finger, penlight 4 Trochlear Motor: eye movements (up/down) 5 Trigeminal Sensory + motor: face, chewing Close eyes- touch face- pt explains what they feel 6 Abducens Motor: eye movement laterally 7 Facial Sensory + Motor: Facial muscles, taste (ant), parotid/lacrimal glands Smile/Frown 8 Vestibulococh lear Sensory: hearing and balance 9 Glossopharyn geal Sensory + Motor: parotid gland, gag reflex, taste (posterior) Gag reflex 10 Vagus Sensory + Motor: voice, pharyngeal/laryngeal muscles, thoracic/abdominal sense 11 Accessory Motor: sternocleidomastoid and trapezius muscle Shrug, turning head 12 Hypoglossal Motor: tongue B. Assess a. Thyroid glands 1. Take sip of water and feeling the thyroid gland as it moves up the trachea a. Sizes, masses, and smoothness b. Eyes 1. 20/30 vision means a client can read a line from 20 ft away that a person who has unimpaired vision can read from 30 ft away 2. Tests: a. Snellen chart- used to screen myopia (nearsightedness) b. Rosenbaum eye chart- used to screen for presbyopia (farsightedness) c. Ishihara Test- color vision d. Corneal light reflex e. Uncover/cover test- Strabismus (misalignment) f. 6 cardinal positions of gaze- wide H pattern 3. PERRLA a. P- pupils clear b. E- equal and between 3-7 mm c. R- round d. RL- reactive to light e. A- accommodation of pupils 4. 2 arteries for every 3 veins 27 Stuvia.com - The Marketplace to Buy and Sell your Study Material c. Ears 1. Check alignment 2. Pull auricle a. Adults: Up and back b. Young children: down and back 3. Insert otoscope 1-1.5 cm bur do not touch ear canal a. Expect to see: pearly gray and intact tympanic membranes i. Light reflex is visible ii. Normal amount of cerumen 4. Tests: a. Whisper test b. Rinne test c. Weber test i. Negative is normal C. Changes with aging a. Eyes: decreased visual acuity, glare/darkness, yellowing of the lens b. Ears: hearing loss, thickening of the tympanic membrane c. Mouth: decreased sense of taste, tooth loss, pale gums, gum disease, decreased salivation d. Voice: rise in pitch e. Nose: decreased sense of smell 29. THORAX, HEART, AND ABDOMEN A. Breasts a. Monthly self-exams after menstruation B. Lungs a. Percussion 1. Dullness: indicates pneumonia 2. Hyperresonance: pneumothorax, emphysema b. Auscultation 28 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Expected: bronchial, bronchovesicular, vesicular 2. Unexpected: crackles (fluid), wheezes, rhonchi, pleural friction rub C. Heart a. S1 sound: mitral and tricuspid close b. S2 sound; aortic and pulmonic close c. Thrills: vibration murmurs d. Bruits: swishing sound obstructed blood flow e. Auscultatory sites: 1. Aortic, Pulmonic, Erbs’ point, Tricuspid, Apical D. Abdomen a. Bowel sounds 1. Expected: high pitched clicks and gurgles 2. Unexpected: loud, growling sounds b. Percussion 1. Expect to hear tympany 2. Expect dullness over liver a. Liver size: 6-12 cm c. Palpate tender areas last E. Expected Changes with Aging a. Breasts 1. Nipples can invert b. Lungs 1. AP diameter similar to transverse diameter (barrel chest) 2. Alveoli dwindle 3. Kyphosis becomes presen c. Cardiovascular 1. Systolic hypertension 2. Blood vessels thicken 29 Stuvia.com - The Marketplace to Buy and Sell your Study Material 3. Increase pulse pressure d. Abdomen 1. More adipose tissue 2. Decrease saliva, gastric secretions, pancreatic enzymes 3. Decrease motility 30. INTEGUMENTARY AND PERIPHERAL VASCULAR SYSTEMS A. Skin a. Pallor- loss of color 1. Indicates: anemia, shock, or lack of blood flow b. Cyanosis- turning blue 1. Indicates: hypoxia c. Jaundice- yellow tint 1. Indicates: liver dysfunction, RBC destruction d. Erythema – redness 1. Indicates: inflammation, sun exposure, rash e. Brown pigmentation indicates venous insufficiency f. Skin turgor can indicate dehydration or aging B. Nails a. Capillary refill- normal return of color within 3 seconds C. Edema a. Evaluate pitting by compressing the skin for at least 5 seconds over a bony prominence 1. + trace, 2 mm, rapid skin response 2. + mild, 4 mm, 10-15 seconds skin response 3. + moderate, 6 mm, prolonged, skin response 4. + severe, 8 mm, prolonged skin response D. Lesions Primary Lesions Mac Flat, skin color change, < 1 cm 30 Stuvia.com - The Marketplace to Buy and Sell your Study Material ule Ex: freckle, petechiae Pap ule Solid elevation of skin, < 1 cm Ex: mole Nod ule Deep, firm, 1-2 cm Ex: wart Vesi cle Serous fluid- filled, < 1 cm Ex: blister, herpes, varicella Pus tule Pus filled, varies in size Ex: acne Tu mor Solid mass, deep, > 2 cm Ex: epithelioma, neoplasm Wh eal Palpable, irregular borders, edematous Ex: insect bite E. Expected changes with aging a. Dry, flaky skin b. Loss of elasticity c. Thinning of hair d. Less moisture and sweat e. Uneven pigmentation f. Slow wound healing g. Little subcutaneous tissue over bony prominences 31. MUSCULOSKELETAL AND NEUROSENSORY SYSTEMS A. Expected range of motion of joint movement Flexion Decreases the angle between 2 adjacent bones Extension Increases the angle between 2 adjacent bones Supination Ventral (front) surface faces up Pronation Ventral (front) surfaces faces down Abduction Moving extremity away from midline Adduction Moving extremity towards the midline Dorsiflexion Foot and toes upward Plantar Foot and toes downward 31 Stuvia.com - The Marketplace to Buy and Sell your Study Material flexion Eversion Turning body part away from midline Inversion Turning body part toward the midline External Rotation Rotating a joint outward Internal Rotation Rotating a joint inward B. Curvatures of the Spine a. Expected: concave cervical spine, convex thoracic spine, concave lumbar spine, convex sacral spine b. Unexpected: 1. Kyphosis- hunchback (in older adults) 2. Lordosis- exaggerated curvature of lumbar spine (toddler years and pregnancy) 3. Scoliosis- S shape C. Mental Status a. Alert 1. Client is responsive and can open eyes and respond spontaneously and appropriately b. Lethargic 1. Client can open eyes but falls asleep readily c. Obtunded 1. Responds to light shaking and can be confused and slow to respond d. Stuporous 1. Requires painful stimuli (rubbing the sternum) e. Comatose- no response 1. Decorticate rigidity- flexion and internal rotation of upper extremity joints and legs(arms-chin) 2. Decerebrate rigidity- neck and elbow extension, with wrists and fingers flexed (arms extended) a. Worse than decorticate D. Glasgow Coma Scale- baseline of level of consciousness a. Looks at eye, verbal, and motor 1. Highest value possible is 15 2. <8 indicates severe head injury 3. 8-12 indicates mild head injury 32 Stuvia.com - The Marketplace to Buy and Sell your Study Material E. Motor Function a. Assessing balance 1. Romberg’s Test a. Ask the client to stand with feet together, his arms at his sides and his eyes closed i. Expected findings: client stands with minimal swaying for at least 5 seconds 2. Heel-to-toe walk: heel to tow and walk in straight line F. Sensory Function a. Stereognosis- place familiar object in the client’s hand and ask them to identify it b. Graphesthesia- trace number on clients hand G. Grade DTR Response a. 4+ very brisk with clonus b. 3+ brisker than average c. 2+ expected d. 1+ diminished e. 0 no response H. Expected changes with aging a. Musculoskeletal system 1. Reduced muscle mass 2. Osteoporosis, loss of bone mass 3. Degenerative alterations in joints 4. Limited range of motion b. Neurological system 1. Short term memory decline 2. Diminished, slowed reflex 3. Altered hearing, vision, smell, and deep pain 32. THERAPEUTIC COMMUNICATION 33 Stuvia.com - The Marketplace to Buy and Sell your Study Material - Use open ended questions (“tell me more”) -ask why -offer opinion -false reassurance -offer personal information but quickly return focus onto the patient -closed ended question(yes/no) -change subject -minimize patient’s feelings - say “I know how you feel” 33. COPING A. General Adaptation Syndrome a. Alarm Reaction- heightened response to stressors 1. Increased blood pressure and heart rate 2. Cortisol released b. Resistance Stage- body functions normalize while responding to the stressor 1. Body returns to homeostasis c. Exhaustion Stage- body functions are no longer able to maintain a response to the stressor 1. Can result in fatigue, depression 34. SELF CONCEPT AND SEXUALITY A. Impaired body image a. Due to amputation, mastectomy, hysterectomy b. loss of body function due to arthritis, spinal cord injury, or stroke 35. CULTURAL AND SPIRITUAL NURSING CARE A. Spirituality a. Christianity 1. may fast during lent b. Islam 1. Women must be cared for by female providers 34 Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. May pray 5 times a day 3. Avoid alcohol and pork 4. Fast during Ramadan c. Jehovah’s Witness 1. Might night accept blood transfusions d. Judaism 1. Some practice a kosher diet a. No shellfish, pork, or meat with dairy e. Mormonism 1. Avoid alcohol, tobacco and caffeine B. Ethnocentrism a. Belief one’s own culture is superior to all other cultures 1. Nurses should avoid this C. Interpreter a. Use facility approved medical interpreter 1. Do not use family/ friends of patient or non-designated employee to interpret b. Only ask one question at a time c. Direct the questions to the client d. Use lay terminology 36. GRIEF, LOSS, AND PALLIATIVE CARE A. Types of Loss a. Maturational loss 1. Loss that is expected, it is associated with normal life transitions a. Ex: child leaving home for college b. Situational Loss 1. Unanticipated loss caused by an external event 35 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Ex: car accident B. Stages of Grief a. Denial- patient has difficulty believing a terminal diagnosis or loss b. Anger- client lashes out at other people or things c. Bargaining- client negotiates for more time or a cure d. Depression- client is overwhelmingly sad e. Acceptance- client moves forward C. Types of grief a. Anticipatory grief- grief before having a loss (ex: terminal illness) b. Complicated grief- prolonged, severe grief 1. No acceptance of the loss after 6 months D. Palliative Care vs hospice care a. Palliative care- symptom relief and cure b. Hospice care- includes palliative care but down not look for cure 1. Patients are not expected to live longer than 6 months] E. Manifestations of approaching death Decreased level of consciousness, labored breathing, mottling (cyanosis), slow/weak pulse, dropping blood pressure, decreased urine output b. Hearing is not diminished F. Preparing the body for viewing a. Remove all tubes and personal belongings and excess supplies b. Lay the body supine with pillow under the bed c. Apply fresh linens, put dentures in, dim the lights 36 Stuvia.com - The Marketplace to Buy and Sell your Study Material 37. HYGIENE A. Foot care a. Important for diabetic patients 1. May experience decreased sensations a. Variations in temperature b. Can’t tell if something is in shoe (Ex: nail in foot) 2. Inspect feet daily, cut nails straight across, check shoes for objects, wear cotton socks 3. Test water temperature for bath 4. Dry feet thoroughly- especially in between toes 5. Apply moisturizer on feet (not in between toes) 6. Do not use over the counter products- go to podiatrist 7. Do not use heating pad on feet B. Oral Care for unconscious patient a. Have suction apparatus ready- prevent aspiration b. Position client on his side with his head turned toward you to allow oral secretions to collect c. Denture care: 1. Top denture: pull down and out 2. Bottom denture: pull up and out 3. Store dentures in denture cup 38. REST AND SLEEP A. Sleep Cycle NREM Stage 1 NREM Stage 2 NREM Stage 3 NREM Stage 4 REM Very light sleep Only a few minutes long Vital signs and metabolism beginning to decrease -Deeper sleep -10-20 min long -Vital signs and metabolism beginning to decrease -initial stages of deep sleep -15-20 min long -difficult to awaken -deepest sleep -15-30 min long -vital signs low - very difficult to awaken - physiologic rest and restoration -sleep walking, sleep talking - vivid dreaming -longer with each sleep cycle -average length 20 min -varying vital signs -very difficult to awaken -cognitive restoration B. Sleep Apnea 37 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. More than 5 breathing cessations lasting longer than 10 seconds per hour during sleep b. CPAP mask C. Factors that interfere with sleep a. Caffeine consumption, heavy meals before bedtime b. Exercise promotes sleep if at least 2 hours before bedtime 39. NUTRITION AND ORAL HYDRATION A. Basic Nutrients the body requires a. Carbohydrates 1. Provide most of the body’s energy 2. Each gram produces 4 kcal b. Fats 1. Provides energy and vitamins 2. No more than 35% of caloric intake should be from fat 3. Each gram produces 9 kcal c. Proteins 1. Repairs body tissues 2. Each gram produces 4 kcal 3. Important for wound healing d. Vitamins 1. Fat soluble vitamins A, D, E, K 2. Water soluble vitamins C and B complex B. Age a. Newborn 1. Breast milk and formula used during the first full year of life 2. Solid food starting at 4-6 months a. No cows milk or honey for the first year b. Older adults 38 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Slower metabolic rate requires fewer calories 2. Thirst sensations diminish 3. Calcium is important for both men and women C. BMI a. Weight (kg) divided by height (m2) b. Scale: 1. <18= underweight 2. 18.5-24.9=healthy 3. 25-29.9= overweight 4. 30>= obese D. Diets a. Clear liquid- water, tea, coffee, broth, clear juices, gelatin, ginger ale b. Full liquid- milk, pudding, fruit, ice cream, juice c. Pureed- pureed meats, fruits, scrambled eggs 1. used if jaw is wired shut or after oral surgery d. Mechanical soft- diced or ground foods 1. Used if patient does not have teeth e. Low residue- low in fiver and easy to digest 1. Used for IBS or other GI disorders E. Dysphagia a. See Speech pathologist b. Semi fowlers position c. Thickened liquids d. Check for food pockets e. Tuck chin to chest when swallowing f. Monitor patient during meals 39 Stuvia.com - The Marketplace to Buy and Sell your Study Material g. Suction equipment ready h. Avoid straws 40. MOBILITY AND IMMOBILITY A. Respiratory a. Nursing interventions 1. Reposition every 1-2 hours 2. Instruct clients to turn, cough, and breathe deeply every 1-2 hours while awake 3. Instruct clients to use an incentive spirometer while awake 4. Instruct clients to consume at least 2000 mL fluid per day, unless intake is restricted B. Instructions a. Cane 1. maintain 2 points of support on the ground at all times 2. Keep the cane on the stronger side of the body 3. Support body weight on both legs move cane forward 6-10 in 4. Move weaker leg forward, then move stronger leg past the cane b. Crutches 1. Do not alter crutches after fitting a. 3 finger widths between axilla and the top of the crutch 2. Support body weight at the hand grips with elbows flexed (20-30 degrees) 3. Stairs- hold rail with one hand and crutches in the other C. DVT a. Symptoms: pain, edema, warmth, and erythema b. Nursing actions 1. Notify provider immediately 2. Position client with leg elevated, give anticoagulants c. Anti-embolic stockings 1. Remove the stockings every 8 hours to assess redness, warmth, or tenderness D. Pulmonary Embolism 40 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Symptoms: shortness of breath, chest pain, decreased BP, increase HR b. Nursing actions 1. Give anticoagulants 2. Position client in high fowlers 3. Obtain pulse ox and monitor vital signs 4. Admin oxygen and prepare blood gas analysis 41. PAIN MANAGEMENT A. Pain Categories a. Acute Pain 1. Protective, temporary, and resolves with tissue healing 2. Tachycardia, hypertension, anxiety, diaphoresis b. Chronic pain 1. Lasts longer than 6 months 2. Do not usually alter vital signs—but can have depression, fatigue 3. Idiopathic pain- chronic pain without a known cause (ex: depression) c. Nociceptive pain 1. Inflammation of tissue 2. Throbbing, aching, localized 3. Responds to opioids and nonopioid medications 4. 3 types: a. Somatic- bones, joints, muscles, skin, connective tissues b. Visceral- internal organs c. Cutaneous- skin or subcutaneous tissue d. Neuropathic pain 1. Damaged pain nerves 2. Includes phantom limb pain, diabetic neuropathy 3. Shooting, burning, pins and needles 4. Responds to antidepressants, muscle relaxers B. Symptom analysis a. Location- superficial, radiating 41 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. How the pain feels- shooting, burning, pins and needles…. c. Intensity- scale 0-10 d. Timing- onset, duration, frequency e. Setting- how it affects ADLs f. Associated findings- fatigue, depression, nausea g. Aggravating/relieving factors- C. Pain care a. Nonopioid analgesics 1. Mild to moderate pain 2. No more than 4 g/day 3. Monitor for salicylism (tinnitus, vertigo) 4. Prevent gastric upset by admin with food 5. Long term use- monitor for bleeding b. Opioid analgesics 1. Moderate-severe pain 2. Around the clock administration 3. Sedation, respiratory depression, orthostatic hypotension, urinary retention, nausea/vomiting, constipation 4. Nolocsone- antidote for opioids 42. COMPLEMENTARY AND ALTERNATIVE THERAPIES A. Types of CAM a. Acupuncture- needles or pressure along meridians to alter body function or produce analgesia b. Chiropractic medicine- spinal manipulation for healing c. Massage therapy- stretching and loosening muscles and connective tissue for relaxation and circulation Biofeedback- using tech to increase awareness of various neurological body responses to minimize extremes 42 Stuvia.com - The Marketplace to Buy and Sell your Study Material e. Therapeutic touch – using hands to help bring energy fields into balance B. Natural products and Herbal Remedies a. Garlic, ginger, ginseng increase bleeding C. Therapies a. Guided imagery- encourage healing and relaxation of the body by having the mind focus on images b. Relaxation techniques- promotes relaxation using breathing techniques while thinking peaceful thoughts or while tensing and relaxing specific muscle groups 43. BOWEL ELIMINATION A. Constipation a. Help constipation 1. Increase fluid intake 2. Increase fiber intake (25-30 g/day) 3. Decrease laxatives 4. Increase activity b. Fecal Occult Blood test 1. Collect stool 3 times from 3 different defecations 2. Blue color indicates the stool is positive for blood B. Enema a. Warm the enema solution b. Position the client on the left side with the right leg flexed forward c. Lubricate the rectal tube or nozzle d. Insert the rectal tube 7.5-10 cm (3-4 in) e. Bag level with the client’s hip, open the clamp f. Raise the bag 30-45 cm (12-18 in) above the anus 43 Stuvia.com - The Marketplace to Buy and Sell your Study Material g. Slow the flow by lowering the container if the client reports cramping C. Ostomy Care a. Remove the pouch b. Inspect the stoma- should appear moist and pink, peristomal area should be intact c. Use mild soap and water to cleanse the skin and dry it gently and completely 1. NO MOISTURIZING SOAPS d. Cut the opening 0.15-0.3 cm (1/18 to 1/8 in) larger e. Fold the bottom of the pouch and clamp it D. Diarrhea a. Fluid and electrolyte disturbances: metabolic acidosis 1. Monitor for dehydration a. Weak/rapid pulse, hypotension, poor skin turgor, elevated body temperature b. Skin breakdown around the anal area—zinc oxide 44. URINARY ELIMINATION A. Input and Output a. Input should be about the same as the output b. Output less than 30 mL/hr for more than 2 hours is a cause for concern B. Timed Urine Specimens a. Collect for 24 hours b. Discard the first voiding and then collect all other urine 1. Refrigerate, label, and transport specimen C. Catheter Care a. Use soap and water at the insertion site 44 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Cleanse the catheter at least 3 times a day c. Check for kinks in the tubing d. Make sure collection bag is below the bladder level to avoid reflux D. Urinary Tract Infections a. Risk factors 1. Urethral meatus close to the anus, Frequent sexual intercourse, menopause- decreasing estrogen levels, uncircumcised males, use of indwelling catheters b. Nursing considerations 1. Female: cleanse from front to back 2. Male: cleanse beneath foreskin 3. Provide catheter care regularly 4. Drink cranberry juice- treat/prevents UTI E. Urinary Incontinence a. Types 1. Stress- loss of small amounts of urine form increased abdominal pressure while laughing, sneezing, or lifting 2. Urge- inability to stop urine flow long enough to reach the bathroom b. Nursing care 1. Establish a toileting schedule 2. Perform kegel exercises 3. Avoid caffeine and alcohol consumption 4. Vaginal cone therapy 45. SENSORY PERCEPTION A. Clients with hearing loss a. Sit and face the client b. Avoid covering your mouth while speaking c. Speak slowly and clearly 45 Stuvia.com - The Marketplace to Buy and Sell your Study Material d. Do not shout, try lowering vocal pitch e. Ask for a sign language interpreter if necessary B. Clients with Aphasia a. Only one person speaking at a time b. Speak clearly and slowly using short sentences and simple words c. Allow time for clients to understand d. Allow plenty of time for clients to respond C. Hearing loss a. Conductive hearing loss 1. Alteration in middle ear that blocks sounds waves before they reach the inner ear 2. Risk factors: history of middle ear infections, older age 3. Expected findings a. Rinne test- air conduction of sound less than bone conduction b. Weber test- lateralizes the affected ear b. Sensorineural hearing loss 1. Alteration in the inner ear and auditory nerve 2. Risk factors: prolonged exposure to loud noises, ototoxic medications, older age 3. Expected findings a. Rinne test- air conduction of sound greater than bone conduction b. Weber test- lateralizing unaffected ear D. Hearing aids a. Client education 1. Use the lowest setting that allows hearing without feedback 2. When not in use: turn it off and remove battery, avoid corrosion of the hearing aid 46. PHARMACOKINETICS AND ROUTES OF ADMINISTRATION A. Absorption a. Oral 46 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. Must pass through the GI tract 2. Absorption varies greatly due to a. Stability and solubility of the meds b. Gastrointestinal pH c. Presence of food in the stomach d. Forms of meds B. Distribution a. Circulation- inhibit of blood flow or perfusion such as peripheral vascular or cardiac disease b. Permeability of the cell membrane c. Plasma protein binding- medication to bind to a protein can affect how much of the medication will leave and travel to target tissues C. Metabolism a. Factors influencing medication metabolism rate 1. Age- older adults require smaller doses of medication 2. First -pass effect a. Liver inactivates some medications on their pass through the liver i. Require non-enteral route 3. Similar metabolic pathways a. Same pathway metabolize two medications, can alter the metabolism of one or both 4. Nutritional status a. Malnourished can be deficient in the factors that are necessary D. Excretion a. Elimination of medications from the body, primarily through the kidneys 1. Other areas: liver, lungs, intestines E. Therapeutic Index (TI) a. Meds with high TI have a wide safety margin b. Meds with low TI need to be closely monitored F. Half Life a. The time for the medication in the body to drop by 50% b. Short half-life- meds leave the body quickly, 4-8 hours 47 Stuvia.com - The Marketplace to Buy and Sell your Study Material c. Long half-life- 1. meds leave the body more slowly: a. over more than 24 hours 2. with a greater risk for meds accumulation and toxicity G. Pharmacodynamics (mechanism of action) a. Agonist- medication that can mimic the receptors activity 1. Morphine is an agonist because it activates the receptors that produce analgesia, sedation, and constipation b. Antagonist- medication that can block the usual receptors activity H. Routes and Administration a. Oral 1. Vomiting, decreased GI motility, absence of a gag reflex, difficulty swallowing, and decreased level of consciousness 2. Have clients sit upright at a 90 degrees angle 3. Do not mix with large amounts of food or beverages 4. Clients Swallow enteric coated or time released meds whole b. Sublingual 1. Sublingual: under the tongue 2. Buccal: between the cheek and the gum 3. Clients should not eat or drink while the tablet is in place or until it has completely dissolved c. Transdermal 1. Wash the skin with soap and water, and dry it thoroughly 2. Place the patch on a hairless area and rotate sites d. Instillation 1. Rest your dominant hand on the client’s forehead, hold the dropper above the conjunctival sac 2. If instilling more than one medication in the same eye, wait at least 5 minutes between them 3. Ears a. Clients lie on their side b. Pulling the auricle upward and outward for adults or down and back for children c. Dropper 1 cm above the ear canal, instill the medication, and then gently apply pressure with your finger to the tragus d. 2-3 min after installation of ear drops 48 Stuvia.com - The Marketplace to Buy and Sell your Study Material e. Inhalation 1. Metered-dose inhalers (MDI) a. Shake inhaler 2. Dry powdered inhalers (DPI)- do not shake f. Nasogastric and gastrostomy tubes 1. Verify proper tube placement 2. Do not mix meds with enteral feedings 3. Completely dissolve crushed tablets and capsule contents in 15-30 mL water 4. Flush the tubing before and after each med with 15-30 mL water g. Intradermal 1. 0.01-0.1 mL in a 26-27 gauge 2. Bevel up, small bleb should appear h. Subcutaneous 1. 3/8-5/8 in, 25-27 gauge or 28-31-gauge insulin syringe a. Inject no more than 1.5 mL of solution 2. 45-90 angle; use a 90 degree and i. Intramuscular 1. Common sites: ventrogluteal, deltoid and vastus lateralis (pediatric) 2. 18-27 gauge, 1-1.5 in long 3. Use Z track method 47. SAFE MEDICATION AND ADMINISTRATION AND ERROR REDUCTION A. Pregnancy risk categories a. A, B, C, D, E, X B. Types of medication prescriptions a. Routine/ standard prescriptions 1. Regular schedule b. Single- or one-time prescriptions 1. Administration once at a specific time or as soon as possible c. Stat prescriptions 49 Stuvia.com - The Marketplace to Buy and Sell your Study Material 1. One and immediately d. Now prescriptions 1. Only admin. Once, but up to 90 min from when the nurse received the prescription e. PRN prescriptions 1. Specifies what dosage, what frequency, and under what conditions a nurse may administer the medication f. Standing prescriptions 1. For specific circumstances or for specific units C. Components of a medication prescription a. The clients full name b. Date and time c. Name of the medication d. strength and dosage e. route of admin f. time and frequency g. number of refills h. signature of the prescribing provider D. Rights of safe medication administration a. Right client b. Right medication c. Right dose d. Right time e. Right route 50 Stuvia.com - The Marketplace to Buy and Sell your Study Material f. Right documentation g. Right client education h. Right to refuse i. Right assessment right evaluation E. Common medication errors a. Administration of a medication to which the client is allergic b. Omission of a dose or extra dose F. Error-prone abbreviation list Do not use Use MS, MSO4 Morphine MgSO4 Magnesium sulfate Decimal point without a leading zero (0.5 mg) Small units (500 mcg) or a leading zero (0.5 mg) Trailing zero (1.0 mg,100.0 g) Without a trailing zero ( 1 mg, 100 g) U, U, IU units q.d, qd, Q.D., QD, q1d, i/d daily q.o.d., QOD Every other day SC, SQ, sub q Subcutaneously G. Implementation a. Prepare medications for one client at a time b. Doses are usually one to 2 tablets or one single-dose vial c. Only give meds that you have prepared d. Do not leave medication at the bedside 48. DOSAGE CALCULATION A. Standard conversion factors 51 Stuvia.com - The Marketplace to Buy and Sell your Study Material 49. INTRAVENOUS THERAPY A. Intraprocedural Apply a clean tourniquet or blood pressure cuff (especially for older adults) 10-15 cm (4-6 in) above the insertion site to compress only venous blow flow b. Distal veins first on the nondominant hand c. Avoid the following 1. Varicose veins 2. Flexion areas 3. Near valves 4. 10-30-degree angle B. Post procedure a. Maintaining the patency of IV access 1. Flush intermittent IV catheters 2. Every 8-12 hours b. Discontinue IV therapy 1. Elevate the extremity and apply pressure 2. Apply tape over the gauze 3. Check the catheter for intactness C. Complications a. Infiltration 1. Local swelling at the site, decreased skin temp around the site, damp dressing, slowed rate of infusion 52 Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. Elevate the extremity and apply a warm or cold compress b. Phlebitis 1. Edema, throbbing, burning, or pain at the site, erythema, red line up the arm 2. Discontinue the infusion 3. Elevate the extremity 4. Apply warm compresses 5. Obtain a specimen for culture c. Fluid overload 1. Distended neck veins, increased blood pressure, tachycardia, , shortness of breath, crackles in the lungs, edema 2. Treatment a. Stop the infusion, raise the head of the bed, measure vital signs and oxygen saturation, adjust the rate after correcting fluid overload, admin diuretics d. Cellulitis 1. Pain, warmth, edema, induration, red streaking, fever, chills malaise 2. Treatment a. Discontinue the infusion and remove the catheter b. Elevate the extremity c. Apply warm compresses 3-4 times/days d. Obtain a specimen for culture e. Admin the following i. Antibiotics, analgesics, antipyretics e. Catheter embolus 1. Missing catheter tip on removal, severe pain at the site with migration 2. Treatment a. Place a tourniquet high on the extremity b. Prepare for removal under x ray or via surgery 50. ADVERSE EFFECTS INTERACTIONS, AND CONTRAINDICATIONS A. Extrapyramidal symptoms a. Tremors, restlessness, acute dystonia (spastic movements) B. Anticholinergic effects a. Dry mouth, urinary retention, constipation 53 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Wear sunglasses, increase dietary fiber and fluids c. Can’t see, can’t pee, cant spit, cant poop C. Medication- food interactions a. Tyramine 1. Avocados, cheese, smoked meats 2. MAOIs can lead to hypertensive crisis b. Vitamin K 1. Can decrease effects of vitamin K c. Dairy 1. Don’t take Tetracycline within 2 hours of consuming any dairy products d. Grapefruit juice 51. INDIVIDUAL CONSIDERATION OF MEDICATION ADMINISTRATION A. Pharmacology and older adults (65+ years) a. Increased gastric pH b. Decreased gastrointestinal motility and gastric emptying time c. Decreased blood flow d. Decreased kidney function e. Decreased protein binding sites, resulting in lower serum albumin levels f. Decreased body water, increased body fat, and decreased lean body mass 52. SPECIMEN COLLECTION FOR GLUCOSE MONITORING A. Intra procedure a. Wrap the site in a warm, moist towel to enhance circulation 54 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Cleanse the site with warm water and soap or an antiseptic swab and allow it to dry c. Put finger in dependent position d. Pierce the skin using a sterile lancet and holding it perpendicular to the skin e. Wipe away the first drop of blood with a cotton ball f. Do not touch the site directly to stimulate bleeding g. Hold the test strip next to the blood on the finger tip 1. Do not smear blood onto the strip because this can cause an inaccurate reading B. Interpretation of findings a. Greater than 200 mg/dL indicates hyperglycemia b. Less than 70 mg/dL indicates hypoglycemia C. Indications a. Perform urine glucose testing b. Greater than 240 mg/dL to identify the presence of ketones 53. AIRWAY MANAGEMENT A. Interpretations of findings a. Expected reference range: 95-100% 1. Hypoxemia: less than 90% b. COPD norm: 89-100% B. Oxygen Therapy 55 Stuvia.com - The Marketplace to Buy and Sell your Study Material C. Low- flow oxygen delivery systems a. Nasal Cannula 1. tubing with 2 small prongs for insertion into the nares 2. 1-6 L/min 3. Provide humidification for flow rates of 4 L/min and greater b. Simple face mask 1. 5-8 L/min c. Partial rebreather mask 1. 6-10 L/min 2. Keep reservoir bag 1/3 to ½ full on respiration d. Nonrebreather mask 1. 10-15 L/min to keep the reservoir bad 2/3 full 2. Hourly assessments of the valve and the flap D. High-Flow oxygen delivery systems a. Venturi mask 1. 4-12 L/min 2. Most precise oxygen concentration b. Aerosol mask 1. Face tent: fits loosely around the face and neck 2. High humidification with oxygen delivery E. Complications 56 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Oxygen toxicity 1. Nonproductive cough, substernal pain, nasal stiffness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation b. Combustion 1. Post “no smoking” or “oxygen in use” signs to alert others to the fire hazard 2. Have client wear cotton gown 3. Ensure electrical devices are working well 4. Make sure all electric machinery is grounded 5. Do not use volatile, flammable materials (alcohol, acetone, nail polish) near clients receiving oxygen F. Chest physiotherapy a. Use set of techniques that loosen respiratory secretions and move them into central airways where coughing or suctioning can remove them b. Percussion- use of cupped hands to clap rhythmically on the chest to break up secretions c. Vibration- use of shaking movements during exhalation to help remove secretions d. Postural drainage- use of various positions to allow secretions to drain by gravity G. Considerations a. Schedule treatments 1 hr before or 2 hr after meals to decrease the likelihood of vomiting b. Admin bronchodilator medication or nebulizer treatment 30 min to 1 hr prior to postural drainage H. Suctioning a. Put client in high fowler’s positions For nasopharyngeal and nasotracheal suctioning lubricate the to distal 6-8 cm with water soluble lubricant c. The catheter should not exceed one half of the internal diameter of the endotracheal tube d. Use suction pressure no higher than 120-150 mmHg e. Additional guidelines for nasopharyngeal and nasotracheal suctioning 1. Insert the catheter into the naris during inhalation 57 Stuvia.com - The Marketplace to Buy and Sell your Study Material 2. Apply suction intermittently by covering and releasing the suction port with the thumb for 10-15 while rotating thumb and forefinger 3. Do not perform more than 2 passes with the catheter. Allow at least 1 min f. Additional guidelines for endotracheal suctioning 1. Advance the catheter until resistance is met- should reach the level of the carina 2. Pull the catheter back 1 cm 3. Apply suction intermittently by covering and releasing the suction port with the thumb for 10-15 seconds and rotate it with the thumb and forefinger 54. NASOGASTRIC INTUBATION AND ENTERAL FEEDINGS A. Nasogastric feedings a. Intra procedure 1. High fowlers position 2. Check placement by testing pH 3. Confirm placement with an X ray B. Enteral Feedings a. Fowlers position b. Auscultate for bowel sounds c. Monitor tube placements 1. Contents for pH (between 0-4) d. Check placement every 4-6 hour and check tube placement again 55. PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT A. Stages of wound healing a. Inflammatory stage 1. Lasts 3-6 days 2. Vasoconstriction, clot formation, hemostasis, phagocytosis of microorganisms b. Proliferative stage 1. 3-24 days 2. Replacing lost tissue or granulated tissue 58 Stuvia.com - The Marketplace to Buy and Sell your Study Material 3. Contracting with wound’s edges 4. Resurfacing of new epithelial cells c. Maturation or remodeling stage 1. After day 21 2. It can take more than 1 year to complete B. Healing processes a. Primary intention 1. Edges approximated as with a surgical incision 2. Heals rapidly 3. Minimal scarring b. Secondary intention 1. Loss of tissue 2. Wound edges widely separated longer healing time 3. Increase for risk of infection 4. Scarring c. Tertiary intention 1. Spontaneous opening of a previously closed wound 2. Closure of wound occurs when free of infection C. Factors affecting wound healing a. Increased age delays healing b. Impaired immune system function D. Assessment/data collection a. Red- healthy regeneration of tissue b. Yellow- presence of purulent drainage and slough c. Black- presence of eschar that hinders healing and requires removal d. Types of drainage 1. Serous drainage: Watery and clear 2. Sanguineous drainage: serum and red blood cells 3. Serosanguineous drainage- both serum and blood 59 Stuvia.com - The Marketplace to Buy and Sell your Study Material 4. Purulent drainage- result of infection e. Perform wound cleansing 1. Cleanse from the least contaminated toward the most contaminated 2. If irrigating a. Apply 5-8 psi 3. Use a 30-60 mL syringe E. Dehiscence vs evisceration F. Press a. Stages 1. Stage 1- non-blanchable erythema- intact skin 2. Stage 2- partial thickness- affects epidermis and dermis 3. Stage 3- full thickness skin loss- cannot see muscle and bone 4. Stage 4- full thickness skin loss- can see muscle and bone 5. Unstageable- depth unknown b. Prevention 1. Reposition the client in bed at least every 2 hours and every 1 hour in a chair 2. Keep the head of the bed at or below 30 degrees 3. Encourage proper nutrition 56. SKIP- WENT OVER ALREADY 57. FLUID IMBALANCES A. Fluid Volume deficiency 60 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Expected findings 1. Tachycardia, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, dry mucus membranes, oliguria, diminished capillary refill, diaphoresis, flattened neck veins, decreased skin turgor b. Lab tests 1. Hct- increased 2. Serum osmolarilty- increase 3. Urine specific gravity- increase c. Nursing Care 1. Monitor I&O – less than 30 mL/hr 2. Observe level of gait stability B. Fluid Volume excess a. Expected findings 1. Tachycardia, bounding pulse, hypertension, tachypnea, weight gain, dyspnea, crackles, edema, distended b. Lab tests 1. Hct- decreased 2. Serum osmolarity- decreased 3. Decreased electrolytes, BUN, and creatinine 4. Urine specific gravity decreased 58. ELECTROLYTE IMBALANCES Hyponatremia Hypernatremia Less than 136 mEq/L risk factors: - GI losses, diuretics, skin losses, edematous, hyperglycemia expected findings: - tachycardia, hypotension, confusion, fatigue, nausea, vomiting Greater than 145 mEq/L risk factors: - water deprivation, excessive sodium intake, kidney failure, Cushing’s syndrome Expected findings - Tachycardia, muscle twitches, muscle weaknesses, edema Hypokalemia Hyperkalemia Less than 3.5 mEq/L Risk factors Greater than 5.0 mEq/L Risk factors 61 Stuvia.com - The Marketplace to Buy and Sell your Study Material - GI losses, diuretics, skin losses, metabolic alkalosis Expected findings - Diabetic ketoacidosis, uncontrolled diabetes mellitus, kidney failure, salt substitutes - Hypotension, muscle weakness, muscle cramping, dysrhythmias Expected findings: - dysrhythmias Hypocalcemia Hypercalcemia Less than 9 mg/dL Risk factors: - diarrhea, vitamin D deficiency, hypoparathyroidism expected findings: - numbness and tingling, muscle spasms, positive Chvostek’s sign, positive trousseau’s sign More than 10.5 mg/dL Risk factors: - hyperparathyroidism, bone cancer, long term glucocorticoid use expected findings - decreased reflexes. Constipation, lethargy Hypomagnesemia Hypermagnesemia Less than 1.3 mEq/L Risk factors: - GI losses, loop diuretics, malnutrition, alcohol use disorder Expected findings - Hyperactive DTRs, seizures, positive Chvostek’s and trousseau’s sign, seizures - Dysrhythmias, tachycardia, hypertension More than 2.1 mEq/L Risk factors - Kidney disease, laxatives Expected findings - Muscle paralysis, shallow respirations, decreased respiratory rate, hypotension, cardiac arrest, lethargy 62 Stuvia.com - The Marketplace to Buy and Sell your Study Material ATI Fundamentals 1. a nurse in a clinical is caring for a middle age adult 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 responsesshould 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 decal occult blood test every year." D. "the recommendation is to have a sigmoidoscopy every 10 years." "You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. Oneoption for screening is a fecal occult blood test annually. 2. a nurse is caring for a client who is having difficulty breathing. the client is laying in bed with a nasal cannula delivering oxygen. which of the followingintervention 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 assist the client to an upright position When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed tothe semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on thediaphragm from abdominal organs. 3. 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-fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure the medication ismixed. 4. a nurse is planning care to improve self-feeding for a client who has visionloss. 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 Stuvia.com - The Marketplace to Buy and Sell your Study Material Use a clock pattern to describe food on the client's plate. Use a clock pattern to describe food on the client's plate.MY ANSWERDescribing the location of the food on the plate by using a clock patternallows the client to have greater independence during meals. 5. a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning 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 walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps toprevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. 6. 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." "I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing thebest time for him to learn. 7. a nurse is giving discharge instructions to a client who will require oxygen therapy at home. which of the following statements should the nurse identifyas 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 feetaway 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 goodworking order." Stuvia.com - The Marketplace to Buy and Sell your Study Material D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over." "I'll check the wires and cables on my TV to make sure they are in good workingorder." Oxygen is a highly flammable gas. The client should make sure any electricalequipment in the room where she is using supplemental oxygen is functioningproperly so it does not create any electrical sparks. 8. a nurse is caring for a client who is reporting difficulty falling asleep. whichof 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 Use progressive relaxation techniques at bedtime. Progressive relaxation promotes sleep by decreasing stress and reducing muscletension. 9. a nurse is assisting a client who is postoperative with the use of an incentivespirometer. into which of the following positions should the nurse place theclient? A. side-lying B. supine C. semi-fowlers D. trendelenburg Semi-Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows formaximum expansion of the lungs. 10. a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requiresfurther intervention? A. erythema on pressure points B. lower-extremity pulse strength on 2+ C. fluid intake of 3,000 mL per day D. a bowel movement every other day Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additionalmeasures to protect the skin from further breakdown. 11. a nurse is caring for a client who requires a 24-hour urine collection. which Stuvia.com - The Marketplace to Buy and Sell your Study Material of the following statement 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 flushes what I urinated at 7 am and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the txt quickly." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and saveall subsequent voidings. 12. a nurse is caring for a client who has herpes zoster and asks the runs aboutthe use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies? A. biofeedback B. aloe C. feverfew D. acupuncture Acupuncture The nurse should inform the client that the use of acupuncture is contraindicatedfor a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection. 13. a nurse is preparing to transfer a client who has right-sided weakness fromthe bed to a chair. in what order should the nurse take the following actionsto assist the client? 1. ask the client is he can bear weight 2. use the stand-pivot technique to move the client to the chair 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 1. ask the client is he can bear weight 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 2. use the stand-pivot technique to move the client to the chair 14. a nurse is preparing to administer an injection of an opioid medication to aclient. 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 eating the medication C. lock the remaining medication in the controlled substance cabinet Stuvia.com - The Marketplace to Buy and Sell your Study Material D. dispose of the vial with the remaining medication in a sharps container Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlledsubstance. 15. a nurse is preparing a herparing infusion for a client who was hospitalizedwith deep- vein thrombosis. the orders read: 25,000 units of heparin in 250mL of 0.9% sodium chloride to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? (round to the nearest whole number) 8mL/hr 16. a nurse is caring for a client who has a prescription for 5 units of regularinsulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure. 1. inject 5 units of air into the bottle of regular insulin 2. withdraw the correct dose of NPH insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 4. withdraw the correct dose of regular insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 1. inject 5 units of air into the bottle of regular insulin 4. withdraw the correct dose of regular insulin from the bottle 2. withdraw the correct dose of NPH insulin from the bottle 17. a nurse is caring for a client who is postoperative and refused to use anincentive 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 spirometer B. determine the reasons why the client is refusing to use the onetime spirometer C. document the client's refusal to participate in health restorative activities D. administer a pain medication to the client Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assessthe client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment. 18. a nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." which of the following components ofthe prescription should the runs question? A. the medication Stuvia.com - The Marketplace to Buy and Sell your Study Material B. the route C. the dose D. the frequency The dose The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. 19. 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 preventskin breakdown? A. place the client in high-flowers position B. increase the client's intake of carbohydrates C. massage the reddened areas with unscented lotion D. have the client use a trapeze bar when changing positions Have the client use a trapeze bar when changing position. By using a trapeze bar to assist with repositioning and transferring, the clientavoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure- ulcer development. 20. 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 on the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg 0.3 mg The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. 21. a nurse is caring for a client receiving fluid through a peripheral IV catheter.which of the following filings at the IV site should the nurse identify as infiltration? A. purulent exudate B. warmth C. skin blanching D. bleeding Skin blanching Stuvia.com - The Marketplace to Buy and Sell your Study Material Skin blanching, edema, and coolness at the IV site indicate infiltration. 22. 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 planto take? A. dissolve each medication in 5 mL of sterile water B. draw up medication together in the syringe C. push the syringe plunger gently when feeling resistance D. flush the tube with 15 mL of sterile water Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feedingtube with 30 to 60 mL of sterile water following the administration of the last medication. 23. a nurse is planning an education session for an older adult client who hasjust 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 lento's past experiences D. keeping the learning session private and one-on-one Allow extra time for the client to respond to questions. Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to askquestions and absorb the information. 24. a nurse is evaluating a client's use of a cane. which of the following actionsshould 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 move 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 The client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increasesupport and maintain alignment. 25. a nurse is caring for a client who has had his diet prescription changed to amechanical soft diet. which of the following food items should the nurse remove from the client's breakfast tray? A. smoothie Stuvia.com - The Marketplace to Buy and Sell your Study Material B. sliced banana C. pancakes D. sunny side up (fired) eggs sunny side up (fired) eggs Evidence-based practice indicates the nurse should remove fried eggs from theclient's tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item. 26. 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 theevent of a serious illness." C. "the permit a client to withhold medical information from heath care personnel." D. "they allow heath care personnel in the emergency department tostabilize a client's condition." "They indicate the form of treatment a client is willing to accept in the event of aserious illness." Advance directives include a living will, which permits the client to directtreatment in the event of a terminal illness. 27. 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 indicationthat the client has developed thrombophlebitis? A. bladder distention B. decreased blood pressure C. calf swelling D. diminished bowel sounds Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations ofthrombophlebitis, a common complication of immobility. 28. a nurse is caring for a client who report pain. when documenting the qualityof 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." Stuvia.com - The Marketplace to Buy and Sell your Study Material "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in herown words. 29. a nurse is administering an otic medication to an older adult client. which ofthe following actions should the nurse take to ensure that the medication reaches the inner ear? A. press gently on the tarsus of the client's ear B. pack a small piece of cotton deep into the cent'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 Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into theinner ear. 30. a nurse in a long-term care facility is planning to perform hygiene care for anew 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 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 you hygiene care?" "Are you able to help with your hygiene care?" The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, thenurse's priority is to assess the client's ability to assist with her hygiene care. 31. a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following informationshould 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 he client's room C. clean contaminated surfaces in the client's room with a phone solution D. have family members wear gown and gloves when visiting Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregiversmust also wear gowns and gloves. 32. a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the cent's safety Stuvia.com - The Marketplace to Buy and Sell your Study Material needs? (Select all that apply). A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctivae D. visual fields E. visual acuity B. pupil clarity D. visual fields E. visual acuity 33. a nurse is caring for a client who is expressing anger over his diagnosis ofcolorectal 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 managehis illness C. provide the client with written information about the phases of loss andgrief D. reassure the client that this is an expected response to grief Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reactionto a cancer diagnosis. 34. a nurse is planning to insert a peripheral IV catheter for an older adultclient. which of the following actions should the nurse plan to take? A. insert the other at a 45º angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiative IV therapy in the veins of the hand place the client's arm in a dependent position The nurse should place the client's arm in a dependent position because the veinswill dilate due to gravity. 35. a nurse is lifting a bedside cabinet to move it closer to a client who is sittingin 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 banner when lifting it Stand close to the cabinet when lifting it. Stuvia.com - The Marketplace to Buy and Sell your Study Material This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. 36. a nurse is providing care to four clients. which of the following situationsrequires the nurse to complete an incident report? A. a nurse tied a client's restraints straps to the moveable part of the bedframe B. an assuétude personnel placed a surgical mask on a client who has TBbefore transporting her to radiology C. a nurse administer 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 IVfluid A client who has an IV infusion pump receives an additional 250 mL of IV fluid. The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management todetermine actions to take to prevent further similar incidents. 37. a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should thenurse manger 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 indicating an injection." "Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providerswrite the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate 38. 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 ofthe following precautions should the nurse take? A. ensure sterilization of non disposable items with ethylene oxide B. wrap monitoring cords with stockinette and tape them in place C. cleanse latex pots on IV tubing with chlorohexidine before injection medication D. wear hypoallergenic latex gloves that contain powder Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent anycontact of these cords and devices with the client's skin by covering them with a Stuvia.com - The Marketplace to Buy and Sell your Study Material nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. 39. a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take wheninserting the NG tube? A. position the client with the head of the bed elevated to 30º prior toinsertion of the NG tube B. remove the NG tube if the client begins to gag of 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 intothe esophagus Have the client take sips of water to promote insertion of the NG tube into theesophagus. Taking sips of water as the NG tube passes through the oropharynx will close theepiglottis over the trachea and prevent the tube's passage into the trachea. 40. a nurse is admitting a client who has an abdominal wound with a largeamount of purulent drainage. which of the following types of transitionprecautions hold the nurse initiate? A. protective environment B. airborne precautions C. droplet precautions D. contact precautions Contact precautions Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown andgloves during direct contact with this client. 41. 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 of 40.5ºc (105ºF) C. cleanse the wound from the center outward D. use a 20 mL syringe to irrigate the wound Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to preventintroduction of micro- organisms from the outer skin surface. 42. a nurse is caring for a client who requires bed rest and has a prescription foranti embolic stocking. which of the following actions should the nurse take? Stuvia.com - The Marketplace to Buy and Sell your Study Material A. apply the stockings so the creases are on the front 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 Remove the stockings at least once per shift. The nurse should remove the stocking once per shift to check the client'scirculation and skin integrity. 43. 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 actionsshould 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 30º C. make sure the enteral formula is at room temperature D. wipe the top of the formula can with alcohol Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteralformula; therefore, the priority intervention is to keep the head of the bedelevated at least 30° to prevent reflux of the formula backward into the esophagus. 44. a nurse is caring for a client who has tuberculosis. which of the followingactions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care E. use antimicrobial sanitizer for hand hygiene 45. a nurse is responding to a call light and finds a client lying on the bathroomfloor. 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 Check the client for injuries. The first action the nurse should take when using the nursing process is to assess Stuvia.com - The Marketplace to Buy and Sell your Study Material the client for injuries. 46. 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-performing stress? A. role ambiguity B. sick role C. role overload D. role conflict Role overload The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can perform. 47. a nurse is administering IV fluid to an older adult client. the nurse shouldperform which priority assessment to monitor for adverse effects? A. auscultate lung sounds B. masure urine output C. monitor blood pressure readings D. monitor serum electrolyte levels Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing,circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volumeexcess include moist crackles heard in lung fields, dyspnea, and shortness of breath. 48. a nurse is performing a peripheral vascular assessment for a client. whenplacing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent bloodflow. this sound indicates which of the following? A. narrowed arterial lumen B. distended jugular veins C. impaired ventricular contraction D. asynchronous closure of the aortic and pulmonic valve Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occludedor narrowed arteries. 49. a nurse is completing an admission assessment for a client who reports Stuvia.com - The Marketplace to Buy and Sell your Study Material 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 Rapid heart rate Tachycardia indicates fluid-volume deficit, which is an expected finding for aclient who has had vomiting and diarrhea for 3 days. 50. a nurse is caring for a client who has terminal live cancer. which of thefollowing 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?" "What could I have done to deserve this illness?" The client's terminal illness might prompt him to review his life and question itsmeaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him. 51. a nurse is using an open irrigation technique to irrigate a client's indwellingurinary 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 irritant used from the client's urine output D. perform the irrigation using a 20 mL syringe Subtract the amount of irrigant used from the client's urine output. The nurse should calculate the fluid used for irrigation and subtract it from theclient's total urinary output. 52. a nurse is caring for a client who is refusing a blood transfusion for religiousreasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? A. ask the client to consider a direct donation B. withhold the blood transfusion C. request a consolation with the ethics committee D. ask the client's family to intervene Withhold the blood transfusion. Stuvia.com - The Marketplace to Buy and Sell your Study Material The principle of autonomy ensures that a client who is competent has the right to refuse treatment. 53. a nurse is reviewing a client's fluid and electrolyte status. which of thefollowing findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mg/dL D. Potassium 5.4 mg/dL Potassium 5.4 mEq/L The value is above the expected reference range and the nurse should report thisfinding. This client is at risk for dysrhythmias. 54. a nurse is admitting a client who has influenza. which of the following typesof transmission precautions hold the nurse initiate? A. airborne B. droplet C. contact D. protective environment Droplet Droplet precautions are a requirement for clients who have infections that spreadvia droplet nuclei that are larger than 5 microns in diameter, including influenza,rubella, meningococcal pneumonia, and streptococcal pharyngitis. 55. 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 familymember is coping effectively with the situation? A. "we are not worried. we still have hope that everything will be ok." B. "this is a difficult time, but we are helping each other though this." C. "after he comes home, we can plan out family reunion." D. "we don't need to talk about funeral arraignments at this time." "This is a difficult time, but we are helping each other through this." An effective coping strategy is talking with others in the family and supportingeach other. This statement displays effective coping skills because the family isusing social supports to assist them throughout the grief process. 56. a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that iswithin the RN scope of practice? A. insert an implanted port B. close a laceration with sutures Stuvia.com - The Marketplace to Buy and Sell your Study Material C. place an endotracheal tube D. initiate an enteral feeding though a gastrostomy tube Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedingsthrough nasoenteric, gastrostomy, and jejunostomy tubes. 57. a nurse manager is overseeing the care on a unit. which of the followingshould 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 withthe 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 durablepower of attorney for health care designee to discuss the client's care D. a nurse discusses a client's status with the physical therapies that iscaring for the client's bedside A nurse asks a nurse from another unit to assist with her documentation. Only health care professionals directly caring for a client may access medicalinformation; therefore, this is a violation of HIPAA guidelines. 58. a nurse is reviewing protocol in preparation for suctioning secretions from client who has a new tracheostomy. which of the following actions should thenurse plan to take? A. use a resuscitation bag with 80% oxygen prior to the procedure B. select a suction catheter that is half of the size of the lumen C. place the end of the function catheter in water-soluble lubricant D. adjust the wall suction apparatus to a pressure of 170 mm Hg Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen toprevent hypoxemia and trauma to the mucosa. 59. a nurse is performing a Romberg's test during the physical assessment of aclient. 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 clients 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 Have the client stand with her arms at her side and her feet together. Romberg's test helps identify alterations in balance. The nurse should have theclient stand with her arms at her sides and her feet together to observe her forswaying and a loss of balance. Stuvia.com - The Marketplace to Buy and Sell your Study Material 60. a nurse is preparing a change-of-shift report. which of the of the following tools or documents should the nurse use to communicate continuity of care? A. critical pathway B. SBAR C. transfer report D. medication administration record (MAR) Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool used to relate a client's status during a change-of-shift report. 61. 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 Decrease in heart rate Fluid-volume deficit causes tachycardia. With correction of the imbalance, theheart rate should return to the expected range. 62. A nurse working in the emergency department is witnessing the signing ofinformed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legallywitness? (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 A 16-year-old client who is married is correct. A minor who is married is emancipated and can give consent for his own treatment. A 27-year-old client who has schizophrenia is correct. An adult client who requires psychiatric care can give consent for her own care unless the court hasdetermined the client to be incompetent. An adoptive parent who brings in his 8-year-old son is correct. The adoptiveparent of a child is a parent and legal guardian and can sign to give consent for the child's care. Stuvia.com - The Marketplace to Buy and Sell your Study Material A 17-year-old mother who brings in her toddler is correct. A custodial parent who is a minor can legally give consent for the medical treatment of her child. 63. A nurse is caring for a client who has a respiratory infection. Which of thefollowing 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. Apply intermittent suction when withdrawing the catheter. The nurse should apply intermittent suction during the withdrawal of the catheterto prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. 64. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggestthat the client add to his diet? A) Beef liver B) Shellfish C) Egg yolks D) Avocados Avocados Avocados contain no cholesterol. Plant foods contain no cholesterol; foods fromanimals contain cholesterol. 65. A nurse is preparing to transfer a client who can bear weight on one legfrom the bed to a chair. After securing a safe environment, which of thefollowing 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. Assess the client for orthostatic hypotension. The first action the nurse should take using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. Thenurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair. 66. A nurse is caring for a group of clients. Which of the following actions Stuvia.com - The Marketplace to Buy and Sell your Study Material 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-pressureairflow. 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 asecond trash bag. Place a client who has tuberculosis in a room with negative-pressure airflow. A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the riskof infection transmission. 67. 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 thefollowing 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. Talk directly to the client, instead of the interpreter, when speaking. When using an interpreter, the nurse should speak directly to the client andobserve the client when the interpreter is translating. 68. A nurse is caring for a client who has an indwelling urinary catheter. Whichof 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. Bladder scan shows 525 mL of urine. A client who has an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse shouldirrigate the catheter to resolve a blockage. 69. A nurse is caring for a client who has diarrhea due to shigella. Which of thefollowing 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 exchange. D) Instruct all visitors to limit their time with the client. Stuvia.com - The Marketplace to Buy and Sell your Study Material Wash her hands before and after contact with the client. Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria. The nurse should also use standard precautions, which require the nurse to perform hand hygiene before and after direct contactwith every client, regardless of their diagnosis. 70. A nurse on a medical unit is preparing to discharge a client to home. Whichof 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 medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization. Compare prescriptions with medications the client received during hospitalization. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with thosethe provider has prescribed for the client to take after discharge. 71. 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 thenurse 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. Thread the IV catheter so that the hub rests at the insertion site. Inserting the catheter up to the hub reduces the risk of contamination along thelength of the catheter. 72. 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 thenurse recommend as a good source of complete protein? A) Oat cereal B) Refried beans C) Peanut butter D) Cheddar cheese Cheddar cheese Complete proteins contain enough of all nine of the essential amino acids that Stuvia.com - The Marketplace to Buy and Sell your Study Material help maintain and promote nitrogen balance. Cheese, poultry, and fish are examples of foods that are good sources of complete protein. [Show More]

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