A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the
... [Show More] dressing material?
A. Discard the dressing in the bedside trash receptacle.
B. Dispose of the dressing in a biohazardous waste container.
C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle.
B. Dispose of the dressing in a biohazardous waste container.
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements should the nurse report to the provider?
A. "I drink at least 2 quarts of fluid every day."
B. "The last time I voided it was painful and red-tinged."
C. "My period ended 2 days ago."
D. "I don't eat shellfish because it gives me hives."
D. "I don't eat shellfish because it gives me hives."
A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
CALCULATION
125 mL/hr
A nurse working for a home agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
A. Swollen gums
B. Pruritus
C. Urinary Hesitancy
D. Dysphagia
D. Dysphagia
A nurse is going to give a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)
BMI of 20
Recent long flight
Hypertension
High calcium intake
Immobility
Flights
Immobility
A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?
A. Determine the pH of the gastric secretions.
B. Supply nutrients via tube feedings.
C. Decompress the stomach.
D. Administer medications.
C. Decompress the stomach.
A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.)
The shoulders droop.
The facial muscles relax.
The respiratory rate increases.
The pulse is within the expected range.
The client draws his legs up into a fetal position.
The shoulders droop.
The facial muscles relax.
The pulse is within the expected range.
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?
A. Fatigue
B. Hypertension
C. Bradycardia
D. Diarrhea
A. Fatigue
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
A. pH below 7.35
B. HCO3 above 26 mEq/L
C. PaO2 below 70 mmHg
D. PaCO2 above 45 mmHg
A. pH below 7.35
A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.)
Provide skin care with a moisture barrier cream.
Administer artificial tear PRN.
Obtain vital signs every 2 hr.
Perform mouth care every hour.
Administer oxygen 2L/min via nasal cannula.
Provide skin care with a moisture barrier cream.
Administer artificial tear PRN.
Perform mouth care every hour.
Administer oxygen 2L/min via nasal cannula.
A nurse is planning care for a client who is postoperative and at risk of paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?
A. Increase ambulation.
B. Decrease fluid intake.
C. Increase protein intake.
D. Offer the client the bedpan every 2 hr.
A. Increase ambulation.
A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last?
A. Mask
B. Gloves
C. Gown
D. Goggles
A. Mask
A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?
A. "I will tie restraints in double knots."
B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved."
C. "I will ensure that restraints fit tightly against the client."
D. "I will put four side rails up if a client is confused."
B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved."
A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
A. "If you wear gloves, you do not have to wash your hands."
B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
C. "Use an alcohol rub when your hands are visibly soiled."
D. "If you don't have an infection, your hands won't infect others."
B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).
Notify the provider immediately if mucus is present in the urine.
Maintain the client on a fluid restriction.
Apply skin barrier around the stoma site.
Educate the client that hematuria is expected following the procedure.
Monitor hourly urine output.
Apply skin barrier around the stoma site.
Educate the client that hematuria is expected following the procedure.
Monitor hourly urine output.
A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?
A. Contact
B. Droplet
C. Protective
D. Airborne
D. Airborne
A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?
A. Assuring the current health status of the client.
B. Explaining the operative procedure, risks, and benefits.
C. Reviewing preoperative laboratory test results.
D. Ensuring that a signed surgical consent was completed.
B. Explaining the operative procedure, risks, and benefits.
A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan?
A. Vital sign management
B. The client's self-report of pain intensity.
C. Visual observation for nonverbal signs of pain.
D. The nature and invasiveness of the surgical procedure.
B. The client's self-report of pain intensity.
A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?
A. Measuring vital signs.
B. Removing the abdominal dressing.
C. Helping the client into the shower.
D. Ambulating the client in the hallway.
B. Removing the abdominal dressing.
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mmHg, and temperature 36.8ºC (98.2ºF). Which of the following actions should the nurse perform?
A. Complete a neurological check.
B. Administer the prescribed PRN antihypertensive medication.
C. Increase the client's fluid intake.
D. Hold the client's evening dose of digoxin.
A. Complete a neurological check.
A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?
A. Emphasize four important points at each session.
B. Use a passive voice to explain the information.
C. Refer to the client in the third person during the session.
D. Have short teaching sessions.
D. Have short teaching sessions.
A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?
A. The client had an appendectomy 6 months ago.
B. The client has bipolar disorder.
C. The client is a male.
D. The client is 71 years old.
D. The client is 71 years old.
A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Assist the client to cough and deep breathe every hour.
Administer PRN analgesics as needed.
Encourage the client to turn every 4 hr.
Give the client a back massage.
Teach the client relaxation techniques.
Assist the client to cough and deep breathe every hour.
Administer PRN analgesics as needed.
Give the client a back massage.
Teach the client relaxation techniques.
A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving?
A. "I know that I will get a kidney transplant. I am a good candidate."
B. "I can now eat whatever I want. The dialysis will remove it from my system."
C. "I just can't believe that this dialysis is going to ruin my whole life."
D. "I know that kidney disease runs in my family, but I can prevent it."
C. "I just can't believe that this dialysis is going to ruin my whole life."
A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
A. Check the client's medical record for the provider's prescription.
B. Explain to the client that the provider prescribed the procedure.
C. Assure the client that enemas are commonly prescribed for constipation.
D. Inform the charge nurse that the client refused the enema.
A. Check the client's medical record for the provider's prescription.
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
A. Pain
B. Hearing loss
C. The client's culture
D. Motor impairment
A. Pain
A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
A. Reposition the client every 3 hr.
B. Massage bony prominences to promote circulation.
C. Provide the client with a diet high in protein.
D. Apply cornstarch to keep the skin dry.
C. Provide the client with a diet high in protein.
A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test (FOBT) and a colonoscopy at which of the following intervals?
A. Five years
B. Ten years
C. One year
D. Two years
B. Ten years
A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
A. "Don't worry, most clients dislike the prep more than the procedure itself."
B. "Before the examination, your provider will give you a sedative that will make you sleepy."
C. "I know you're anxious, but this procedure is recommended for people your age."
D. "After you have signed the consent form, we can talk more about this."
B. "Before the examination, your provider will give you a sedative that will make you sleepy." [Show Less]