A nurse is teaching a client with lower extremity weakness how to use a 4-point
crutch gait. Which of the following instructions should the nurse include
... [Show More] in the
teaching?
A. "Support the majority of your weight on the axillae."
B. "Keep your elbows extended."
C. "Bear weight on both of your legs."
D. "Move both crutches forward at the same time."
- C. "Bear weight on both of your legs."
A nurse is monitoring a client's laboratory results. Which of the following results
should the nurse report to the provider?
A. Sodium 140 mEq/L
B. Potassium 3.0 mEq/L
C. Chloride 100 mEq/L
D. Magnesium 2.0 mEq/L
- B. Potassium 3.0 mEq/L
A nurse is preparing a sterile field for a procedure the provider will perform at the
client's bedside. Which of the following actions should the nurse take?
A. Hold the sterile drape above the waist and away from the body
B. Drop sterile objects toward the edges of the sterile field
C. Hold packaged supplies 7.6 (3 in) above the sterile field
D. Hold sterile objects over the field before setting them down on the field
- A. Hold the sterile drape above the waist and away from the body
A client has 1L of dextrose 5% in 0.45% sodium chloride infusion IV at 125
mL/hr. How many hours will it take for the liter to infuse? (Fill in the blank with
the numeric value only and round to the nearest whole number.) - 8
A nurse is performing a breast examination for a female client. Which of the
following techniques should the nurse use first?
A. Inspect both breasts simultaneously
B. Squeeze the nipples
C. Palpate the breast and tail of SpenceD. Palpate the axillary lymph nodes
- A. Inspect both breasts simultaneously
A nurse is caring for a client who is exhibiting confusion. The nurse should
identify that which of the following laboratory values can cause confusion?
A. Sodium 123 mEq/L
B. Blood Glucose 100 mg/dL
C. Potassium 3.5 mEq/L
D. Hemoglobin 13 g/dL - A. Sodium 123 mEq/L
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 not whether it springs
back
B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it
springs back
C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the
impression
D. Measure the skinfold thickness on the upper arm using a pair of calibrated
skinfold calipers - B. Grasp a skin fold on the chest under the clavicle, release it,
and note whether it springs back
A nurse in the emergency department is caring for a client who has abdominal
trauma. Which of the following assessment findings should the nurse identify as an
indication of hypovolemic shock?
A. Warm, dry skin
B. Increased urinary output
C. Tachycardia
D. Bradypnea - C. Tachycardia
A nurse is planning care for a client who has a wound infection following
abdominal surgery. To promote healing and fight infection, which of the following
vitamins and minerals should the nurse plan to increase in the client's diet?
A. Vitamin C and zinc
B. Vitamin DC. Vitamin K and iron
D. Calcium - A. Vitamin C and zinc
A nurse is reviewing the laboratory data of a client who has a fever and watery
diarrhea. Which of the following results should the nurse report to the provider?
A. Calcium 9.5 mg/dL
B. Sodium 150 mEq/L
C. Potassium 4 mEq/L
D. Magnesium 1.5 mEq/L - B. Sodium 150 mEq/L
During the insertion of a urinary catheter for a client, the tip of the catheter brushes
against the nurse's arm. Which of the following actions should the nurse take?
A. Wipe the catheter with povidone-iodine and continue the catheter insertion
B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion
C. Continue with the catheter insertion
D. Obtain a new catheter and reattempt insertion - D. Obtain a new catheter and
reattempt insertion
A nurse is caring for a client who has chronic kidney disease. The kidneys regulate
body fluids as well as assisting with which of the following functions?
A. Regulation of acid-base balance
B. Reabsorption of nutrients for cellular growth
C. Regulation of body temperature
D. Secretion of hormones needed for growth - A. Regulation of acid-base balance
A nurse is caring for an adult client who has an NG tube in place and a prescription
for continuous enteral feedings. Which of the following actions should the nurse
perform to reduce the client's risk of aspiration?
A. Irrigate the tubing with 30 mL of sterile water
B. Elevate the head of the bed to 30 or 45 degrees
C. Suggest changing the feeding to lactose-free formula
D. Warm the enteral formula to room temperature before feeding - B. Elevate the
head of the bed to 30 or 45 degreesA nurse on a medical unit is caring for a client who has difficulty sleeping. Which
of the following actions should the nurse take to promote the client's ability to fall
asleep?
A. Encourage the client to ambulate in the hallway just before bedtime
B. Allow the client to maintain the same bedtime routine as at home
C. Keep the room temperature warm
D. Offer the client a cup of how chocolate before bedtime - B. Allow the client to
maintain the same bedtime routine as at home
A nurse is planning care for a group of clients receiving oxygen therapy. Which of
the following clients should the nurse plan to see first?
A. A client who has heart failure and is receiving 100% oxygen via partial
rebreather mask
B. A client who has emphysema and is receiving oxygen at 3L/min via
transtracheal oxygen cannula
C. A client who has an old tracheostomy and is receiving 40% humidified oxygen
via tracheostomy collar
D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula -
A. A client who has heart failure and is receiving 100% oxygen via partial
rebreather mask
A nurse is caring for a group of clients in a long-term care facility. One of the
clients is walking along the hallway and bumping into walls and does not respond
to his name. Which of the following actions should the nurse take first?
A. Offer the client a nutritious snack
B. Accompany the client back to his room
C. Reorient the client to his surroundings
D. Administer a PRN antianxiety medication - B. Accompany the client back to his
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