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. - correct answer 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." - correct answer 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 - correct answer 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 - correct answer 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 - correct answer 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. - correct answer 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. - correct answer 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 - correct answer 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 - correct answer 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. - correct answer 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. - correct answer 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 - correct answer 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." - correct answer 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." - correct answer 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. - correct answer 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 - correct answer 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. - correct answer 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. - correct answer 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. - correct answer 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. - correct answer 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. - correct answer 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. - correct answer 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. - correct answer 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." - correct answer 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 - correct answer 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 - correct answer 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. - correct answer 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 - correct answer 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 - correct answer B. "Before the examination, your provider will give you a sedative that will make you sleepy."
A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?
A. Give the ordered KCL as prescribed.
B. Omit the KCL dose and document that it was not given.
C. Call the prescribing physician and inform her of the client's serum potassium level results.
D. Call the lab to verify the client's - correct answer C. Call the prescribing physician and inform her of the client's serum potassium level results.
A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all the apply.)
The date of the incident
The name of the provider who prescribed the medication
The potential adverse effects of the medication
The time the client was to receive the medication
The client's vital signs - correct answer The date of the incident
The time the client was to receive the medication
The client's vital signs
A client was given a narcotic pain med at 0800. At 0900 the nurse finds the client slumped in the chair, hard to arouse, with respirations of 6/minute. Arterial blood gases are ordered what would you expect to see in the ABG results?
A. pH less than 7.35
B. pH higher than 7.45
C. CO2 of about 35
D. Co2 lower than 45 - correct answer A. pH less than 7.35
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
CALCULATION - correct answer 0.2 mL
A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?
A. "The laxative will prevent the absorption of magnesium."
B. "The laxative helps eliminate the barium."
C. "The laxative is the protocol at this facility."
D. "The laxative makes the barium turn brown." - correct answer B. "The laxative helps eliminate the barium."
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mmHg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis - correct answer C. Respiratory acidosis
A nurse is providing postmortem care to a hospitalized patient. Nursing interventions include? (Check all that apply)
Prepare the death certificate
Bathe the patient
Place patient in anatomical position
Remove endotracheal tube - correct answer Bathe the patient
Place patient in anatomical position
Remove endotracheal tube
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?
A. Ask the client to perform a return demonstration of insulin injection.
B. Review the action of insulin therapy.
C. Explore the client's feelings about dietary modifications.
D. Have the client practice blood-glucose monitoring using a glucometer. - correct answer C. Explore the client's feelings about dietary modifications.
A 70 year old client is admitted to the PACU with an intravenous (IV) solution of 0.9% NaCl which is running as 123cc/hour. The nurse detects new onset of crackles in the lung bases and distended neck veins. What is nurses the priority action?
A. Notify a health care provider
B. Immediately document findings in the medical record
C. Decrease the IV flow rate
D. Discontinue the IV - correct answer C. Decrease the IV flow rate
A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?
A. Urine specific gravity 1.035
B. Hematocrit 44%
C. BUN 19 mg/dL
D. Sodium 155 mEq/L - correct answer A. Urine specific gravity 1.035
A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take?
A. Cover the wound with a sterile-saline dressing.
B. Place the client in high-Fowler's position.
C. Auscultate all quadrants of the abdomen for bowel sounds.
D. Gently reinsert the protruding tissue. - correct answer A. Cover the wound with a sterile-saline dressing.
A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?
A. Have the client lie flat in bed.
B. Use sterile gauze to place gentle pressure on the exposed organs.
C. Cover the area with saline-soaked sterile dressings.
D. Apply an abdominal binder. - correct answer C. Cover the area with saline-soaked sterile dressings.
A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?
A. Serous
B. Purulent
C. Sanguineous
D. Serosanguineous - correct answer D. Serosanguineous
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?
A. Hypoactive bowel sounds in two quadrants
B. Request for a cup of tea and some toast
C. Passage of flatus
D. Abdominal distention - correct answer C. Passage of flatus
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
A. Blood pressure 102/66 mmHg
B. Straw-colored urine from an indwelling urinary catheter
C. Yellow-green drainage on the surgical incision
D. Respiratory rate 18/min - correct answer C. Yellow-green drainage on the surgical incision
The nurse is caring for a new diabetic client who is being taught how to administer insulin. The nurse knows that the patient care objectives have been met when the patient is able to?
A. Verbalize the method of insulin administration and how insulin works
B. Teach back what precautions are to take when taking insulin
C. State the value and importance self insulin injection for diabetics
D. Demonstrate how fill insulin syringe and give insulin injection - correct answer D. Demonstrate how fill insulin syringe and give insulin injection
A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?
A. Yogurt
B. Popsicle
C. Gelatin
D. Broth - correct answer A. Yogurt
A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. Now many mL should the nurse record in the medical record as the client's output?
CALCULATION - correct answer 1,370 mL
A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?
A. Expect ringing in your ears.
B. Take the medication with food.
C. Store the medication in the refrigerator.
D. Monitor for weight loss. - correct answer B. Take the medication with food. [Show Less]