RN A T I Fundamentals Test Bank, Latest Complete Questions & answers All Chapters,2024 A, Exams of Nursing

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A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I am having mild pain" "The pain is like a dull ache in my stomach" "I notice that the pain gets worse after I eat" "The pain makes me feel nauseous" - ANSWER "The pain is like a dull ache in my stomach" A client in non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm Extinguish the fire Evacuate the client Confine the fire - ANSWER Evacuate the client 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? Neck vein distention Urine specific gravity 1. Rapid Heart rate Blood pressure 144/82 mmHg - ANSWER Rapid heart rate A nurse has accepted a verbal prescription for "thee tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

.3 mg 0.3 mg 0.30 mg 3/10 mg - ANSWER 0.3 mg 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/hour. At what rate should the nurse set the infusion pump? - ANSWER 8 ml/hour A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5 C (105 F) Cleanse the wound from the center outward Use a 20 ml syringe to irrigate the wound - ANSWER Cleanse the wound from the center outward 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? Purulent exudate Warmth Skin blanching Bleeding - ANSWER Skin blanching 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? "When descending the stairs, I will first shift my weight to my right leg" "I should place my crutches 12 inches in front and to the side of each foot" "As I sit down, I will hold one crutch in each hand" "I will make sure the shoulder rests are snug against my armpits" - ANSWER "When descending the stairs, I will first shift my weight to my right leg"

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? Rinse the feeding back with water between feedings Tell the client to keep the head of the bed elevated at least 30 degrees Make sure the enteral formula is at room temperature Wipe the top of the formula can with alcohol - ANSWER Tell the client to keep the head of the bed elevated at least 30 degrees A nurse is reviewing a client's 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? Medication name Route of administration Medication dose Frequency of administration - ANSWER Medication dose 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 the client understands the use of this assistive device? "This type of hearing aid does not allow for fine tuning of volume" "I shouldn't have trouble keeping the hearing aid in place during exercise" "I expect to hear a whistling sound when I first insert the hearing aid" "I will be sure to remove my hearing aid before taking a shower" - ANSWER "I will be sure to remove my hearing aid before taking a shower" A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? "Incident report completed" "Client climbed over the side rails" "Client found lying on the floor" "Client was trying to get out of bed" - ANSWER "Client found lying on the floor"

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? Seal unused medications from the facility in a plastic bag Evaluate the client's ability to self administer medications Report an identified discrepancy to The Joint Commission Compare prescriptions with medications the client received while at the facility - ANSWER Compare prescriptions with medications the client received while at the facility A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? Describe the procedure to the client Witness the client's signature on the consent form Inform the client of alternatives to the procedure Tell the client which team members will assist with the procedure - ANSWER Witness the client's signature on the consent form 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? "You should have an eye examination every 2 years" "You should receive a tetanus booster every 5 years" "You should receive a shingles vaccine when you are 70 years old" "You should receive a pneumococcal vaccine when you are 65 years old" - ANSWER "You should receive a pneumococcal vaccine when you are 65 years old" A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? Ask the client to consider a direct donation Withhold the blood transfusion Request a consultation with the ethics committee Ask the client's family to intervene - ANSWER Withhold the blood transfusion

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? droplet airborne contact protective environment - ANSWER droplet A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? Auscultate lung sounds Measure urine output Monitor blood pressure readings Monitor electrolyte levels - ANSWER Measure urine output 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? "Most people are happy when their children grow up and leave home" "You should be proud that your children are becoming independent" "Maybe you should consider why you are feeling useless" "People in middle adulthood often find satisfaction in nurturing and guiding young people" - ANSWER "People in middle adulthood often find satisfaction in nurturing and guiding young people" 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? (select all that apply) Check the cord routinely for frays or tearing Keep the unit at least 1-2 m (4 feet) away from a gas stove Consider purchasing a generator for power backup Observe for signs of hypoxia Select synthetic clothing and bedding - ANSWER Check the cord routinely for frays or tearing Keep the unit at least 1-2 m (4 feet) away from a gas stove

Observe for signs of hypoxia 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? Use a resuscitation bag with 80% oxygen prior to the procedure Select a suction catheter that is half the size of the lumen Place the end of the suction catheter in water soluble lubricant Adjust the wall suction apparatus to a pressure of 170 mmHg - ANSWER Select 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? Instruct the family to refrain from pushing the button for the client while she is asleep Inform the client that because she is on PCA, vital signs will be taken every 8 hours Teach the client to avoid pushing the button until the pain is above 7 on a scale of 0 to 10 Increase the basal rate and shorten the lock out interval time if the client's pain level is too high - ANSWER Instruct the family to refrain from pushing the button for the client while she is asleep 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? Wrap blankets around all 4 sides of the bed Apply restraints during seizure activity Place the client in a supine position during seizure activity Have a tongue depressor at the client's bedside - ANSWER Wrap blankets around all 4 sides of the bed A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manage intervene due to a violation of HIPPAA guidelines? A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse A nurse asks a nurse from another unit to assist with documentation for a client A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care

A nurse discusses a client's status with the physical therapist who is caring for the client - ANSWER A nurse asks a nurse from another unit to assist with documentation for a client A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficle infection. Which of the following information should the nurse include in the teaching? Assign the client to a room with a negative airflow system Use alcohol based hand sanitizer when leaving the client's room Clean contaminated surfaces in the client's room with a phenol solution Have family members wear a gown and gloves when visiting - ANSWER Have family members wear a gown and gloves when visiting 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? Gently shake the container of medication prior to administration Transfer the medication to a medicine cup Place the client in a semi fowler's position prior to medication administration Verify the dosage by measuring the liquid before administering it - ANSWER Gently shake the container of medication prior to administration A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? Place the client in high fowler's position Increase the client's intake of carbohydrates Massage reddened areas with unscented lotion Have the client use a trapeze bar when changing position - ANSWER Have the client use a trapeze bar when changing position A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate? Ambulating a client who is postoperative Inserting an indwelling urinary catheter for a client Demonstrating the use of an incentive spirometer to a client

Confirming that a client's pain has decreased after receiving an analgesic - ANSWER Ambulating a client who is postoperative A nurse is an acute care facility 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? Client flow sheet Acuity ratings Current medications Incident reports - ANSWER Current medications 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? "What could I have done to deserve this illness?" "I blame medical science for not curing me" "Where is my daughter at a time like this?" "Will I ever begin to fell in charge of my life again?" - ANSWER "What could I have done to deserve this illness?" A nurse is calculating a client's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client's intake and output record as 120 ml of fluid? 2 cups of soup 1 quart of water 8 oz of ice chips 6 oz of tea - ANSWER 1 quart of water A nurse is planning teaching for a group of adolescents who each recently had a surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? Role play Group discussions Question-answer meetings Practice sessions - ANSWER Practice sessions

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mmHg. Which of the following is the measurement in mmHg to which the nurse should inflate the cuff when obtaining blood pressure? 92 mmHg 102 mmHg 122 mmHg 140mmHg - ANSWER 122 mmHg 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? Assign a staff member to feel the client Provide small handheld utensils for the client Thicken liquids on the client's tray Arrange food in a consistent pattern on the client's plate - ANSWER Arrange food in a consistent pattern on the client's plate 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? "We can talk about advance directives, and I can also give you some brochures about them" "You should set up a time to talk with your provider about that" "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" "Why do you want to discuss this without your partner here to plan this with you?" - ANSWER "We can talk about advance directives, and I can also give you some brochures about them" 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? Insert an implanted port Close a laceration with sutures Place an endotracheal tube

Initiate an enteral feeding through a gastrostomy tube - ANSWER Initiate an enteral feeding through a gastrostomy tube 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? Hypotension Weak, thready pulse Slow capillary refill Distended neck veins - ANSWER Distended neck veins A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Ensure sterilization of nondisposable items with ethylene oxide Wrap monitoring cords with stockinette and tape them in place Cleanse latex ports on IV tubing with chlorhexidine before injecting medication Wear hypoallergenic latex gloves that contain powder - ANSWER Wrap monitoring cords with stockinette and tape them in place 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? A client who has a history of physical abuse A client who has a permanent pacemaker A client who has ulcerative colitis A client who has asthma - ANSWER A client who has asthma 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? Gown N95 respirator Shoe covers

Surgical cap - ANSWER N95 respirator A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units on NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle Inject 10 units of air into the bottle of NPH insulin Withdraw the correct dose of NPH insulin from the bottle - ANSWER 1. Inject 10 units of air into the bottle of NPH insulin

2. Inject 5 units of air into the bottle of regular insulin
3. Withdraw the correct dose of regular insulin from the bottle
4. Withdraw the correct dose of NPH insulin from the bottle A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? Erythema on pressure points Lower extremity pulse strength of 2+ Fluid intake of 3,000 ml per day One bowel movement every other day - ANSWER Erythema on pressure points 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? The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field The new licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring The sterile field is positioned at the level of the newly licensed nurse's waist - ANSWER The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field 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?

"I'll get a blood sample from you and send it for a screening test" "Beginning at age 60, you should have a colonoscopy" "You should have a fecal occult blood test every year" "The recommendation is to have a sigmoidoscopy every 10 years" - ANSWER "You should have a fecal occult blood test every year" 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? "I can take echinacea to improve my immune system" "I can take feverfew to reduce my level of anxiety" "I can take ginger to improve my memory" "I can take ginkgo biloba to relieve nausea" - ANSWER "I can take echinacea to improve my immune system" A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? Urine has an unusual odor Urine specific gravity is 1. Bladder scan shows 535 ml of urine Urine is positive for ketones - ANSWER Bladder scan shows 535 ml of urine 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? Admitting diagnosis Breath sounds Body temperature Diagnostic test results - ANSWER Breath sounds 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?

The caregiver is the client's financial power of attorney The client is in a wheelchair with the wheels locked The client reports receiving a full bath twice each week The caregiver insists on remaining in the room - ANSWER The caregiver insists on remaining in the room A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears a "bruit". This sound indicates which of the following? Narrowed arterial lumen Distended jugular veins Impaired ventricular contraction Asynchronous closure of the aortic and pulmonic valves - ANSWER Narrowed arterial lumen 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 or veracity? A client who is unaware of her cancer diagnosis asks the nurse if she has cancer and the nurse responds affirmatively A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes A client who has a DNR order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer - ANSWER A client who is unaware of her cancer diagnosis asks the nurse if she has cancer and the nurse responds affirmatively A community health nurse is checking blood pressures for a group of clients at community health screening. Which of the following clients is at an increased risk for hypertension? A client who is 52 years old A client who smokes 1 pack of cigarettes a day A client who walks for 30 min every day A client who drinks 1 glass of wine 3 times per week - ANSWER A client who smokes 1 pack of cigarettes a day

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? The tube aspirate has a pH of 7 An x ray shows the end of the tube above the pylorus Bowel sounds are present on auscultation The client reports relief of nausea - ANSWER An x ray shows the end of the tube above the pylorus A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? Touch the face with a cotton ball Apply a vibrating tuning fork to the client's forehead Have the client stand with their arms at their sides and their feet together Perform direct percussion over the area of the kidneys - ANSWER Have the client stand with their arms at their sides and their feet together 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? Walking briskly Riding a bike Performing isometric exercises Engaging in high impact aerobics - ANSWER Walking briskly A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply Place the client in a room with negative pressure airflow Wear gloves when assisting the client with oral care Limit each visitor to 2 hour increments Wear a surgical mask when providing client care Use antimicrobial sanitizer for hand hygiene - ANSWER Place the client in a room with negative pressure airflow Wear gloves when assisting the client with oral care

Use antimicrobial sanitizer for hand hygiene A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? Place a pillow under the client's knees Position a trochanter roll under each of the client's hips Advise the client to wear rubber soled slippers Apply an ankle foot orthotic device to the client's feet - ANSWER Apply an ankle foot orthotic device to the client's feet A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? Dissolve each mediation in 5 ml of sterile water Draw up medications together in the syringe Push the syringe plunger gently when feeling resistance Flush the tube with 15 ml of sterile water - ANSWER Flush the tube with 15 ml of sterile water A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? "Drink a cup of hot cocoa before bedtime" "Maintain a consistent time to wake up each day" "Exercise 1 hour before going to bed" "Watch a television program in bed before going to sleep" - ANSWER "Maintain a consistent time to wake up each day" A nurse is caring for a client who requires a 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I had a bowel movement, but I was able to save the urine" "I have a specimen in the bathroom for about 30 min ago" "I flushed what I urinated at 7 am, and have saved all urine since"

"I drank a lot, so I will fill up the bottle and complete the test quickly" - ANSWER "I flushed what I urinated at 7 am, and have saved all urine since" 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? Rock the client up to a standing position Pivot on the foot that is the farthest from the chair Assess the client for orthostatic hypotension Apply a gait belt to the client - ANSWER Assess the client for orthostatic hypotension 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? Remove the outer cannula cautiously for routine cleaning Use tracheostomy covers when outdoors Use sterile techniques when performing tracheostomy care at home Cleanse irritated skin with full-strength hydrogen peroxide - ANSWER Use tracheostomy covers when outdoors A home health nurse is performing a follow up visit for a client who as 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? The client is receiving formula at room temperature The feedings infuse at a slow, continuous drip over 8 hour each night The client's caregiver washes out the feedings bag with warm water once every 24 hours The client's caregiver flushes the tubing with water before and after administering medications - ANSWER The client's caregiver washes out the feedings bag with warm water once every 24 hours 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 am not sure I want to retire." Which of the following responses should the nurse make? "You would have so much more time to spend with your family" "You should consider getting a part time job or doing volunteer work"

"Let's talk about how the change in your job status will affect you" "Why wouldn't you want to retire and relax?" - ANSWER "You should consider getting a part time job or doing volunteer work" 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? "Is your pain constant or intermittent" "What would you rate your pain on a scale of 0 to 10?" "Does the pain radiate?" "Is your pain sharp or dull?" - ANSWER "Is your pain sharp or dull?" 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 and grief Reassure the client that this is an expected response to grief - ANSWER Reassure the client that this is an expected response to grief A nurse is on a medical surgical unit caringterm-66 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 hours after application Remove the restraints every 4 hours to evaluate the client's status Secure the restraint to the bed side rails - ANSWER Pad the client's wrist before applying the restraints 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 - ANSWER The client identifies the location of a fire extinguisher 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? Insert the suction catheter while the client is swallowing Apply intermittent suction when withdrawing the catheter Place catheter in a location that is clean and dry for later use Hold the suction catheter with her clean, nondominant hand - ANSWER Apply intermittent suction when withdrawing the catheter A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? Administer the medication with the needle at a 45 angle Administer the medication in the client's nondominant arm Pull the client's skin laterally or downward prior to administration Massage the injection site after administration - ANSWER Administer the medication with the needle at a 45 angle A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? Advocacy ensures client's safety, health, and rights Advocacy ensures that nurses are able to explain their own actions Advocacy ensures that nurses follow through on their promises to client's Advocacy ensures fairness in client care delivery and use of resources - ANSWER Advocacy ensures client's safety, health, and rights A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? Press gently on the tragus of the client's ear Pack a small piece of cotton deep into the client's ear canal Move the client's auricle down and back toward her head

Tilt the client's head backward for 5 minutes - ANSWER Press gently on the tragus of the client's ear 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 one soft wrist restraint Dim the lights in the client's room - ANSWER Use a bed exit alarm system A nurse is initiating a protective environment for a client who has an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the client's room has at least 6 air exchanges per hour Make sure the client wears a mask when outside her room if there is construction in the area Place the client in a private room with negative pressure air flow Wear an N95 respirator when giving the client direct care - ANSWER Make sure the client wears a mask when outside her room if there is construction in the area 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 area 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 for a new one" - ANSWER "I will hire someone to trim the area that hangs low over the stairs of my front porch" 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 - ANSWER Use the planning step of the nursing process to prioritize client care delivery 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 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 - ANSWER Place the client's arm in a dependent position A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (select all that apply Assist the client with a partial bed bath Measure the client's BP after the nurse administers an antihypertensive medication Test the client's swallowing ability by providing thickened liquids Use a communication board to ask what the client wants for lunch Irrigate the client's indwelling urinary catheter - ANSWER Assist the client with a partial bed bath Measure the client's BP after the nurse administers an antihypertensive medication Use a communication board to ask what the client wants for lunch 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 a skin malignancy? A lesion with uniform pigmentation New appearance of petechiae A mole with an asymmetrical appearance The presence of a papule - ANSWER A mole with an asymmetrical appearance A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? Numbness of the extremities

Bradycardia Positive chvostek's sign Abdominal cramping - ANSWER Abdominal cramping 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, and recommendation (SBAR) Transfer report Medication administration record (MAR) - ANSWER Situation, background, assessment, and recommendation (SBAR) 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 - ANSWER During the admission process 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 emergency department and 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 trough 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" - ANSWER "We would give you oxygen trough a tube in your nose" A nurse is caring for a client who requires a 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 to 30 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 - ANSWER Have the client take sips of water to promote insertion of the NG tube into the esophagus A nurse is auscultating the anterior chest of a client who was newly admitted to a medical surgical unit. What is it called when it sounds like blowing as air moves through the larger airways on inspiration and expiration? Friction rub Normal breath sounds Crackles Rhonchi - ANSWER Normal breath sounds 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. Wash the client's body Obtain the pronouncement of death from the provider Ask the client's family members if they would like to view the body Remove tubes and indwelling lines Place a name tag on the body - ANSWER 1. Obtain the pronouncement of death from the provider

2. Remove tubes and indwelling lines
3. Wash the client's body
4. Ask the client's family members if they would like to view the body
5. Place a name tag on the body A nurse is providing discharge teaching to a client about self administering heparin. Which of the following instructions should the nurse include in the teaching? Insert the needle at 15 angle Aspirate for blood return prior to administration Administer the medication into the abdomen

Massage the site following the injection - ANSWER Administer the medication into the abdomen A nurse is caring for a client who asks about the purpose of advance directive. 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" - ANSWER "They indicate the form of treatment a client is willing to accept in the event of a serious illness" A new is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply) Lacrimal apparatus Pupil clarity Appearance of bulbar conjuctivae Visual fields Visual acuity - ANSWER Pupil clarity Visual fields Visual acuity A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as a indication that the client has developed thrombophlebitis? Bladder distention Decreased blood pressure Calf swelling Diminished bowel sounds - ANSWER Calf swelling 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 in hematocrit Increase in respiratory rate Decrease in heart rate Decrease in capillary refill time - ANSWER Decrease in heart rate A nurse is reviewing evidenced 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 then 6 L/min Make sure the reservoir bag of a partial rebreathing mask remains deflated Use petroleum jelly to lubricate the clients nares, face, and lips - ANSWER Regulate oxygen via nasal cannula at a flow rate of no more then 6 L/min A nurse is responding a call light and 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 - ANSWER Check the client for injuries A nurse is caring for a client who has a 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 nurse Tell the patents 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 - ANSWER Examine personal values about the nurse A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hours Administer an antiemetic every 6 hours Hold oral care Increase the room's temperature - ANSWER Turn the client every 2 hours A nurse is assessing a client's readiness to learn about insulin self administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? "I can concentrate best in the morning" "It is difficult to read the instructions because my glasses are at home" "I'm wondering why I need to learn this" "You will have to talk to my wife about this" - ANSWER "I can concentrate best in the morning" A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 ml/hour. When the nurse performs the initial assessment, he notes that the client has received only 80 ml over the last 2 hours. Which of the following actions should the nurse take first? Reposition the client Document the client's IV intake in the medical record Request a new IV fluid prescription Check the IV tubing for obstruction - ANSWER Check the IV tubing for obstruction 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 medications Lock the remaining mediation in the controlled substance cabinet Dispose the vial with the remaining medication in a sharps container - ANSWER Ask another nurse to observe the medication wastage A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? Carry a client's soiled linens out of the room in a mesh linen bad