a nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions assess the quality of the clients pain? 1) "is your pain constant or intermittent?" CORRECT: 4) "Is your pain sharp or dull? 1) determines the onset, duration and pattern of the
pain a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol? 1) the client uses a wool blanket on
their bed CORRECT: 2) the client uses nonacetone nail polish remover 1) client should use a cotton blanket. Wool blanket should be avoided. it can generate static electricity that could ignite the oxygen A nurse is caring for a client who has a respiratory infection. which of the following techniques should the nurse use when performing nasotracheal suctioning for this client? 1) insert the suction catheter while the client is swallowing CORRECT: 2) apply intermittent suction when withdrawing the catheter 1) nurse should insert the suction catheter while the client is inhaling to avoid insertion into the esophagus 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? 1) insert the catheter at a 45 degree angle CORRECT: 2) place the clients arm in a dependent position 1) generally the nurse should insert at a 10 to 30 degree angle but for older adults an angle of 10 to 15 degrees is preferable because veins are closer to the skin surface as aging diminishes SQ tissue a nurse is admitting a client who is having an exacerbation of heart failure. in planning this clients care, when should the nurse initiate discharge planning? 1) during the admission process CORRECT: 1) during the admission process 1)
discharge planning should begin as soon as the client is undergoing the admission process a nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks "what would happen if I arrived at the emergency department and I had difficulty breathing?" which of the following responses should the nurse make? 1) "we would consult the person appointed by your health care proxy to make decisions" CORRECT: 2) "we would give you oxygen through a tube in your nose" 1) staff must honor the clients wishes as stated in their living will 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 1) position the client with head of the bed elevated to 30 degree prior to insertion of the NG tube CORRECT: 4) have the client take sips of water to promote insertion of the NG tube into the esophagus 1) client should be sitting in high-fowlers position with head of bed elevated to 90 degrees to reduce risk for aspiration a nurse is assessing an older adult clients risk for falls. which of the following assessments should the nurse use to identify the clients safety needs? 1) lacrimal apparatus CORRECT: 2) pupil clarity, 4) visual fields, 5) visual acuity 1) if the client has an impairment in the ability to produce tears. should not affect fall risk a nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? 1) increase in hematocrit CORRECT: 3) decrease in heart rate 1) fluid volume deficit causes an increase in hematocrit due to depletion of extracellular fluid a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. which of the following actions should the nurse take? 1) assist the client into a prone position CORRECT: 3) make sure two fingers can fit under the sleeves 1) nurse should place client in a dorsal recumbent or semi-fowlers position to facilitate application of the sleeves a nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter. which of the following actions should the nurse take? 1) place the client in a side-lying position CORRECT: 3) subtract the amount of irrigant used from the clients urine output 1)
for a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter a nurse is reviewing a clients fluid and electrolytes status. which of the following findings should the nurse report to the provider? 1) BUN 15 mg/dL CORRECT: 4) potassium 5.4 mEq/L 1) In expected range of 10 to 20 mg/dL
a nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much." which of the following interventions is the nurse's priority action? 1) encourage the client to relax and take deep breaths during the dressing change CORRECT: 4) administer pain medication 45 mins before changing the clients dressing 4) Maslow's hierarchy of needs is to meet clients physiological need for comfort and pain relief 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 initiate? 1) protective equipment CORRECT: 4) contact precautions 1) clients with a compromised immune system require protective equipment a nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. which of the following types of dressing should the nurse use? 1) alginate CORRECT: 4) hydrocolloid 1) alginate dressings are used to treat stage III and IV pressure injuries to absorb drainage. alginate forms a soft gel when it comes in contact with drainage a nurse is talking with the partner of a client who has dementia. the clients partner expresses frustration about finding time to manage household responsibilities while caring for their partner. the nurse should identify that the partner is experiencing which of the following types of role performance stress? 1) role ambiguity CORREECT: 3) role overload 1) role ambiguity occurs when people are unclear about the expectations of their role in given situation a nurse is caring for a client who has herpes zosters and asks the nurse about the use of complementary and alternative therapies for pain control. the nurse should inform the client that this condition is a contraindication for which of the following therapies? 1) biofeedback CORRECT: 4) acupuncture 1) biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many others 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 which of the following client statements? 1) "im having mild pain" CORRECT: 2) "the pain is like a dull ache in my stomach" 1) this describes the severity of he pain a nurse is discussing the use of herbal supplements for health promotion with a client. which of the following clients statements indicate an understanding of herbal supplement use? 1) "i can take echinacea to improve my immune system" CORRECT: 1) "i can take echinacea to improve my immune system" 1) echinacea is taken to promote immunity and reduce the risk of infection 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? 1) "you should have an eye examination every 2 years" CORRECT: 4) "you should receive a pneumococcal vaccine when you are 65 years old" 1)
older adults should have an eye examination every year a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect? 1) neck vein distention CORRECT: 3) rapid heart rate 1) clinical manifestation of fluid volume excess 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? 1) auscultate lung sounds CORRECT: 1) auscultate lung sounds 1) priority
assessment the nurse should make when using the airway, breathing, circulation (ABC) approach is to listen for fluid volume excess, a complication of IV therapy. a nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take first? 1) rock the client up to a standing position CORRECT: 3) assess the client for orthostatic hypotension 1) nurse should rock client to standing position to generate
momentum and reduce the nurses workload in lifting the client up off the bed 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 SQ. determine the correct order of steps -inject 10 units of air into the bottle of NPH insulin a nurse is caring for a group of clients on a medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity? 1) a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse
responds affirmatively CORRECT: 1) a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse respinds affirmatively 1) following the ethical principle of veracity, the nurse must tell the truth at all times and not deceive others a nurse is caring for a client who is receiving fluid through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration? 1) purulent exudate CORRECT: 3) skin blanching 1) exudate indicates infection 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? 1) "ill get a blood sample from you and send it for a screening test" CORRECT: 3) "you should have a fecal occult blood test every year" 1) blood tests do not detect colorectal cancer. one option for screening is a double-contrast barium enema every 5yrs a nurse is caring for a client who has an indwelling urinary catheter. which of the following findings indicates that the catheter requires irrigation? 1) urine has unusual odor CORRECT: 3) bladder scan shows mL of urine 1) can be a sign of infection a nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescription reads: 25,000 units of heparin in 0.9% sodium chloride mL to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? 8 mL/hr dose to administer: desired 800 units/hr X = desired quantity/ have --> X mL/hr = 800 250/25,000 A nurse is providing discharge teaching for a client who has a new prescription for home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? 1) check the cord routinely for frays or tearing CORRECT: 1) check
the cord routinely for frays or tearing, 3) consider purchasing a generator for backup 1) oxygen concentrators require electrical power. Safe use of this system requires assessing the electrical function of the device A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? 1) place the client in a room with negative pressure airflow CORRECT: 1) place the client in a room with negative pressure airflow, 2) wear gloves when assisting the client with oral care, 5) use antimicrobial sanitizer for hand hygiene 1) airborne precautions |