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A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and dias... tole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible Click B. Murmur C. Third heart sound D. Pericardial friction rub - ✔✔D) Pericardial friction rub A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following action should the nurse take? A. Auscultate for the blood presure at the dorsalis pedis artery. B. Measure the blood pressure with the client sitting on the side of the bed. C. Place the cuff 7.6cm (3in) above the popliteal artery. D. Place the bladder of the cuff over the posterior aspect of the thigh. - ✔✔D) place the bladder of the cuff over the posterior aspect of the thigh A charge nurse is teaching adult cardiopulmonary resusciation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assisstance B. Begin Chest compressions C. Confirm unresponsiveness. D. Give rescue breaths. - ✔✔C) Confirm unresponsiveness A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? A. Explain the x-ray procedure to the client. B. Help the client into a wheelchair before the transporter arrives. C. Ask if the client has any questions. D. Identify the client using two identifiers. - ✔✔D) Identify the client using to identifiers A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia. B. Place a heating pad at the child's neck for comfort. C. Administer analgesics to the child on a routine schedule throughout the day and night. D. Provide the child with ice cream when oral intake is initiated. - ✔✔C) Administer analgesics to the child on a routine schedule throughout the day and night A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the client in planning the change. B. The emphasis the provider places on the dietary changes. C. The learning theory the nurse uses to teach the dietary changes. D. The extent of the dietary changes planned for the client. - ✔✔A) The involvement of the client in planning the change A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for the trachesotomy care. B. Obtainging cotton balls for the tracheostomy care. C. Obtaining sterile gloves for the tracheostomy care. D. Obtaining a sterile brush for the tracheostomy care. - ✔✔B) Obtaining cotton balls for the tracheostomy A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep. - ✔✔C) Raise the level of the bed A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A. The client fully understands the provider's explannation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanantion of the procedure. D. The signature on the preoperative consent form is the client's. - ✔✔D) The signature on the pre-operative consent form is the clients A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Don sterile gloves D. Perform hand hygiene - ✔✔D) Perform hand hygiene A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse .make? A.It's for your safety. Dentures can slip and block your airway during surgery. B. You wouldn't want your teeth to be lost or broken during surgery, would you? C. The anesthesiologist requires everyone to remove their dentures. D. What worries you about being without your teeth? - ✔✔D) What worries you about being without your teeth? A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. My parents are retired, and they have come to help out with our children. B. I am going to ask my husband to go to counseling with me. C. I keep having nightmares about my upcoming surgery. D. My girlfriends bought me a nice wig. - ✔✔C) I keep having nightmares about my upcoming surgery A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? A. Identify goals for client care. B. Obtain client information. C. Document nursing care needs. D. Evaluate the effectivness of nurse care. - ✔✔B) Obtain client information A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails. B. Perform range-of-motion exercises to the wrists every 3 hrs. C. Remove the restraints one at a time. D. Obtain a PRN prescription for the restraints. - ✔✔C) Remove the restraints one at a time A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 (102.6 F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority. A. Heart rate 105/min B. soft, nontender abdomen C. temperature D. overdue menses - ✔✔C) Temperature A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carfefully remove the gloves and follow with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection. - ✔✔C) Carefully remove the gloves and follow with hand hygiene A nurse is caring for a client who is postoperative and has parlytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus. B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea. D. Normal bowel sounds with increased peristalsis. - ✔✔B) Absent Val sounds with distention A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I am sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections." - ✔✔A) Tell me what I can do to help you overcome your fear of giving yourself injections A nurse is recieving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse make to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5cm (1in) above the height of the bed. D. Log roll the client. - ✔✔A) lock the wheels on the bed and stretcher A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask them to stay with the client. B. Offer to call client's minister. C. Sit and hold the client's hand. D. Leave the room and allow the client to cry privately. - ✔✔C) Sit and hold the clients hand A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skinfold on chest under clavicle, release, and note whether is springs back. C. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. D. Measure the skin fold thickness at the upper arm using a pair of calbrated skinfold calipers. - ✔✔B) Grasp a skinfold on chest under clavicle, release, and note whether it's springs back. A nurse is caring for a client who has terminal illness. The client asks several questions about the nurse's religion beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse. B. Encourage the client to express his thoughts about death and dying. C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain. - ✔✔B) Encourage the client to express his thoughts about death and dying A nurse is caring for a client who is unstable and has vital signs measured every 15 min by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only blood pressure readings needed for the 15-min intervals. C. Obtain manural and automatic readings and compare them/. D. Disconnect the machine, and measure the blood pressure manually every 15 min. - ✔✔D) Disconnect the machine, and measure the blood pressure manually every 15 min A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45degree angle to the bed. D. Assume a narrow stance with feet 15 cm (6in) apart. - ✔✔C) Place a wheelchair at 45° angle to the bed Place in order: Inspection Palpation Percussion Auscultation - ✔✔Inspection, Auscultation, Palpation, Percussion A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room, when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider about the client's decision. - ✔✔D) Notify the provider about the clients decision A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? A. The nurse washes each part of her hands with 5 strokes. B. The nurse washes from the elbows down to the hands. C. the nurse washes with her hands held higher then her elbows. D. The nurse uses minimal friction when washing her hands. - ✔✔C) The nurse washes her hands held higher than her elbow A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should ask your provider about taking iron supplements prior to the surgery." C. Request a family member to donate blood for you." D. "Donate autologous blood before the surgery. - ✔✔D) donate autologous blood before the surgery A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands I will dry them from the elbows down." - ✔✔A) There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope. B. Check the client's pedal pulses. C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds. - ✔✔C) Count the apical pulse rate for one full minute and describe the written in the chart A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. As long as the cuff will circle the arm the reading will be accurate. D. "Using a cuff that is too small will result in an inaccurately high reading." - ✔✔D) Using a cuff that is too small will result in an inaccurately high rating A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercise. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery. - ✔✔B) The client reports severe A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching. A. "Drink a min. of 1,000 mL of fluid daily." B. "Increase your intake of refined-fiber foods" C. "Sit on the toilet 30 min after eating a meal. D. "Take a laxative every day to maintain regularity." - ✔✔C) Sit on the toilet 30 minutes after eating a meal A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal - ✔✔D) Temporal A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention. A. Holding a community clinic to adminster influenza immunizations. B. Screening groups of older adults in nursing care facilites for early influenza manifestations. C. Educating parents of young children about dangers of influenza. D. Finding rehabilitation programs for older adults who have complications from influenza. - ✔✔B) Screening groups of older adults and nursing care facilities for early influencer manifestations A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses. B. Obtain a medical history. C. Measure vital signs. D. Assess for leg pain. - ✔✔A) evaluate pedal pulses A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? A. Assessment B. Plan of care C. Nursing interventions performed. D. Evaulation of progress. - ✔✔A) Assessment A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older." - ✔✔A) I should expect my heart rate to take longer to return to normal after exercise as I get older A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? A. Attempt to increase the client's self motivation B. Keep detailed records of each client's progress. C. Test client learning after each teaching session. D. Avoid discussing areas that might cause client anxiety. - ✔✔A) Attempt to increase the clients self motivation A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethescope to auscultate the aortic valve? A. Fifth intercostal space just medical to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum. - ✔✔D) Second intercostal space to the right of the sternum A nurse is discussing restorative Health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply). A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - ✔✔A B D A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following healthcare financing mechanisms are federally funded? (Select all that apply). A. Preferred provider organization (PPO) B. Medicare C. Long term care insurance D. Exclusive provider organization (EPO) E. Medicaid - ✔✔B E A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary healthcare strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. Educating acute care nurses on post operative complications related to obesity - ✔✔A A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as a responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that healthcare providers comply with regulations C. Setting quality standards for accreditation of healthcare facilities D. Determining if medications are safe for administration to clients - ✔✔B A nurse is explaining the various levels of healthcare services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary? (Select all that apply) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home healthcare - ✔✔A B C A nurse is caring for a group of clients on a medical surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply) A. A client who has terminal cancer requests hospice care in her home B. A client asks about community resources available for older adults C. A client states that she wants her child baptized before surgery D. A client requests an electric wheelchair for use after discharge E. A client states that he does not understand how to use a nebulizer - ✔✔A B D A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist - ✔✔D A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medications affects? (Select all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist - ✔✔A C D A client who has had a CVA (cerebrovascular accident) has persistent problems with dysphasia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional team? A. Social worker B. Certified nursing assistant C. Occupational therapist [Show More]

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