ATI Fundamentals Final Exam (F1)

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A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (SATA)

A) Home health care
B) Rehabilitation facilities
C) Diagnostic centers
D) Skilled nursing facilities
E) Oncology centers

A) Home health care B) Rehabilitation facilities D) Skilled nursing facilities

A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (SATA)

A) Preferred provider organization (PPO)
B) Medicare
C) Long-term care insurance
D) Exclusive provider organization (EPO)
E) Medicaid

B) Medicare E) Medicaid

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 health care strategy?

A) Collaborating with providers to perform obesity screenings during routine office visits.
B) Ensuring the availability of specialized beds in rehab centers for clients who have obesity.
C) Providing specialized intraoperative training regarding surgical treatments for obesity
D) Educating acute care nurses on postoperative complications related to obesity

A) Collaborating with providers to perform obesity screenings during routine office visits.

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?

A) Monitoring evidence-based practice for clients who have a specific diagnosis
B) Ensuring that HCP comply with regulations
C) Setting quality standards for accreditation of health care facilities
D) Determining if medications are safe for administration to clients

B) Ensuring that HCP comply with regulations

A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse identify as tertiary care? (SATA)

A) ICU
B) Oncology treatment center
C) Burn center
D) Cardiac rehab
E) Home health care

A) ICU B) Oncology treatment center C) Burn center

A nurse is caring for a client who is 24 hours post operative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurses report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?

A) Basic
B) Commitment
C) Complex
D) Integrity

A) Basic

A nurse receives a RX for an antibiotic for a client who has cellulitis. The nurse checks the clients medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a RX for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate?

A) Fairness
B) Responsibility
C) Risk taking
D) Creativity

B) Responsibility

A nurse is caring for a client who is 24 hours postoperative following abdominal surgery. The nurse suspects the clients pain management is inadequate. Which of the following data reinforce this suspicion? (SATA)

A) The client seems easily agitated
B) The client is nonadherent with coughing, deep breathing, and dangling.
C) The client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr.
D) The client reports tenderness in his right lower leg.
E) The clients vital signs are HR 110/min, RR 20/min, temp 98.6 F, and BP 136/80 mm Hg.

B) The client is nonadherent with coughing, deep breathing, and dangling. C) The client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr. E) The clients vital signs are HR 110/min, RR 20/min, temp 98.6 F, and BP 136/80 mm Hg.

A nurse is caring for a client who has a new RX for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information?

A) Knowledge
B) Experience
C) Intuition
D) Competence

A) Knowledge

A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate?

A) Confidence
B) Perseverance
C) Integrity
D) Discipline

D) Discipline

A nurse in a providers office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a hx of three vaginal births, but no serious accidents of illnesses. Which of the following interventions should the nurse suggest for helping to control of eliminate the clients incontinence? (SATA)

A) Limit total daily fluid intake
B) Decrease of avoid caffeine
C) Take calcium supplements
D) Avoid drinking alcohol
E) Use the Crede maneuver

B) Decrease of avoid caffeine D) Avoid drinking alcohol

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

A) Check to see whether the catheter is patent.
B) Reassure the client that it is not possible for her to urinate.
C) Recatheterize the bladder with a larger-gauge catheter.
D) Collect a urine specimen for analysis

A) Check to see whether the catheter is patent.

A nurse is caring for a client who has a RX for a 24-hr urine collection. Which of the following actions should the nurse take?

A) Discard the first voiding
B) Keep the urine in a singe container at room temp
C) Ask the client to urinate and pour the urine into a specimen container
D) Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

A) Discard the first voiding

A nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? (SATA)

A) Frequent sexual intercourse
B) Lowering of testosterone levels
C) Wiping from front to back
D) Location of the urethra in relation to the anus
E) Frequent catheterization

A) Frequent sexual intercourse D) Location of the urethra in relation to the anus E) Frequent catheterization

A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (SATA)

A) Establish a schedule of urinating prior to meal times.
B) Have the client record urination times
C) Gradually increase the urination intervals
D) Remind the client to hold urine until the next scheduled urination time
E) Provide a sterile container for urine

B) Have the client record urination times C) Gradually increase the urination intervals D) Remind the client to hold urine until the next scheduled urination time

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of which of the following ethical principles?

A) Fidelity
B) Autonomy
C) Justice
D) Nonmaleficence

B) Autonomy

A nurse offers pain meds to a client who is post-op prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

A) Fidelity
B) Autonomy
C) Justice
D) Beneficence

D) Beneficence

A nurse is instructing a group of nursing students about the responsibilities of organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles?

A) Fidelity
B) Autonomy
C) Justice
D) Nonmaleficence

C) Justice

A nurse questions a medication RX as too extreme in light of the clients advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?

A) Fidelity
B) Autonomy
C) Justice
D) Nonmaleficence

D) Nonmaleficence

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma?

A) A nurse on a med-surg unit demonstrates signs of chemical impairment
B) A nurse overhears another nurse telling an older adult client that if he doesn’t stay in bed, she will have to apply restraints.
C) A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.
D) A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.

C) A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?

A. Assault
B. Battery
C. False imprisonment
D. Invasion of privacy

A. Assault

An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client’s best interest, so she administers a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed?
A. Assault
B. False imprisonment
C. Negligence
D. Breach of confidentiality

B. False imprisonment

A client who will undergo neurosurgery the following week tells the nurse in the surgeon’s office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives?

A. "I’d rather have my brother make decisions for me, but I know it has to be my wife."
B. "I know they won’t go ahead with the surgery unless I prepare these forms."
C. "I plan to write that I don’t want them to keep me on a breathing machine."
D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C. "I plan to write that I don’t want them to keep me on a breathing machine."

A client is about to undergo an elective surgical procedure. Which of the following actions are
appropriate for the nurse who is providing preoperative care regarding informed consent? (SATA)

A. Make sure the surgeon obtained the client’s consent.
B. Witness the client’s signature on the consent form.
C. Explain the risks and benefits of the procedure.
D. Describe the consequences of choosing not to have the surgery.
E. Tell the client about alternatives to having the surgery.

A. Make sure the surgeon obtained the client’s consent. B. Witness the client’s signature on the consent form.

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take?
A. Remind the nurse that safe client care is a priority on the unit.
B. Ask others on the team whether they have observed the same behavior.
C. Report her observations to the nurse manager on the unit.
D. Conclude that her coworker’s fatigue is not her problem to solve.

C. Report her observations to the nurse manager on the unit.

A nurse is caring for a 20 YO client who is sexually active and has come to the college health clinic for the first time for a checkup. Which of the following interventions should the nurse perform first to determine the client’s need for health promotion and disease prevention?
A. Measure the client’s vital signs.
B. Encourage HIV screening.
C. Determine the client’s risk factors.
D. Instruct the client to use condoms.

C. Determine the client’s risk factors.

A nurse at a provider’s office is talking with a 45-year-old client who has no specific family history of
cancer or diabetes mellitus about planning her routine screeings. Which of the following client statements
indicates that the client understands how to proceed?
A. "So I don’t need the colon cancer procedure for another 2 or 3 years."
B. "For now, I should continue to have a mammogram each year."
C. "Because the doctor just did a Pap smear, I’ll come back next year for another one."
D. "I had my blood glucose test last year, so I won’t need it again till next year."

B. "For now, I should continue to have a mammogram each year."

A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy
nutrition presentation at a neighborhood center. His total cholesterol result from the screening was
248 mg/dL, so he saw his provider and received a medication prescription to improve his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities of this client is an example of primary prevention?
A. Cholesterol screening
B. Nutrition presentation
C. Medication therapy
D. Cardiac rehabilitation

B. Nutrition presentation

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for CV disease. Which of the following interventions should the nurse include? (SATA)

A) Help the client see the benefits of her actions
B) Identify the clients support systems
C) Suggest and recommend community resources
D) Devise and set goals for the client
E) Teach stress management stratagies

A) Help the client see the benefits of her actions B) Identify the clients support systems C) Suggest and recommend community resources E) Teach stress management stratagies

A nurse in a health clinic is caring for a 21 YO client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client?

A) Testicular examination
B) Blood glucose
C) Fecal occult blood
D) Prostate-specific antigen

A) Testicular examination

By the second post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

A. Reassess the client to determine the reasons for inadequate pain relief
B. Wait to see whether the pain lessens during the next 24 hours
C. Change the plan of care to provide different pain relief interventions
D. Teach the client about the plan of care for managing pain

A. Reassess the client to determine the reasons for inadequate pain relief

A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain med 6 hr ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process?

A. Assessment
B. Planning
C. Intervention
D. Evaluation

A. Assessment

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (SATA)

A. RR of 22/min with even, unlabored respirations
B. The client’s partner states, "He said he hurts after walking about 10 minutes."
C. Pain rating is a 3 on a scale of 0-10.
D. Skin in pink, warm, and dry
E. The AP reports the client walked with a limp

A. RR of 22/min with even, unlabored respirations D. Skin in pink, warm, and dry E. The AP reports the client walked with a limp

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (SATA)

A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a NG tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure ulcer risk

C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure ulcer risk

A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process?

A. "I will determine the most important client problems that we should address."
B. "I will review the past medical history on the client’s record to get more information."
C. "I will go carry out the new prescriptions from the provider."
D. "I will askt the client if his nausea has resolved."

A. "I will determine the most important client problems that we should address."

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?

A. decreased subQ fat
B. muscle atrophy
C. pressure ulcer
D. fecal impaction

C. Pressure ulcer

A nurse is caring for a client who is post-op. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (SATA)

A. instruct client not to perform Valsalva maneuver
B. apply elastic stockings
C. review laboratory values for total protein level
D. place pillows under clients knees and lower extremities
E. assist client to change position often

B. apply elastic stockings E. assist client to change position often

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

A. encourage the client to perform antiembolic exercises every 2 hr
B. instruct the client to cough and deep breathe every 4 hr
C. restrict clients fluid intake
D. reposition the client every 4 hr

A. encourage the client to perform antiembolic exercises every 2 hr

A nurse is evaluating teaching on a client who has a new RX for a sequential compression device. Which of the following client statements should indicate the client understands?

A. "This device will keep me from getting sores on my skin."
B. "This thing will keep the blood pumping through my leg."
C. "With this thing on, my leg muscles wont get weak."
D. "This device is going to keep my joints in good shape."

B. "This thing will keep the blood pumping through my leg."

A nurse is instructing a client who has an injury to the left lower extremity about the use of a cane. Which of the following instructions should the nurse include? (SATA)

A. hold cane to right side
B. keep 2 points of support on floor
C. place cane 38 cm(15in) in front of feet before advancing
D. after advancing care, more weaker leg forward
E. advance stronger leg so that it aligns with the cane

A. hold cane to right side B. keep 2 points of support on floor D. after advancing care, more weaker leg forward

A nurse in a provider’s office is preparing to assess a young adult male client’s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA)

A. Concave thoracic spine posteriorly
B. Exaggerated lumbar curvature
C. Concave lumbar spine posteriorly
D. Exaggerated thoracic curvature
E. Muscles slightly larger on his dominant side

C. Concave lumbar spine posteriorly E. Muscles slightly larger on his dominant side

A nurse is assessing a client’s neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items?

A. A word she whispers 30 cm from his ear
B. A number she traces on the palm of his hand
C. The vibration of a tuning fork she places on his foot
D. A familiar object she places in his hand

D. A familiar object she places in his hand

A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the clients ability to perform which of the following activities?

A. Mopping her floors
B. Brushing the back of her hair
C. Fastening her bra being her back
D. Reaching into a cabinet above her sink

C. Fastening her bra being her back

A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client’s balance? (SATA)

A. Romberg test
B. Heel-to-toe walk
C. Snellen test
D. Spinal accessory function
E. Rosenbaum test

A. Romberg test B. Heel-to-toe walk

A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the
following findings should the nurse expect as changes associated with aging? (SATA)

A. Slower light touch sensation
B. Some vision and hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
E. Slower superficial pain sensation

B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline

When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing
and sneezing. Which of the following actions should the nurse take when preparing the sterile field?

A. keep the sterile field at least 6 ft away from the client’s bedside.
B. instruct the client to refrain from coughing and sneezing during the dressing change.
C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.
D. keep a box of facial tissues nearby for the client to use during the dressing change.

C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in
preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

A. The flap closest to the body
B. The right side flap
C. The left side flap
D. The flap farthest from the body

D. The flap farthest from the body

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the
following objects may the nurse touch without breaching sterile technique? (SATA)

A. A bottle containing a sterile solution
B. The edge of the sterile drape at the base of the field
C. The inner wrapping of an item on the sterile field
D. An irrigation syringe on the sterile field
E. One gloved hand with the other gloved hand

C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the
following instructions should the nurse include when discussing handwashing? (SATA)

A. Apply 3 to 5 mL of liquid soap to dry hands.
B. Wash the hands with soap and water for at least 15 seconds.
C. Rinse the hands with hot water.
D. Use a clean paper towel to turn off hand faucets.
E. Allow the hands to air dry after washing.

B. Wash the hands with soap and water for at least 15 seconds D. Use a clean paper towel to turn off hand faucets.

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the
following events should the nurse recognize as contaminating the sterile field? (SATA)

A. The provider drops a sterile instrument onto the near side of the sterile field.
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
C. The procedure is delayed 1 hr because the provider receives an emergency call.
D. The nurse turns to speak to someone who enters through the door behind the nurse.
E. The client’s hand brushes against the outer edge of the sterile field.

B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is
aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (SATA)

A. Planning and evaluating control and prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks

A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some
crustings. The nurse should identify the client has manifestations of which of the following conditions?

A. Allergic reaction
B. Ringworm
C. Systemic lupus erythematosus
D. Herpes zoster

D. Herpes zoster

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A. Prodromal
B. Incubation
C. Convalescence
D. Illness

D. Illness

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a
localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (SATA)

A. Fever
B. Malaise
C. Edema
D. Pain or tenderness
E. Increase in pulse and respiratory rate

A. Fever B. Malaise E. Increase in pulse and respiratory rate

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a
suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (SATA)

A. Place the client in a room that has negative air pressure of at least six exchanges per hour.
B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable.
D. Use sterile gloves when handling soiled linens.
E. Wear a gown when performing care that may result in contamination from secretions.

B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable E. Wear a gown when performing care that may result in contamination from secretions.

A nurse in a provider’s office is preparing to assess a client’s skin as part of a comprehensive physical
examination. Which of the following findings should the nurse expect? (SATA)

A. Capillary refill in 2 seconds
B. 1+ pitting edema in both feet
C. Pale nail beds in both hands
D. Thick skin on the soles of the feet
E. Numerous light brown macules on the face

A. Capillary refill in 2 seconds D. Thick skin on the soles of the feet E. Numerous light brown macules on the face

A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding?

A. Thin, parchment like skin
B. Loss of adipose tissue
C. Dehydration
D. Diminished skin elasticity
E. Excessive wrinkling

B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity

A nurse is assessing post-op circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (SATA)

A. ROM
B. Skin color
C. Edema
D. Skin lesions
E. Skin temperature

B. Skin color C. Edema E. Skin temperature

A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (SATA)

A. Acne
B. Warts
C. Psoriasis
D. Herpes simplex
E. Varicella

D. Herpes simplex E. Varicella

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention?

A. Pallor
B. Cyanosis
C. Jaundice
D. Erythema

B. Cyanosis

A nurse is caring for a client who recently had a CVA and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (SATA)

A. Increase the volume in your voice
B. Make sure only one person speaks at a time
C. Avoid discouraging the client by saying that you do not understand him
D. Allow plenty of the time for the client to respond
E. Use brief sentences with simple words

B. Make sure only one person speaks at a time D. Allow plenty of the time for the client to respond E. Use brief sentences with simple words

A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement?

A. Immediately complete a thorough assessment
B. Put the client in a room with a client who has hearing loss
C. Provide a quiet room and limit stimulation
D. Speak at a higher volume to the client and encourage ambulation.

C. Provide a quiet room and limit stimulation

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (SATA)

A. Weber test showing lateralization to the right ear
B. Light reflex at 10 o’clock in the left ear
C. Indications of obstruction in the left ear canal
D. Rinne test showing less time for air and bone conduction
E. Rinne test showing air conduction less than bone conduction in the left ear

A. Weber test showing lateralization to the right ear D. Rinne test showing less time for air and bone conduction

A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (SATA)

A. Furosemide
B. Ibuprofen
C. Cimetidine
D. Simvastatin
E. Amiodarone

A. Furosemide B. Ibuprofen

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A. "I use a damp cloth to clean the outside part of my hearing aids."
B. "I clean the ear molds of my hearing aids with rubbing alcohol."
C. "I keep the volume of my hearing aids turned up so I can hear better."
D. "I take the batteries out of my hearing aids when I take them off at night."

D. "I take the batteries out of my hearing aids when I take them off at night."

A nurse is caring for an adolescent who client who is 2 days post-op following an appendectomy and has type I DM. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (SATA)

A. Extremes in age
B. Impaired circulation
C. Impaired/suppressed immune system
D. Malnutrition
E. Poor wound care

B. Impaired circulation C. Impaired/suppressed immune system

A nurse is collecting data from a client who is 5 days post-op following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (SATA)

A. Increase in incisional pain
B. Fever and chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst

A. Increase in incisional pain B. Fever and chills C. Reddened wound edges

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (SATA)

A. Stage III pressure ulcer
B. Sutured surgical incision
C. Casted bone fracture
D. Laceration sealed with adhesive
E. Open burn area

A. Stage III pressure ulcer E. Open burn area

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (SATA)

A. Cover the area with saline-soaked sterile dressings.
B. Apply an abdominal binder snugly around the abdomen.
C. Use sterile gauze to apply gentle pressure to the exposed tissues.
D. Position the client supine with his hips and knees bent.
E. Offer the client a warm beverage, such as herbal tea.

A. Cover the area with saline-soaked sterile dressings. D. Position the client supine with his hips and knees bent.

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (SATA)

A. Keep the head of the bed elevated 30 degrees.
B. Massage the client’s bony prominences frequently.
C. Apply cornstarch liberally to the skin after bathing.
D. Have the client sit on a gel cushion when in a chair.
E. Reposition the client at least every 3 hr while in bed.

A. Keep the head of the bed elevated 30 degrees. D. Have the client sit on a gel cushion when in a chair.

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (SATA)

A. Place a belt restraint on the client when he is sitting on the bedside commode
B. Keep the bed in its lowest position with all side rails up
C. Make sure that the clients call light is within reach
D. Provide the client with nonskid footwear
E. Complete a fall-risk assessment

C. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

A. "I will place the client on his side."
B. "I will go to the nurses station for assistance."
C. "I will administer his medications."
D. "I will prepare to insert an airway."

B. "I will go to the nurses station for assistance."

A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurses priority?

A. Extinguish the fire
B. Activate the fire alarm
C. Move clients who are near by
D. Close all open doors on the unit

C. Move clients who are near by

A nurse is caring for a client who has a history of falls. Which of the following is the nurses priority?

A. Complete a fall-risk assessment
B. Educate the client and family about fall risks
C. Eliminate safety hazards from the clients environment
D. Make sure the client uses assistive aids in his possession

A. Complete a fall-risk assessment

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses station?

A. A middle adult who is post-op following a laproscopic cholecystectomy
B. A middle adult who requires telemetry for a possible myocardial infarction
C. A young adult who is post-op following an open reduction internal fixation of the ankle
D. An older adult who is post-op following a below-the-knee amputation

D. An older adult who is post-op following a below-the-knee amputation

A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his
home. Which of the following should the nurse teach the client about using oxygen safely in his home?
(SATA)

A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A "No Smoking" sign should be placed on the front door.
D. Cotton bedding and clothing should be replaced with items made from wool.
E. A fire extinguisher should be readily available in the home.

B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home.

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states that the client who has heat stroke will have which of the following?

A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea

A. Hypotension

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions?

A. "I will set my water heater at 130 F."
B. "Once my baby can sit up, he should be safe in the bathtub."
C. "I will place my baby on his stomach to sleep."
D. "Once my infant starts to push up, I will remove the mobile from over the crib."

D. "Once my infant starts to push up, I will remove the mobile from over the crib."

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of
the following information should the nurse include in her counseling?

A. Carbon monoxide has a distinct odor.
B. Water heaters should be inspected every 5 years.
C. The lungs are damaged from carbon monoxide inhalation.
D. Carbon monoxide binds with hemoglobin in the body.

D. Carbon monoxide binds with hemoglobin in the body.

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following
information should the nurse including in her counseling? (SATA)

A. Most food poisoning is caused by a virus.
B. Immunocompromised individuals are at risk for complications from food poisoning
C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products.
D. Healthy individuals usually recover from the illness in a few weeks.
E. Handling raw and fresh food separately to avoid cross contamination may prevent
food poisoning.

B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. E. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning.

A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following
bed positions is appropriate for safe care of this client?

A. Supine
B. Semi-Fowler’s
C. Semi-prone
D. Trendelenburg

B. Semi-Fowler’s

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is
the priority action for the nurse to take at this time?

A. Obtain a walker for the client to use to transfer back to bed.
B. Call for additional personnel to assist with the transfer.
C. Use a transfer belt and assist the client to bed.
D. Assess the client’s ability to help with the transfer.

D. Assess the client’s ability to help with the transfer.

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night?

A. Lie on her back with her head and shoulders on a pillow.
B. Lie flat on her stomach with her head to one side.
C. Sit on the side of her bed and rest her arms over follows on top of her bedside table.
D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her.

C. Sit on the side of her bed and rest her arms over follows on top of her bedside table.

A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following
should the nurse manager include in the teaching? (SATA)

A. Request assistance when repositioning a client.
B. Avoid twisting the spine or bending at the waist.
C. Keep the knees slightly lower than the hips when sitting for long periods of time.
D. Use smooth movements when lifting and moving clients.
E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints
and muscles.

A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients.

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (SATA)

A. "My line of gravity should fall outside my base of support."
B. "The lower my center of gravity, the more stability I have."
C. "To broaden my base of support, I should spread my feet apart."
D. "When I lift an object, I should hold it as close to my body as possible."
E. "When pulling an object, I should move my front foot forward."

B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority?

A. A client who received crush injuries to the chest and is expected to die
B. A client who has a 4-inch laceration to the head
C. A client who has partial thickness and full thickness burns to the face, neck, and chest
D. A client who has a fractured fibula and tibia.

C. A client who has partial thickness and full thickness burns to the face, neck, and chest

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (SATA)

A. Open doors to client rooms
B. Place blankets over clients who are confined to beds
C. Move beds away from the windows
D. Draw shades and close drapes
E. Instruct ambulatory clients in the hallways to return to their rooms.

B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?

A. Irrigate the affected area with running water
B. Wash the affected area with antibacterial soap
C. Brush the chemical off the skin and clothing
D. Leave the clothing in place until emergency personnel arrive

C. Brush the chemical off the skin and clothing

A nurse on a med-surg unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (SATA)

A. A client who is dehydrated and receiving IV fluid and electrolytes
B. A client who has an NGT to treat a small bowel obstruction
C. A client who is scheduled for elective surgery
D. A client who has chronic HTN and BP 135/85 mm Hg
E. A client who has acute appendicitis and is scheduled for an appendectomy

C. A client who is scheduled for elective surgery D. A client who has chronic HTN and BP 135/85 mm Hg

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?

A. Give the client thin liquids.
B. Instruct the client to tuck her chin when swallowing.
C. Have the client use a straw.
D. Encourage the client to lie down and rest after meals.

B. Instruct the client to tuck her chin when swallowing.

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy?

A. Fat
B. Protein
C. Glycogen
D. Carbohydrates

D. Carbohydrates

A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the
following foods on the client’s meal tray?

A. Cooked barley
B. Pureed broccoli
C. Vanilla custard
D. Lentil soup

C. Vanilla custard

A nurse in a senior center is counseling a group of older adults about their nutritional needs and
considerations. Which of the following information should the nurse include? (SATA)

A. Older adults are more prone to dehydration than younger adults are.
B. Older adults need the same amount of most vitamins and minerals as younger adults do.
C. Many older men and women need calcium supplementation.
D. Older adults need more calories than they did when they were younger.
E. Older adults should consume a diet low in carbohydrates.

A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation.

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent
feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse?

A. "Water helps clear the tube so it doesn’t get clogged."
B. "Flushing helps make sure the tube stays in place."
C. "This will help you get enough fluids."
D. "Adding water makes the formula less concentrated."

A. "Water helps clear the tube so it doesn’t get clogged."

A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the
following is the nurse’s highest assessment priority before performing this procedure?

A. Check how long the feeding container has been open.
B. Verify the placement of the NG tube.
C. Confirm that the client does not have diarrhea.
D. Make sure the client is alert and oriented.

B. Verify the placement of the NG tube.

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following
nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?

A. Auscultate breath sounds.
B. Stop the feeding.
C. Obtain a chest x-ray.
D. Initiate oxygen therapy.

B. Stop the feeding.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (SATA)

A. Auscultate bowel sounds.
B. Assist the client to an upright position.
C. Test the pH of gastric aspirate.
D. Warm the formula to body temperature.
E. Discard any residual gastric contents.

A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate.

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the
following actions should the nurse perform before beginning the procedure? (SATA)

A. Review a signal the client can use if feeling any distress.
B. Lay a towel across the client’s chest.
C. Administer oral pain medication.
D. Obtain a Dobhoff tube for insertion.
E. Have a petroleum-based lubricant available.

A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client’s chest.

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the
following information should the nurse include when explaining the procedure to the client?

A. Eating more protein is optimal prior to testing.
B. One stool specimen is sufficient for testing.
C. A red color change indicates a positive test.
D. The specimen cannot be contaminated with urine.

D. The specimen cannot be contaminated with urine.

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?

A. Macaroni and cheese
B. Fresh fruit and whole wheat toast
C. Rice pudding and ripe bananas
D. Roast chicken and white rice

B. Fresh fruit and whole wheat toast

A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the
nurse should expect which of the following findings? (SATA)

A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema

B. Hypotension C. Fever D. Poor skin turgor

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic
procedure. Which of the following are appropriate steps for the nurse to take? (SATA)

A. Warm the enema solution prior to instillation.
B. Position the client on the left side with the right leg flexed forward.
C. Lubricate the rectal tube or nozzle.
D. Slowly insert the rectal tube about 2 inches.
E. Hang the enema container 24 inches above the client’s anus.

A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the
following actions should the nurse take?

A. Have the client hold his breath briefly.
B. Discontinue the fluid instillation.
C. Remind the client that cramping is common at this time.
D. Lower the enema fluid container.

D. Lower the enema fluid container.

A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (SATA)

A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Pallor

A. Restlessness B. Tachypnea E. Pallor

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already
receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?

A. Increase the oxygen flow.
B. Assist the client to Fowler’s position.
C. Promote removal of pulmonary secretions.
D. Obtain a specimen for arterial blood gases.

B. Assist the client to Fowler’s position.

A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are
appropriate guidelines for the nurse to follow? (SATA)

A. Apply suction while withdrawing the catheter.
B. Perform suctioning on a routine basis, every 2 to 3 hr.
C. Maintain medical asepsis during suctioning.
D. Use a new catheter for each suctioning attempt.
E. Limit suctioning to two to three attempts.

A. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts.

Which of the following actions should the nurse
take each time he provides tracheostomy care? (SATA)

A. Apply the oxygen source loosely if the SpO2 decreases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.

A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward.

A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client
and family teaching by the nurse should include which of the following instructions? (SATA)

A. Apply petroleum jelly around and inside the nares.
B. Remove the nasal cannula during mealtimes.
C. Check the position of the cannula frequently.
D. Report any nasal stuffiness, nausea, or fatigue.
E. Post "no smoking" signs in a prominent location.

C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location.

A nurse is using an interpreter to communicate with a client. Which of the following are appropriate
when communicating with a client and his family? (SATA)

A. Talk to the interpreter about the family while the family is in the room.
B. Ask the family one question at a time.
C. Look at the interpreter when asking the family questions.
D. Use lay terms if possible.
E. Do not interrupt the interpreter and the family as they talk.

B. Ask the family one question at a time. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk.

A nurse is caring for a client who shares the same religious background. Which of the following information should the nurse anticipate?

A. members of the same religion share similar feelings about their religion.
B. a shared religious background generates mutual regard for one another.
C. the same religious beliefs may influence individuals differently.
D. they should discuss the differences and commonalities in their beliefs.

C. the same religious beliefs may influence individuals differently.

A nurse is caring for a client who is crying while reading from his devotional book. Which of the
following interventions should the nurse take?

A. Contact the hospital’s spiritual services.
B. Ask him what is making him cry.
C. Provide quiet times for these moments.
D. Turn on the television for a distraction.

C. Provide quiet times for these moments.

A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a
hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the Muslim client?

A. "I will make sure the menu includes kosher options."
B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer."
C. "I will make sure to use direct eye contact when speaking with this client."
D. "I will make sure daily communion is available for this client."

B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer."

A nurse is caring for a client who is a Jehovah’s Witness and is scheduled for surgery as a result of a
motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the
nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses by the nurse is appropriate?

A. "I believe in this case you should really make an exception and accept the blood transfusion."
B. "I know your family would approve of your decision to have a blood transfusion."
C. "Why does your religion mandate that you cannot receive any blood transfusions?"
D. "Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and
come to a reasonable solution."

D. "Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."

A nurse in a providers office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the clients difficulty sleeping? (SATA)

A. "Does your lack of sleep interfere with your ability to function during the day?"
B. "Do you feel confused in the late afternoon?"
C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?"
D. "Has anyone ever told you that you seem to stop breathing for a few seconds when you are asleep?"
E. "Tell me about any personal stress you are experiencing."

A. "Does your lack of sleep interfere with your ability to function during the day?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds when you are asleep?" E. "Tell me about any personal stress you are experiencing."

A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (SATA)

A. Practice muscle relaxation techniques
B. Exercise each morning
C. Take an afternoon nap
D. Alter the sleep environment for comfort
E. Limit fluid intake to at least 2 hr before bed

A. Practice muscle relaxation techniques B. Exercise each morning D. Alter the sleep environment for comfort E. Limit fluid intake to at least 2 hr before bed

A nurse is caring for an older adult client who has been following the facilities routines and bathing in the morning. However, at home, she always takes a warm bath just before bed time. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first?

A. Rub the clients back for 15 minutes before bedtime
B. Offer the client warm milk and crackers at 2100
C. Allow the client to take a bath in the evening
D. Ask the provider for a sleeping medication

C. Allow the client to take a bath in the evening

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining REM sleep, which of the following characteristics should the nurse include? (SATA)

A. REM sleep provides cognitive restoration
B. REM sleep lasts about 90 minutes
C. It is difficult to awaken a person in REM sleep
D. Sleepwalking occurs during REM sleep
E. Vivid dreams are common during REM sleep

A. REM sleep provides cognitive restoration C. It is difficult to awaken a person in REM sleep E. Vivid dreams are common during REM sleep

A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A. "I’ll add plenty of carbs to my meals."
B. "I’ll take a short nap whenever I feel sleepy."
C. "I’ll make sure I stay warm when I am at my desk at work."
D. "It’s okay to drink alcohol as long as I limit it to one drink per day."

B. "I’ll take a short nap whenever I feel sleepy."

A nurse is caring for a client whose partner passed away 4 months ago and who has been recently
diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following is an appropriate response by the nurse?

A. "It takes time to get over the loss of a loved one."
B. "You are right; I cannot really understand. Perhaps you’d like to tell me more about what you’re feeling."
C. "Why don’t you try something to take your mind off your troubles, like watching a funny movie."
D. "I might not share

B. "You are right; I cannot really understand. Perhaps you’d like to tell me more about what you’re feeling."

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client’s vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?

A. Exhaustion stage
B. Resistance stage
C. Alarm reaction
D. Recovery reaction

C. Alarm reaction

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following
nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (SATA)

A. Suggest coping skills for the client to utilize in this situation.
B. Allow the client to provide input in the treatment plan.
C. Assist the client with time management, and address the client’s priorities.
D. Provide extensive instructions on the client’s treatment regimen.
E. Encourage the client in the expression of feelings and concerns.

B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client’s priorities. E. Encourage the client in the expression of feelings and concerns.

A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client’s role problem?

A. Role conflict
B. Role overload
C. Role ambiguity
D. Role strain

A. Role conflict

A nurse caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?

A. Prescribing tasks unilaterally
B. Delegating care to one member
C. Speaking to the primary client privately
D. Convening a family meeting

D. Convening a family meeting

A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?

A. Pacing
B. Reflecting
C. Paraphrasing
D. Restating

B. Reflecting

Which of the following actions should the nurse take when using the communication technique of active listening? (SATA)

A. Use an open posture
B. Write down what the client says to avoid forgetting details
C. Establish and maintain eye contact
D. Nod in agreement with the client throughout the conversation
E. Respond positively when giving feedback

A. Use an open posture C. Establish and maintain eye contact E. Respond positively when giving feedback

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (SATA)

A. "You will do great! You just have to get used to it."
B. " Why are you worried about going home?"
C. "Your daily routines will be different when you get home."
D. "Tell me about your support system you’ll have after you leave the hospital."
E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."

C. "Your daily routines will be different when you get home." D. "Tell me about your support system you’ll have after you leave the hospital." E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."

Which of the following strategies should a nurse use to establish a helping relationship with a client?

A. Make sure the communication is equally reciprocal between the nurse and client
B. Encourage the client to communicate his thoughts and feelings
C. Give the nurse-client communication no time limit
D. Allow communication to occur spontaneously throughout the nurse-client relationship

B. Encourage the client to communicate his thoughts and feelings

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?

A. Touch the childs arm
B. Sit at eye level with the child
C. Stand facing the child
D. Stand with a relaxed posture

B. Sit at eye level with the child

A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether or not he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine?

A. Presence of associate manifestations
B. Location of the pain
C. Pain quality
D. Aggravating and relieving factors

A. Presence of associate manifestations

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the clients pain?

A. Ask the client what precipitates the pain
B. Question the client about the location of the pain
C. Offer the client a pain scale to measure his pain
D. Use open-ended questions to identify the clients pain sensation

C. Offer the client a pain scale to measure his pain

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?

A. A client who has a broken femur and reports hip pain
B. A client who has incisional pain 72 hr following pacemaker insertion
C. A client who has food poisoning and reports abdominal cramping
D. A client who has episodic back pain following a fall 2 yr ago

D. A client who has episodic back pain following a fall 2 yr ago

A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (SATA)

A. Urinary incontinence
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
E. Nausea

C. Bradypnea D. Orthostatic hypotension E. Nausea

A nurse is caring for a client who is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

A. "I’ll wait to use the device until it’s absolutely necessary."
B. "I’ll be careful about pushing the button too much so I don’t get an overdose."
C. "I should tell the nurse if the pain doesn’t stop while I am using the device."
D. "I will ask my adult child to push the dose button while I am sleeping."

C. "I should tell the nurse if the pain doesn’t stop while I am using the device."

A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take?

A. Offer info on a relaxation technique and ask the client if he is interested in trying it
B. Request a social worker see the client to discuss meditation
C. Attempt to use biofeedback techniques with the client
D. Tell the client many people feel the same way before surgery and try to think of something else.

A. Offer info on a relaxation technique and ask the client if he is interested in trying it

A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes which of the following ingredients?

A. Chamomile
B. Ginseng
C. Ginger
D. Echinacea

A. Chamomile

A nurse is reviewing CAM therapies with a group of nursing students. The nurse should classify which of the following as a mind-body therapy? (SATA)

A. Art therapy
B. Acupuncture
C. Yoga
D. Therapeutic touch
E. Biofeedback

A. Art therapy C. Yoga E. Biofeedback

A nurse is teaching a group of nursing students on CAM therapies the can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (SATA)

A. Guided imagery
B. Massage therapy
C. Meditation
D. Music therapy
E. Therapeutic touch

A. Guided imagery C. Meditation D. Music therapy

A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention?

A. Tell the client the goal of the therapy as to promote healing
B. Ask whether the client is comfortable with using prayer
C. Encourage the client participate actively for best results
D. Instruct the client to relax during the therapy

B. Ask whether the client is comfortable with using prayer

A nurse is preparing information for change-of-shift report. Which of the following information should
the nurse include in the report?

A. The client’s input and output for the shift
B. The client’s blood pressure from the previous day
C. A bone scan that is scheduled for today
D. The medication routine from the medication administration record

C. A bone scan that is scheduled for today

A nurse is reviewing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? (SATA)

A. A single electronic records password is provided for nurses on the same unit
B. Family members should provide a code prior to receiving client health information
C. Communication of client information can occur at the nurses station
D. A client can request a copy of her medical record
E. A nurse may photocopy a clients medical record for transfer to another facility

B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client can request a copy of her medical record E. A nurse may photocopy a clients medical record for transfer to another facility

A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients record? (SATA)

A. Cover errors with correction fluid and write in the correct information
B. Put the date and time in all entries
C. Document objective data, leaving out opinions
D. Use as many abbreviations as possible
E. Wait until the end of shift to document

B. Put the date and time in all entries C. Document objective data, leaving out opinions

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (SATA)

A. Medication error
B. Needlesticks
C. Conflict with provider and nursing staff
D. Omission of prescription
E. Complaint from a clients family member

A. Medication error B. Needlesticks D. Omission of prescription

A nurse is receiving a providers RX by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (SATA)

A. Repeat the details of the RX back to the provider
B. Have another nurse listen to the telephone RX
C. Obtain the providers signature on the RX within 24 hr
D. Decline the verbal RX because it is not an emergency situation
E. Tell the charge nurse that the provider has prescribed morphine by telephone

A. Repeat the details of the RX back to the provider B. Have another nurse listen to the telephone RX C. Obtain the providers signature on the RX within 24 hr

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

A. client is able to discuss the appropriate technique
B. client is able to demonstrate appropriate technique
C. client states that he understands
D. client is able to write the steps on paper

B. client is able to demonstrate appropriate technique

A nurse in a providers office is collecting data from the mother of a 12 month old infant. Client states her son is old enough for toilet training. Following an educational session with a nurse the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the domains?

A. cognitive
B. affective
C. psychomotor
D. kinesthetic

B. affective

A nurse is providing pre-op education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

A. i dont want my spouse to see my incision
B. will you give me pain meds after surgery
C. can you tell me about how long the surgery will take
D. my roommate listens to everything i say

C. can you tell me about how long the surgery will take

A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take when first meeting with the client?

A. encourage client to participate actively in learning
B. select instructional materials appropriate for older adults
C. identify goals the nurse and client agree are reasonable
D. determine what the client know about stress incontinence

D. determine what the client know about stress incontinence

A nurse is evaluating how well a client learned the info he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the clients learning?

A. encourage client to ask questions
B. ask client to explain how to select or prep meals
C. encourage client to fills out eval form
D. ask client if she has resources for further instruction on this topic

B. ask client to explain how to select or prep meals

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?

A. Orient the client to his room
B. Conduct a client care conference
C. Review medical prescriptions
D. Develop a plan of care

A. Orient the client to his room

A nurse is admitting a client who has acute cholecystitis to a med-surg unit. Which of the following actions are essential steps of the admission procedure? (SATA)

A. Explain the roles of other care delivery staff
B. Begin discharge planning
C. Provide info about advance directives
D. Document the clients wishes about organ donation
E. Introduce the client to his roommate

A. Explain the roles of other care delivery staff B. Begin discharge planning C. Provide info about advance directives E. Introduce the client to his roommate

A nurse is caring for a client who has had a stroke and is scheduled for transfer to a rehab center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (SATA)

A. Ensure that the client has possession of his valuables
B. Conform the the rehab center has room available at the time of transfer
C. Assess how the client tolerates the transfer
D. Give a verbal transfer report via telephone
E. Complete a transfer form for the receiving facility

A. Ensure that the client has possession of his valuables B. Conform the the rehab center has room available at the time of transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility

A nurse is preparing for the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following info about the client should the nurse include in the discharge summary? (SATA)

A. Advance directive status
B. Follow-up care
C. Instructions for diet and medications
D. Most recent vital sign data
E. Contact info for the home health care agency

B. Follow-up care C. Instructions for diet and medications E. Contact info for the home health care agency

As part of the admission process, a nurse at a long-term facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the clients family?

A. BMI
B. Usual times for meals and snacks
C. Favorite foods
D. Any difficulty swallowing

D. Any difficulty swallowing

Trust vs. Mistrust

Infancy (0-1) A sense of trust requires a feeling of physical comfort & minimal amount of fear about the future. Infant’s basic needs are met by responsive, sensitive caregivers. Important event: feeding

Autonomy vs. Shame and doubt

Toddler (1-3) after gaining trust infants discover they have a will. They assert their sense of autonomy or independence. If restrained or punished too harshly, they are likely to develop a sense of shame & doubt Important event: toilet training

Initiative vs. guilt

Preschool (3-5) learn to initiate tasks and carry out plans or they feel guilty about efforts to be independent Important event: independence

Industry vs. Inferiority

Elementary school (6-puberty) Children direct their energy toward mastering knowledge & intellectual skills. The danger at this stage involves feeling incompetent & unproductive. Important event: school

Identity vs. Role confusion

Adolescence (teens-20s) Teenagers work at refining a sense of self by testing roles and then intergrating them in form a single idenity or become confused about who they are Important event: peer relationships

Intimacy vs. Isolation

Young adulthood (20s-early 40s) Young adults struggle to from close relstionships and to gain the capacity for intimate love, or they feel socially isolated Important event: love relationships

Generatively vs. Stagnation

Middle adulthood (40s-60s) The middle-aged discover a sense of contrbuting to the world usually through family and work, or they feel a lack of purpose Important event: parenthood

Integrity vs. despair

Late adulthood (late 60s and up) When reflecting on his or her life the older adult may feel a sense of satisfaction or failure Important event: reflection on/acceptance of ones life

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