ATI Fundamentals Proctored 2020. (GRADED 100%)

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Practice A 1. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does ... that involve?" Which of the following responses should the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "Beginning at age 60, you should have a colonoscopy." C. "You should have a fecal occult blood test every year." D. "The recommendation is to have a sigmoidoscopy every 10 years." C. "You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. One option 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 lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? A. Suction the client's airway B. Administer a bronchodilator C.Increase the humidity in the client's room D. Assist the client to an upright position D. 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 to the semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm 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-Fowler's position prior to medication administration D. Verify the dosage by measuring the liquid before administration A. Gently shake the container of medication prior to administration The nurse should gently shake the liquid medication to ensure the medication is mixed. 4. A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? A. Tell the client which food should 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 D. Use a clock pattern to describe food on the client's plate Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals. 5. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobics A. Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent 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." A. "I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing the best 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 identify as an indication that the client understands how to manage this therapy at home? A. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen. B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen. C. "I'll check the wires and cables on my TV to make sure they are in good working order. D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over. C. "I'll check the wires and cables on my TV to make sure they are in good working order. Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks. The visitors should smoke outside the house. Woolen and synthetic materials can create sparks, so the client should use a cotton blanket during O2 therapy. 8. A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? A. Drink a cup of hot cocoa before bedtime B. Exercise 1 hr before going to bed C. Use progressive relaxation techniques at bedtime D. Reflect on the day's activities before going to bed C. Use progressive relaxation techniques at bedtime Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension. Cocoa contains caffeine, a stimulant, and can interfere with sleep. Exercising within 2 hr of bedtime can interfere with sleep. Reflecting can cause stress and worry, which can interfere with sleep. 9. A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? A. Side-lying B. Supine C. Semi-Fowler's D. Trendelenburg C. Semi-Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows for maximum expansion of the lungs. 10. A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A. Erythema on pressure points B. Lower-extremity pulse strength 2+ C. Fluid intake of 3,000 mL of fluid per day D. A bowel movement every other day A. Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measure to protect the skin from further breakdown A pt should drink 2,500 to 3,000 mL of fluid per day Bowel movement less frequent than three per week indicate constipation and the need for intervention 11.A nurse is caring for a client who require a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushed what I urinated at 7:00 a.m. and have save all urine since." D. "I drink a lot, so I will fill up the bottle and complete the test quickly." C. "I flushed what I urinated at 7:00 a.m. and have save all urine since." The pt should collect urine that is free of feces. The pt should place any urine in the container immediately and keep it on ice or in a refrigerator. The client should discard the first voiding and save all subsequent voidings. There is not specified amount needed for a 24-hour urine collection. 12. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? A. Biofeedback B. Aloe C. Feverfew D. Acupuncture D. Acupuncture Acupuncture is contraindicated for a pt who has herpes zoster (aka shingles), or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk for further infection. Feverfew is contraindicated in pts who are prescribed warfarin or other blood thinners. 13. A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? 1. Ask the client if he can bear weight 2. Position the chair on the left side of the bed 3. Have the client sit and dangle his feet at the bedside 4. Use the stand-and-pivot technique to move the client to the chair 14. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage B. Notify the pharmacy when wasting the medication C. Lock the remaining medication in the controlled substances cabinet D. Dispose of the vial with the remaining medication in a sharps container A. Ask another nurse to observe the medication wastage A second nurse must witness the disposal of any portion of a dose of a controlled substance Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance The nurse should not lock the remaining medication in the cabinet because this is a violation of the Controlled Substances Act The nurse should NOT dispose of the remaining medication in the sharps container because this is a violation of the Controlled Substances Act 15. A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 8 mL/hr 16. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. 1. Inject 10 units of air into the bottle of NPH insulin. CLOUDY. 2. Inject 5 units of air into the bottle of regular insulin. CLEAR. 3. Withdraw the correct dose of regular insulin from the bottle. CLEAR. 4. Withdraw the correct dose of NPH insulin from the bottle. CLOUDY. Cloudy insulin (NPH, Humulin N, Novolin N) should NOT enter clear insulin (regular, Humulin R, Novolin R) Inject air into cloudy, Inject air into clear, Draw up clear, Draw up cloudy ------ Inject 10 units of air into the bottle of NPH insulin. Inject 5 units of air into the bottle of regular insulin. Withdraw the correct dose of regular insulin from the bottle. Withdraw the correct dose of NPH insulin from the bottle. ------ The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin. 17. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? A. Request that a respiratory therapist discuss the technique for incentive spirometry B. Determine the reasons why the client is refusing to use the incentive spirometer C. Document the client's refusal to participate in health restorative activities D. Administer a pain medication to the client B. Determine the reasons why the client is refusing to use the incentive spirometer. Assess first 18. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? A. The medication B. The route C. The dose D. The frequency C. 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 prevent skin breakdown? A. Place the client in high-Fowler's position B. Increase the client's intake of carbohydrates C. Massage reddened areas with unscented lotion D. Have the client use a trapeze bar when changing position D. Have the client use a trapeze bar when changing position By using a trapeze bar to assist with repositioning and transferring, the client avoids 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 in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg B. 0.3 mg 21. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding C. Skin blanching Skin blanching, edema, and coolness and 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 plan to take? A. Dissolve each medication in 5 mL of sterile water B. Draw up medications together in the same syringe C. Push the syringe plunger gently when feeling resistance D. Flush the tube with 15 mL of sterile water D. Flush the tube with 15 mL of sterile water When dissolving medications, the nurse should dissolve each medication in at least 30 mL of warm, sterile water The nurse should draw up medications separately and not mix them together If the nurse encounters resistance when administering medications, he should stop and contact the provider 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 feeding tube 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 has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? A. Allow extra time for the client to respond to questions B. Expect the client to have difficulty understanding the information C. Avoid references to the client's past experiences D. Keep the learning session in private and one-on-one A. Allow extra time for the client to respond to questions Older adult clients often process information at a slower rate than younger clients The nurse SHOULD explore the client's past experiences and use them to establish connections to new knowledge It is helpful when working with older adult clients to invite another household member to the teaching session so that person can help reinforce new information later. The nurse, however, should honor the client's preference. 24. A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist B. When walking, the client moves the cane 46cm (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 C. The client holds the cane on the stronger side of her body. The top of the cane should be parallel to the client's greater trochanter To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time The can should be held on the stronger side of the body to increase support and maintain alignment The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg 25. A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? A. Tomato juice B. Banana slices C. Pancakes D. Fried egg D. Fried egg Soft fruits, such as bananas or cooked fruits, are acceptable for a client who requires a mechanical soft diet Evidence-based practice indicates the nurse should remove the fried eggs from the client'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 the client is willing to accept in the event of serious illness." C. "They permit a client to withhold medical information from health care personnel." D. "They allow health care personnel in the emergency department to stabilize a client's condition." B. "They indicate the form of treatment the client is willing to accept in the event of serious 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 indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds C. Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility. 28. A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "The pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "The pain makes me feel nauseous." B. "The pain is like a dull ache in my stomach." A. describes the severity of the pain B. describes the quality of the the pain C. describes a factor that aggravates the pain 29. A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. Press gently on the tragus of the client's ear B. Pack a small piece of cotton deep into the ear canal C. Move the client's auricle down and back toward her head D. Tilt the client's head back for 5 minutes A. Press gently on the tragus of the client's ear If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward For an adult client, the nurse should move the auricle upward and backward OR upward and outward to straighten the ear canal The client should lie on her side with the ear that received the instillation facing upward for 2 to 5 minutes 30. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? A. "When do you usually bathe, in the morning or in the evening?" B. "Do you prefer a bath or a shower?" C. "At what temperature do you prefer your bath water?" D. "Are you able to help with your hygiene care?" D. "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, the nurse'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 information should the nurse include in the teaching? A. Assign the client to a room with a negative air-flow system B. Use alcohol-based hand sanitizer when leaving the client's room C. Clean contaminated surface in the client's room with a phenol solution D. Have family members wear a gown and gloves when visiting D. Have family members wear a gown and gloves when visiting The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, it does not kill Clostridium difficile spores. 32. A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields C. Visual acuity B. Pupil clarity D. Visual fields C. Visual acuity Cloudy pupils mean that the pt has cataracts, which can increase his risk for falls Visual fields are tested by the use of a finger test by moving it out of range and then back into his visual field to determine when he sees the finger Visual acuity should be assessed using a Snellen chart 33. A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer B. Focus teaching on what the client will need to do in the future to manage his illness C. Provide the client with written information about the phases of loss and grief D. Reassure the client that this is an expected response to grief D. 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 reaction to a cancer diagnosis 34. A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45 degree angle B. Place the client's arm in a dependent position C. Shave excess hair from the insertion site D. Initiate IV therapy in the veins of the hand B. Place the client's arm in a dependent position The nurse should insert the catheter at a 10 to 30 degree angle The nurse should place the pt's arm in a dependent position because the veins will dilate due to gravity The nurse should CLIP excess hair and AVOID shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection The nurse should AVOID using the fragile veins of an older adult's hands because the loss of subcutaneous tissue makes those veins roll away from the needle 35. 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 the object? A. Bend at the waist B. Keep his feet close together C. Use his back muscles for lifting D. Stand close to the cabinet when lifting D. Stand close to the cabinet when lifting 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 situations requires the nurse to complete an incident report? A. A nurse tied a client's restraint straps to the moveable part of the bed frame B. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology C. A nurse administers a medication to a client 30 minutes before the dose is due D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid D. 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 to determine actions to take to prevent further medical incidents 37. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statement should the nurse manager plan to include in the teaching? A. "Use the complete name of the medication magnesium sulfate." B. "Delete the space between the numerical dose and the unit of measure." C. "Write the letter U when noting the dosage of insulin.: D. "Use the abbreviation SC when indicting an injection." A. "Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providers write 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 medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Ensure sterilization of non-disposable items with ethylene oxide B. Wrap monitoring cords with stockinette and tape them in case C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication D. Wear hypoallergenic later gloves that contain powder B. Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a 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 when inserting the NG tube? A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube B. Remove the NG tube if the client begins to gag or choke C. Apply suction to the NG tube prior to insertion D. Have the client take sips of water to promote insertion of the NG tube into the esophagus D. Have the client take sips of water to promote insertion of the NG tube into the esophagus The patient should be sitting in a high-Fowler's position with the head of the bed elevated to 90 degrees to reduce the risk for aspiration The nurse should withdraw the NG tube slightly, not remove it, when the client gags or chokes to reduce the risk of injury to the client Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis 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 large amount of purulent drainage. Which of the following types of transmission precautions should the nurse indicate? A. Protective environment B. Airborne precautions C. Droplet precaution D. Contact precautions D. Contact precautions Clients who have an immune-system compromise require a protective environment Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown and gloves 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 to 40.5 degrees Celsius (105 degrees Fahrenheit) C. Cleanse the wound from the center outward D. Use a 20 mL syringe to irrigate the wound C. Cleanse the wound from the center outward The nurse should clean the wound from the center outward to prevent introduction of microorganisms from the outer skin surface 42. A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A. Apply the stockings so the creases are on the side of the leg B. Apply the stockings while the client's legs are in a dependent position C. Remove the stockings at least once per shift D. Remove the stockings while the client is sitting in a reclining chair C. Remove the stockings at least once per shift The nurse should ensure there are no creases or wrinkles in the stockings to prevent skin irritation and promote venous return The nurse should apply the stockings in the morning before the client gets out of bed because the client's legs are less edematous at that time The nurse should remove the stocking once per shift to check the client's circulation and skin integrity The client should wear the stockings while sitting in the chair to promote venous return. He should also avoid crossing his legs 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 actions should the nurse take first? A. Rinse the feeding bag with water between feedings B. Tell the client to keep the head of the bed elevated at least 30 degrees C. Make sure the enteral formula is at room temperature D. Wipe the top of the formula can with alcohol B. Tell the client to keep the head of the bed elevated at least 30 degrees All of the actions are appropriate; HOWEVER, the first action the nurse should take when using the ABC approach to pt care is to prevent aspiration of the enteral formula. This is done to prevent reflux of the formula backward into the esophagus 44. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care C. Limit each visitor to 2 hr increments D. Wear a surgical mask when providing client care E. Use antimicrobial sanitizer for hand hygiene A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care E. Use antimicrobial sanitizer for hand hygiene The nurse does NOT need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and have him wear a surgical mask when he does leave the room. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions 45. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries B. Move hazardous objects away from the client C. Notify the provider D. Ask the client to describe how she felt prior to the fall A. Check 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 roleperformance stress? A. Role ambiguity B. Sick role C. Role overload D. Role conflict C. Role overload 47. A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A. Auscultate lung sounds B. Measure urine output C. Monitor blood pressure readings C. Monitor serum electrolyte levels A. Auscultate lung sounds All of the actions are appropriate; HOWEVER, the priority assessment the nurse should make when using the ABC approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. ----- 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 volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath. 48. A nurse if performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? A. Narrowed arterial lumen B. Distended jugular veins C. Impaired ventricular contraction D. Asynchronous closure of the aortic and pulmonic valves A. Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries 49. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? A. Neck vein distention B. Urine specific gravity 1.010 C. Rapid heart rate D. Blood pressure 144/82 mmHg C. Rapid heart rate Tachycardia indicated fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days Neck vein distension is a clinical manifestation of fluid-volume excess Typically, a client's urine specific gravity is greater than 1.030 in the presence of fluid-volume deficit Hypotension is an expected finding for a client who has fluid-volume deficit 50. A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "What could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "Where is my daughter at a time like this?" D. "Will I ever begin to feel in charge of my life again?" A. "What could I have done to deserve this illness?" 51. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position B. Instill 15 mL of irrigation fluid into the catheter with each flush C. Subtract the amount of irrigant used from the client's urine output D. Perform the irrigation using a 20 mL syringe C. Subtract the amount of irrigant used from the client's urine output For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter Open irrigation technique requires instilling 30 to 40 mL or irrigation fluid. The nurse should use a 30 to 50 mL syringe to perform open irrigation 52. 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? A. Ask the client to consider a direct donation B. Withhold the blood transfusion C. Request a consultation with the ethics committee D.. Ask the client's family to intervene B. Withhold the blood transfusion 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 the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L D. Potassium 5.4 mEq/L The value is above the expected reference range and the nurse should report this finding. The client is at risk for dysrhythmias. Potassium: 3.5-5 mmol/L 54. A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment A. Airborne Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles Contact precautions are needed for: VRE, MRSA, and scabies Droplet precautions are needed for: rubella, meningococcal pneumonia, mumps, 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 family member is coping effectively with the situation? A. "We are not worried. We still have hope that everything will be okay." B. "This is a difficult time, but we are helping each other through this." C. "After he comes home, we can plan our family reunion." D. "We do not need to talk about funeral arrangements at this time." B. "This is a difficult time, but we are helping each other through this." 56. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A. Insert an implanted port B. Close a laceration with sutures C. Place an endotracheal tube D. Initiate an enteral feeding through a gastrostomy tube D. Initiate an enteral feeding through a gastrostomy tube Nurses can initiate enteral feedings through nasoenteric, gastronomy, and jejunostomy tubes All other activities require a physician or Advanced Practice Nurse (APN) to perform them 57. A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPPA guidelines? A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse B. A nurse asks a nurse from another unit to assist with her documentation C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care D. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside B. A nurse asks a nurse from another unit to assist with her documentation Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of HIPPA guidelines 58. A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A. Use a resuscitation bag with 80% oxygen prior to the procedure B. Select a suction catheter that is half the size of the lumen C. Place the end of the suction catheter in water-soluble lubricant D. Adjust the wall suction apparatus to a pressure of 170 mmHg B. Select a suction catheter that is half the size of the lumen The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa the nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation to decrease trauma to the mucosa The nurse should adjust the suction pressure to approximately 120 mmHg and no higher than 150 mmHg to prevent hypoxemia and trauma to the mucosa. 59. A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? A. Touch the face with a cotton ball B. Apply the vibrating tuning fork to the client's forehead C. Have the client stand with her arms at her side and her feet together D. Perform direct percussion over the area of the kidneys C. 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 the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance. 60. A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A. Critical pathway B. Situation, background, assessment, and recommendation (SBAR) C. Transfer report D. Medication administration record (MAR) B. Situation, background, assessment, and recommendation (SBAR) A critical pathway is an interprofessional approach to planning all phases of client care. The nurse should use a transfer report when the client is moving from one health care area or facility to another The nurse should use the MAR to document medication administration Practice B 1. 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 what?The pain is like a dull ache in my stomach 2. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?Evacuate the client 3. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?rapid heart rate 4. A nurse has accepted a verbal prescription for three tenths of a milligram of Synthroid 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? 0.3 mg 5. A nurse is preparing a heparin infusion. The order reads 25,000 units of heparin in 250mL of 0.9% sodium chloride to infuse at 800units/hr. At what rate should the nurse set the infusion pump? Round to nearest whole number 8 mL/hr 6. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Cleanse the wound from the center outward 7. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? skin blanching 8. 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 stairs, I will first shift my weight to my right leg." 9. 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? Tell the client to keep the head of the bed elevated at least 30° 10. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? medication dose 11. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? "I will be sure to remove my hearing aid before taking a shower." 12. 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 bedrail onto the floor. Which of the following statements should the nurse document about this incident? "client found lying on floor" 13. 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? compare prescription with medications the client received while at the facility 14. 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 witness the client's signature on the consent form 15. 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 receive a pneumococcal vaccine when you are 65 years old" 16. 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? Withhold the blood transfusion 17. A nurse is admitting a client who has rubella. Which of the following types of transmissionbased precautions should the nurse initiate? Droplet 18. 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 19. 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?"People in middle adulthood often find satisfaction in nurturing and guiding young people." 20. 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 give to the client and his family? Select all that apply. Check the cord routinely for frays and tearing Consider purchasing a generator for power backup Monitor for signs of hypoxia 21. A nurse is reviewing protocol in prep for suctioning secretions from a client who has a new tracheostomy. What action should the nurse plan to take?Select a suction catheter that is half the size of the lumen 22. A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?A. Instruct the family to refrain from pushing the button for a client while she is asleep. Instruct the family to refrain from pushing the button for a client while she is asleep. 23. 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 four sides of the bed. 24. A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines? A nurse asks a nurse from another unit to assist with her documentation. 25. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?Have family members wear gown and gloves when visiting. 26. A nurse is preparing to administer 0.5mL of oral single dose liquid medication to a client. What action should the nurse take?Gently shake the container of medication prior to administration 27. 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? Have the client use a trapeze bar when changing position. 28. a nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? ambulating a client who is postoperative (I think) 29. 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? current medications 30. 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?" 31. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? 8 oz of ice chips 32. 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? Practice sessions 33. 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 appropriate mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? 122 34. 35. 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? Arrange food in a consistent pattern on the clients plate 36. 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." 37. 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 scope of RN practice? Initiate an enteral feeding through a gastrostomy tube 38. 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? distended neck veins 39. A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Wrap monitoring cords with stockinette and tape them in place 40. 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 asthma 41. 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? N95 respirator 42. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject air into NPH insulin Inject air into regular insulin Withdraw regular insulin Withdraw NPH insulin 43. A nurse is assessing an adult who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? Erythema on pressure points 44. 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 placed the cap of the bottle of sterile saline solution on the sterile field 45. 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? You should have a fecal occult blood test every year 46. A nurse is discussing the use of herbal supplements for health promotion to a client. Which of the following client statements indicates an understanding of herbal supplement use? I can take echinacea to improve my immune system 47. A nurse is caring for a client who has an in dwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? Bladder scan shows 525 mL of urine 48. 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? Breath sounds 49. 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 insists on remaining in the room 50. A nurse is preforming a peripheral vascular assessment for a client, when placing the bell of the stethoscope on the clients neck, the nurse hears the following sound. This sound indicates which of the following Narrowed arterial lumen 51. A nurse is caring for a group of clients on a medical surgical unit. Which of the following situations does the nurse demonstrate the ethical principle of veracity? A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. 52. 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? A client who smokes one pack of cigarettes each day 53. A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm the correct tube placement? An x-ray shows the end of the tube above the pylorus 54. A nurse is preforming a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? Have the client stand with their arms at their sides and their feet together 55. 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 56. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?  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. 57. 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? Apply an ankle foot orthotic device to the clients feet 58. A nurse is planning to administer multiple medications to a client who has an enteral tube feeding. Which of the following actions should the nurse plan to take? Flush the tube with 15 mL of sterile water 59. A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? Maintain a consistent time to wake up each day 60. A nurse is caring for a client who is receiving 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? I flushed what I urinated at 7:00 am and have saved all urine since 61. A nurse is preparing to transfer a client who can bear weight in one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next? assess the client for orthostatic hypotension 62. [Show More]

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