NGN 2023 ATI RN Fundamentals Online Practice A & B Updated 2024-2025 New Latest Version, Exams of Nursing

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NGN 2023 ATI RN Fundamentals Online

Practice A & B Updated 202 4 - 2025 New

Latest Version with All Questions and

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A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse Identify as indicating infiltration? ----------- Correct Answer -------- Skin blanching A nurse is teaching for a client who has heart failure. which of the following 3 statements by the client indicates an understanding of the teaching?

• "I have been weighing myself every other morning"
• "i am trying to decrease my intake of foods with potassium"
• i" i am limiting my sodium intake to 2 grams daily"
• " i am eating fewer potato chips and more fruit for snacks"
• " i will lie down and rest after meals"
• " i know to call my doctor if i gain 3 pounds or more in 2 days" --------- Correct Answer -- -------- - i am limiting my sodium intake to 2 grams daily"
• i am eating fewer potato chips and more fruit for snacks
• i know to call my doctor if i gain 3 pounds or more in 2 days" A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
• The top of the cane is parallel to the client's waist
• When walking, the client moves the cane 46 cm (18 in) forward
• The client holds the cane on the stronger side of her body
• The client moves her stronger limb forward with the cane --------- Correct Answer -------- -- - The client holds the cane on the stronger side of her body 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?
• Position the client with the head of the bed elevated 30 degrees prior to insertion of the NG tube.
• Remove the NG tube if the client begins to gag or choke.
• Apply suction to the NG tube prior to insertion.
• Have the client take sips of water to promote insertion of the NG tube into the esophagus. --------- Correct Answer ---------- Have the client take sips of water to promote insertion of the NG tube into the esophagus. A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

• Insert the catheter at a 45 degree angle
• Place the client's arm in a dependent position
• Shave excess hair from the insertion site
• Initiate IV therapy in the veins of the hand --------- Correct Answer ---------- Place the client's arm in a dependent position A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? Bend at the waist Keep his feet close together Use his back muscles for lifting Stand close to the cabinet when lifting it --------- Correct Answer ---------- Stand close to the cabinet when lifting it A nurse is caring for a client who has a terminal illness & is approaching death. The client is short of breath & has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? Turn the client every 2 hr Administer an antiemetic ever 6 hr Hold oral care Increase the room's temperature --------- Correct Answer ---------- Turn the client every 2 hr the nurse is proving teaching for the client who has diarrhea. select 4 instructions that the nurse should include in the teaching
• increase intake of high-calcium foods
• eat probiotic foods such as yogurt
• avoid alcohol while experiencing diarrhea
• eat raw veggies
• eat three large meals a day
• avoid caffeine while experiencing diarrhea
• drink hot liquids several times a day
• drink carbonated beverages to replace lost fluids
• follow a low-fiber diet --------- Correct Answer ---------- - eat probiotic foods such as yogurt
• avoid alcohol while experiencing diarrhea
• avoid caffeine while experiencing diarrhea
• follow a low-fiber diet 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? During the admission process As soon as the client's condition is stable During the initial team conference

After consulting with the client's family --------- Correct Answer ---------- During the admission process A nurse manager is preparing to review medication documentation with a group of newly licenses nurses. Which of the following statements should the nurse manager plan to include in the teaching? "Use the complete name of the medication magnesium sulfate." "Delete the space between the numerical dose & the unit of measure." "Write the letter U when noting the dosage of insulin." "Use the abbreviation SC when indicating an injection." --------- Correct Answer ---------- "Use the complete name of the medication magnesium sulfate." A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? - ---------- Correct Answer -------- You should have a fecal occult blood test every year A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? ----- ------ Correct Answer -------- Tell the client to keep the head of the bed elevated at least 30° A nurse is admitting a client who has an abdominal wound with a large amount of purple tissue drainage. Which of the following types of transmission precautions should the nurse initiate? Protective environment Airborne precautions Droplet precautions Contact precautions --------- Correct Answer ---------- Contact precautions 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?

• Discuss the risk factors for colon cancer.
• Focus teaching on what the client will need to do in the future to manage his illness.
• Provide the client with written information about the phases of loss & grief.
• Reassure the client that this is an expected response to grief. --------- Correct Answer -- -------- - Reassure the client that this is an expected response to grief. A nurse is caring for a client who is postoperative following a knee arthroplasty & requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
• Assist the client into a prone position
• Place a sleeve over the top of each leg with the opening at the knee
• Make sure two finger can fit under the sleeves

• Set ankle pressure at 65 mmHg --------- Correct Answer ---------- - Make sure two finger can fit under the sleeves A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use? Alienate Gauze Transparent Hydrocolloid --------- Correct Answer ---------- Hydrocolloid A nurse is preparing an education program for the staff about advocacy. Which of the following information should the nurse include?
• Advocacy ensures clients' safety, health, & rights.
• Advocacy series that nurses are able to explain their own actions.
• Advocacy ensures that nurses follow through on their promises to clients.
• Advocacy ensures fairness in client care delivery and use of resources. --------- Correct Answer ---------- Advocacy ensures clients' safety, health, & rights. A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
• Verify the client's name on their identification bracelet with the medication administration record
• Call the pharmacy to determine whether the client's medications are available
• Compare the clients home medications with the provider's prescriptions
• Place the client's home medication bottles in a secure location --------- Correct Answer - --------- Compare the clients home medications with the provider's prescriptions A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety need? (Select all that apply)
• Lacrimal apparatus
• Pupil clarity
• Appearance of bulbar conjunctivae
• Visual fields
• Visual acuity --------- Correct Answer ---------- Pupil clarity Visual fields Visual acuity A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?
• "I can place an extension cord across my living room to plug in my television."
• "I will hire someone to trim the tree that hangs low over the stairs of my front porch."
• "I will place my alarm clock on my bedroom dresser across the room."
• "I will replace the old throw rug in my kitchen with a new one." --------- Correct Answer -- -------- - "I will hire someone to trim the tree that hangs low over the stairs of my front porch."

A nurse is reviewing a client's fluid & electrolyte status. Which of the following findings should the nurse report to the provider? BUN 15 mg/dL Creatinine 0.8 mg/dL Sodium 143 mEq/L Potassium 5.4 mEq/L --------- Correct Answer ---------- Potassium 5.4 mEq/L nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min & to report back in 1 hr. Which of the following actions should the nurse take next?

• Document the providers statement in the medical record
• Complete an incident report
• Consult the facility's risk manager
• Notify the nursing manager --------- Correct Answer ---------- Notify the nursing manager The client states: "I am unable to eat anything without vomiting" select 3 tasks the nurse should delegate
• document the client's vitals
• measure the client's intake and output
• transfer the client from wheelchair to bed
• insert an NG tube for the client
• collect data about the client's pain level. --------- Correct Answer ---------- - document the client's vitals
• measure the clients intake and output
• transfer the client from wheelchair to bed 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?
• Increase hematocrit
• Increase respiratory rate
• Decrease heart rate
• Decrease in capillary refill time --------- Correct Answer ---------- - Decrease heart rate A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
• Combine client care tasks when caring for multiple clients
• Wait until the end of the shift to document client care
• Use the planning step of the nursing process to prioritize client care delivery
• Allow for interruptions in tasks to discuss client care issues with colleagues --------- Correct Answer ---------- Use the planning step of the nursing process to prioritize client care delivery

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? Role ambiguity Sick role Role overload Role conflict --------- Correct Answer ---------- Role overload The client reported fever, chills, cough, and night sweats for the past 2 weeks the nurse is placing the client on isolation precautions. which of the following interventions should the nurse include?

• wear an N95 mask when caring for the client
• place a container for soiled linens inside the client's room
• place the client in a negative airflow room
• remove the mask after exiting the client's room
• wear a sterile, water-resistant gown if within 3 feet of the client. --------- Correct Answer ---------- - wear an N95 mask when caring for the client
• place a container for soiled linens inside the clients room
• place the client in a negative airflow room
• remove mask after exiting the clients room A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
• Ask another nurse to observe the medication wastage.
• Notify the pharmacy when wasting the medication.
• Lock the remaining medication in the controlled substances cabinet.
• Dispose of the vial with the remaining medication in a sharps container. --------- Correct Answer ---------- Ask another nurse to observe the medication wastage. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
• Place the client in a side-lying position
• Instill 15 mL of irrigation fluid into the catheter with each flush
• Subtract the amount of irritant used from the clients urine output
• Perform the irrigation using a 20 mL syringe --------- Correct Answer ---------- Subtract the amount of irritant used from the clients urine output A nurse is teaching a client & his family how to care for the client's tracheotomy at home Which of the following instructions should the nurse include in the teaching?
• Remove the outer cannula cautiously for routine cleaning
• Use tracheostomy covers when outdoors
• Use sterile technique when performing tracheostomy care at home
• Cleanse irritated skin w/ full strength hydrogen peroxide --------- Correct Answer ---------
• Use tracheostomy covers when outdoors

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What will happen if I arrived at the emergency department & I had difficulty breathing?" Which of the following responses should the nurse make?

• "We would consult the person appointed by your health care proxy to make decisions."
• "We would give you oxygen through a tube in your nose."
• "You would be unable to change your previous wishes about your care."
• "We would insert a breathing tube while we evaluate your condition." --------- Correct Answer ---------- "We would give you oxygen through a tube in your nose." the nurse should first , ...... followed by........ --------- Correct Answer ---------- - review medications that might be causing confusion
• using other methods to keep the client safe 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?
• Make sure the client's room has at least six air exchanges per hour.
• Make sure the client wears a mask when outside her room if there's construction in the area.
• Place the client in a private room with negatives-pressure airflow.
• Wear an N95 respirator when giving client direct care. --------- Correct Answer ---------- Make sure the client wears a mask when outside her room if there's construction in the area. The nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ------- -- Correct Answer ---------- 107 mL/hr 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. (By placing them in the order of performance) --------- Correct Answer ---------- 1. Obtain the pronouncement of death from the provider2. Remove tubes and indwelling catheters3. Wash the clients body4. Ask the client's family members if they'd like to view the body5. Place a name tag on the body A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds crackles rhonchi friction rub normal breath sounds --------- Correct Answer ---------- normal breath sounds

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? Pad the client's wrist before applying the restraints Evaluate the client's circulation every 8 hr after application Remove the restraints every 4 hr to evaluate the client's status Secure the restraints to the bed's side rails --------- Correct Answer ---------- Pad the client's wrist before applying the restraints A nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care? Critical pathway Situation, background, assessment, & recommendation (SBAR)Transfer report Medication administration record (MAR) --------- Correct Answer ---------- (SBAR)Transfer report A nurse is caring for a client who is postoperative following abdominal surgery click to highlight the assessment findings below that the nurse should report to the provider. --------- Correct Answer ---------- urinary output reported pain level vital signs 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? The client uses a wool blanket on their bed. The client identifies the location of a fire extinguisher The client stores an extra oxygen tank on its side under the bed. The client has a weekly inspection checklist for oxygen equipment. --------- Correct Answer ---------- The client identifies the location of a fire extinguisher A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

• Use the Face, Legs, Activity, Cry, & Consolability (FLACC) pain rating scale for a client who is experiencing pain.
• Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
• Obtain an apical heart rate by auscultating the third intercostal space left of the sternum.
• Palpate the client's abdomen before auscultating bowel sounds. --------- Correct Answer ---------- Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

A nurse in a providers 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 clients patellar reflex? --------- Correct Answer ---------- tap the patellar tendon just below the knee using a reflex hammer nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include?

• Insert the needle at 15 degree angle
• Aspirate for blood return prior to administration
• Administer the medication into the abdomen
• Massage the site following the injection --------- Correct Answer ---------- - Administer the medication into the abdomen A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury to the client?
• Use a bed exit alarm system
• Raise four side rails while the client is in bed
• Apply soft wrist restraint
• Dim the lights in the client's room --------- Correct Answer ---------- Use a bed exit alarm system A nurse is caring for a client who is receiving a unit of packed RBC'S complete the following sentence by using the list of options
• the client has manifestations of ..... as evidenced by the clients..... --------- Correct Answer ---------- allergic reaction, itching A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of skin malignancy?
• A lesion with uniform pigmentation
• New appearance of petechiae
• A mole with an asymmetrical appearance
• The presence of a papule --------- Correct Answer ---------- A mole with an asymmetrical appearance A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? Contact Droplet Airborne Protective --------- Correct Answer ---------- Droplet A nurse is talking with an older adult client who is contemplating retirement. This 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?

• "You would have so much more time to spend time with your family."
• "You should consider getting a part-time job or doin volunteer work."
• "Let's talk about how the change in your job status will affect you."
• "Why wouldn't you want to retire & relax?" --------- Correct Answer ---------- Let's talk about how the change in your job status will affect you." A nurse is caring for a client who has a peripheral IV inserted for fluid replacement the nurse is assessing the client. which of the following actions should the nurse take? - -------- Correct Answer ---------- - stop the IV infusion
• elevate the client's left arm
• apply heat to the clients left hand A nurse is caring for a client who is postoperative & refuses to use an incentive spirometer following a major abdominal surgery. Which of the following actions is the nurse's priority?
• Request that a respiratory therapist discuss that technique for incentive spirometry with the client
• Determine the reasons why the client is refusing to use the incentive spirometer.
• Document the client's refusal to participate in health restorative activities.
• Administer a pain medication to the client. --------- Correct Answer ---------- Determine the reasons why the client is refusing to use the incentive spirometer. A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
• "They allow the court to overrule an adult client's refusal of medical treatment."
• "They indicate the form of treatment a client is willing to accept in the event of a serious illness."
• "They permit a client to withhold medical information from health care personnel."
• "They allow health care personnel in the emergency department to stabilize a client's condition." --------- Correct Answer ---------- "They indicate the form of treatment a client is willing to accept in the event of a serious illness." A nurse is caring for a client who has a terminal illness & is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?
• "I am not worries because I still have hope that he will be okay."
• "I am relying on support from our family during this time."
• "We can plan our family reunion once he recovers & comes home."
• "We don't see any reason to start discussing funeral arrangements right now." --------- Correct Answer ---------- - "I am relying on support from our family during this time." A nurse is caring for a client who has pneumonia complete the following sentence by using the list of options The nurse should identify that the client might be experiencing ...... as evidenced by the client's........... --------- Correct Answer ---------- extravasation, IV catheter site

A nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options & leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client decides. Which of the following statements should the nurse make?

• "I will return shortly after I document this in your record."
• "Most men live a long time with prostate cancer."
• "I am available to talk if you should change your mind."
• "I will make a referral to a cancer support group for you." --------- Correct Answer ---------
• • "I am available to talk if you should change your mind." A nurse is responding to a call light & finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
• Check the client for injuries
• Move hazardous objects away from the client
• Notify the provider
• Ask the client to describe how she felt prior to the fall --------- Correct Answer ---------- Check the client for injuries A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complimentary & alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for with of the following therapies?Biofeedback Aloe Feverfew Acupuncture --------- Correct Answer ---------- Acupuncture A nurse is caring for a client who has a new diagnosis of seizure disorder. the nurse should first address the clients....... followed by the clients ....... --------- Correct Answer ---------- physical safety positioning 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?
• Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter
• Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
• Make sure reservoir bag of partial rebreather mask remains deflated
• Use petroleum jelly to lubricate the client's nares, face, & lips --------- Correct Answer --- ------- - Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the ruse take?
• Administer the mediation with the needles at a 45 degree angle
• Administer the medication into the client's nondominant arm
• Pull the clients skin laterally or downward prior to administration

• Massage the injection site after administration --------- Correct Answer ---------- Administer the mediation with the needles at a 45 degree angle 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 pain? "Is your pain constant or intermittent?' "What would you rate your pain on a scale of 0-10?" "Does the pain radiate?" "Is your pain sharp or dull?" --------- Correct Answer ---------- "Is your pain sharp or dull?" A nurse is caring for a child who has prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
• Examine personal values about the issue
• Tell the parents that this is a necessary procedure
• Inform the parents that the staff does not require their consent
• Contact a spiritual support person to explain the importance of the procedure --------- Correct Answer ---------- Examine personal values about the issue A nurse is caring for a client who has COPD select 3 findings that require follow-up breath sounds blood pressure oxygen saturation temperature heart rate --------- Correct Answer ---------- breath sounds oxygen saturation temperature A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
• "I think I should take my pain medication more often since it is not controlling my pain."
• "Breathing faster will help keep my mind off of the pain."
• "It might help me to listen to music while I'm lying in bed."
• "I don't want to walk today because I have some pain." --------- Correct Answer ---------- "It might help me to listen to music while I'm lying in bed." A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? ----------- Correct Answer -------- The caregiver insists on remaining in the room 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? -----------

Correct Answer -------- "People in middle adulthood often find satisfaction in untiring and guiding young people." A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? ----------- Correct Answer -------- Initiate an enteral feeding through a gastrostomy tube A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? Round to nearest whole number ----------- Correct Answer -------- 8 ml/hr 800 units/hr x 250ml /25,000 units A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment, the nurse should record which of the following client statements? ----------- Correct Answer -------- The pain is like a full ache in my stomach A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? ----------- Correct Answer -------- I flushed what I urinated at 7:00 am and have saved all urine since A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? --- -------- Correct Answer -------- Rapid heart rate 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? ----------- Correct Answer -------- When descending stairs, I will shift my weight to my right leg. A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? ----------- Correct Answer -------- Current medications A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? ----------- Correct Answer -------- Arrange food in a consistent pattern on the clients plate A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? ----------- Correct Answer -------- Walking briskly

A nurse is providing discharge teaching for 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? ----------- Correct Answer -------- - check the cord routinely for frays or tearing is correct

• consider purchasing a generator for power backup
• observe for signs of hypoxia A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? ----------- Correct Answer -------- A client who has asthma A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? - ---------- Correct Answer -------- Spect a suction catheter that is half the size of the lumen A nurse is caring for a client who is receiving pain medication through a patient- controlled analgesia (PCA) pump. Which of the following actions should the nurse take? ----------- Correct Answer -------- Instruct the family to refrain from pushing the button for the client while she is asleep. A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? ----------- Correct Answer -------- N A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? ----------- Correct Answer -------- I can take echinacea to improve my immune system A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? ----------- Correct Answer -------- The newly licensed nurse places the cap of the bottle of sterile salon solution on the sterile field. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? ----------- Correct Answer -------- Withhold the blood transfusion A nurse on a medical unit is preparing to discharge a client to home. Which of the following should the nurse take as part of the medication reconciliation process? --------- -- Correct Answer -------- Compare prescriptions with medications the client received while at the facility

A charge nurse is discussing the responsibility of nurses caring for clients who have a C-diff infection. Which of the following information should the nurse include in the teaching? ----------- Correct Answer -------- Have family members wear a gown and gloves when visiting. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? ----------- Correct Answer -------- Ambulating a client who is postoperative A nurse is calculating a clients fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the clients intake and output record as 120 malodorous fluid? ----------- Correct Answer -------- 8 oz of ice chips A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the BP? ----------- Correct Answer -------- 120 mm Hg A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurses responsibility? ----------- Correct Answer ----- --- Witness the clients signature on the consent form. A nurse in a surgical suite notes documentation on a clients medical record that he has a latex allergy. In preparation for the clients procedure, which of the following precautions should the nurse take? ----------- Correct Answer -------- Wrap monitoring cords with stockinette and tape them in place. A nurse manager is overseeing the care on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? ----------- Correct Answer -------- A nurse asks a nurse from another unit to assist with documentation for a client A nurse has Accepted a verbal prescription for 3/10 of a milligram of levothyroxine IV stat for a client who has myxedema coma how should the nurse transcribe the dosage of this medication in the clients medical record? ----------- Correct Answer -------- 0.3 mg A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? ----------- Correct Answer -------- A client who smokes one pack of cigarettes each day A nurse is reviewing a clients medication prescription that reads, Digoxin 0.25 by mouth every day. Which of the following components of the prescription should the nurse verify with the provider? ----------- Correct Answer -------- Medication dose

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? ----------- Correct Answer -------- what could I have done to deserve this illness? A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? ----------- Correct Answer -------- Flush the tube with 15 mL of Sterile water A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures? ----------- Correct Answer -------- Apply and ankle - foot orthotic device to the clients feet A client who is non-ambulatory notifies the nurse that his trashcan is on fire. After the nurse confirms the presence of the fire, which of the following action should the nurse take next? ----------- Correct Answer -------- Evacuate the client A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessment should the nurse identify as the priority? ----------- Correct Answer -------- Auscultate lung sounds 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 psycho motor approach to learning? ----------- Correct Answer -------- Practice sessions A nurse is giving change - of - shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? ----------- Correct Answer -------- Breath sounds 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? ----------- Correct Answer -------- Assess the client for orthostatic hypotension A nurse is caring for a client who has a prescription for five units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure ----------- Correct Answer -------- 1.) inject 10 units of air into NPH 2.)inject 5 units of air into regular 3.)withdraw the correct amount of regular insulin 4.)withdraw the correct dose of NPH insulin 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? ----------- Correct Answer --- ----- Gently shake the container of medication prior to administration

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? ----------- Correct Answer -------- Maintain a consistent time to wake up each day 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(telling the truth)? ----------- Correct Answer -------- A client who is unaware of her recent cancer diagnosis asked the nurse if she has cancer, and the nurse response affirmatively. A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? ----------- Correct Answer -------- You should receive a pneumococcal vaccine when you are 6 5 years old A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? - ---------- Correct Answer -------- Distended neck veins A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse Use? ----------- Correct Answer -------- Have a client stand with their arms that their sides and their feet together A nurse is caring for a client who has a terminal diagnosis and Who's health is declining. The client request information about advance directives. Which of the following responses should the nurse make? ----------- Correct Answer -------- We can talk about advance directives, and I can also give you some brochures about them. A nurse is caring for a client who has tuberculosis. Which of the following action should the nurse take? Select all that apply ----------- Correct Answer -------- - place the client in a room with negative pressure airflow

• Wear gloves when assisting a client with oral care
• Used antimicrobial sanitizer for hand hygiene