Fill This Form To Receive Instant Help
Fill This Form To Receive Instant Help
Homework answers / question archive / California State University, Long Beach TTT 67777 2013 - Folder 1 1)A nurse is providing teaching to a client who has a new med prescription
California State University, Long Beach
TTT 67777
2013 - Folder 1
1)A nurse is providing teaching to a client who has a new med prescription. Which of the following manifestations of a mild allergic reaction should the nurse include?
a. Ptosis
b. Hematuria
c. Urticaria
d. Nausea
2. A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood glucose test. Which of hte following instructions should the nurse include in the teaching?
a. Don sterile gloves prior to puncturing the site
b. Puncture site after cleansing and before antiseptic dries.
c. Gently squeeze the puncture site until a large droplet of blood forms
d. Hold the finger to puncture above the level of the heart
3. A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures .
b. I will hold my breath when rising from a sitting position
c. I will remove my antiembolic stockings while I am in bed
d. I will have my partner help me change positions every 4 hours
4. A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phelbitis at the IV site?
a. Erythema along the path of the vein
b. Pitting edema at the insertion site- infiltration since water is probably displaced.
c. Coolness of the client’s left forearm - infiltration
d. Pallor of the client’s left forearm
5. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?
a. Provide a late supper
b. Offer a wet washcloth for the client to wash her face
c. Perform range of motion excercise
d. Prepare a hot cocoa or tea for the client
6. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the following statements by the newly licensed nurse indicates an understanding of teaching?
a. I will place the client in a private room
b. I will tell the client’s visitors to wear a mask when they are within 3 feet of the client
c. I will remove my gown after leaving the client’s room
d. I will wear an N95 respirator mask when caring for the client
7. A nurse is teaching a client who requires maximal support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching.
a. The client moves the walker ahead 25.4cm with each step
b. The client picks up the walker with each step
c. The client stands with her elbow slightly while holding the walker
d. The client stoops slightly forward when moving the walker
8. A nurse in a provider’s office is caring for a client who states “I always have trouble sleeping”. Which of the following actions should the nurse take first?
a. Teach the client stress reduction techniques
b. Recommend that the client avoid caffeine intake in the evening
c. Identify the client typical bedtime routine
d. Encourage the client to exercise regularly during day time hours.
9. A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the nurse include when developing the plan of care?
a. The hispanic culture views late adulthood as a negative time in the client’s life
b. The hispanic culture identifies the eldest female family member as the decision maker
c. The Hispanic culture expects individuals to make their own decisions when death is imminent.
d. The hispanic culture expects adult children to care for older adult parents.
10. A nurse is teaching about home safety with a client. Which of the following instructions should the nurse include?
a. Unplug electronics by grasping the cord
b. Use electrical tape to secure extension cords next to baseboards on the floor
c. To use a fire extinguisher, aim high at the top of the flames.
d. Replace carpeted floors with tile
11. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?
a.) Perform deep palpation at the end of the admission assessment
b.) Auscultate the client’s abdomen before palpation
c.) Begin palpation of the abdomen at the site of pain
d.) Assess the client’s bowel sounds using the bell of the stethoscope
12. A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
a.) Allow the client to hear running water while attempting to void
b.) Provide the client a bedpan while lying supine
c.) Insert an indwelling urinary catheter and connect it to gravity drainage d.) Encourage fluid intake up to 1,000 mL daily
13. A nurse on a medical surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?
a. ) A client who has new onset of dyspnea 24 hr after a total hip arthroplasty0 can mean dvt
b.) A client who has acute abdominal pain of 4 on a scale from 0 to 10 c.) A client who has a UTI and low-grade fever
d.) A client who has pneumonia and an oxygen saturation of 96%
<always look for new onset of anything, other findings are normal also.>
14. A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern about his future. Which of the following is therapeutic response by the nurse?
a.) “You’re concerned about what will happen when you leave the hospital?”
b.) “If you work hard on your physical therapy, you won’t need to worry”
c.) “You shouldn’t worry about the future so you can concentrate on getting well” d.) “Why are you concerned even though everyone is here to help you?”
15. A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take?
a.) Follow a systematic pattern from side-to-side moving down the client’s chest
b.) Ask the client to breathe in deeply through his nose
c.) Instruct the client to sit erect with his head tilted slightly backward d.) Place the bell of the stethoscope on the client’s chest
16. A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select ALL)
a.) “I need to set my hot water heater to 140 degrees Fahrenheit”
b.) “I will use the grab bars when getting in and out of the bathtub”
c.) “I will apply tape over frayed areas of electrical cords”
17. A nurse is caring for a client preoperatively who has given informed consent for an appendectomy. Which of the following statements by the client should the nurse address first?
a.) “I am afraid to walk if it hurts too much”
b.) “I don’t understand why I need this surgery”
c.) “I don’t want my family helping me after the surgery” d.) “I am afraid the scar will make me look disfigured”
18. A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?
a.) “I should roll the NPH vial between my hands before drawing it up”
b.) “I should draw up the NPH insulin before the regular insulin”
c.) “I should inject air into the vial of regular insulin first”
d.) “I should wait 10 minutes after mixing the insulin to inject it”
<NPH - regular - regular - NPH>
19. A nurse is caring for a client who is confused and pulling at the tubing of her IV. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider?
a.) Place the client in a room away from the nurses’ station b.) Limit the client’s visitors
c.) Give the client washcloths to fold
d.) Close the door of the client’s room
20. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?
a.) Where the client ate his breakfast
b.) The times for routine vital sign measurements c.) The exact times the client had visitors
d.) The type of transmission-based precautions in place
21. A nurse on a med-surg unit is teaching newly licensed nurse about tasks to delegate to AP. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
a.) “An AP may take orthostatic blood pressure measurements from a client who reports dizziness” - RNs job since this requires ASESSMENT due to episode of adverse effect.
b.) “An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids”- monitoring is part of assessment since it is using judgment
c.) “An AP may perform a central line dressing change for a client who is ready for discharge”
d.) “An AP may count the respirations of a client who is going to have surgery later the same day”- the client has surgery LATER that day, so this should mean that the patients condition is not that urgent
22. A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?
a.) A surgeon who removed the wrong kidney during a surgical procedures refuses to take responsibility of her actions- please double check anyone
b.) A client who has a new colostomy refuses to take instructions from the ostomy therapist because she “doesn’t like him”
c.) The family of a client who has a terminal illness asks that the provider not tell the client the diagnosis d.) A client who has Crohn’s disease reports that his prescription drug plan will not pay for his
medications
23. A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client’s continuity of care?
a.) Plan to assign a different nurse to the client each shift
b.) Limit the number of interdisciplinary team members managing the client’s care c.) Request that the client complete a satisfaction survey at discharge
d.) Start discharge planning on the day of admission
24. A nurse is caring for a client who begins to experience a generalized seizure while standing in her room.
Which of the following actions should the nurse take?
a.) Place a pad under the client’s head
b.) Hold the client’s limbs tightly to prevent injury
c.) Lift the client into bed with the help of other staff members
d.) Insert a bite block into the client’s mouth
25. A nurse is caring for a client who is grieving the loss of her partner. The client states, “I don’t see the point of living anymore.” Which of the following actions should the nurse take?
a.) Recommend that the client seek spiritual guidance
b.) Request that the client’s family provide additional support c.) Tell the client that this is a normal response to grief
d.) Ask the client if she plans to harm herself
26. A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?
a.) Empty the drainage bag at least every 8 hr
b.) Keep the drainage bag at the level of the bladder
c.) Use the clean technique to collect a specimen from the drainage system
d.) Tape the catheter to the lower abdomen
27. A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include?
a.) “Keep a nightlight on the bathroom”
b.) “Set room temperature to 68 degrees Fahrenheit” c.) “Place throw rugs over electrical cords”
d.) “Use chairs without arm rests”
28. A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care” (select ALL)
a.) Secure restrains to allow three fingers to slide under the restrains (1-2 fingers)
d.) Attach the client’s restraints to the bed rail (to the bed frame)
e.) Remove the client’s restraints every 2 hr
29. A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client’s son tells the nurse, “I don’t know what to tell my dad if he asks how he is going to die.” Which of the following is an appropriate response by the nurse?
a.) “Let’s talk more about your dad’s condition” “The social worker will help you answer those questions”
c.) “I think that you should discuss this with the hospice nurse”
d.) “Try to help your dad enjoy this time as much as he can”
30. A nurse is caring for a client who will receive intermittent enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? (select ALL)
a.) Keep the client sitting upright for 15 min following administration
b.) Instill the formula over a period of 30 to 45 min
c.) Heat the formula to 80F prior to administration
d.) Check for residual volumes by aspirating stomach contents
e.) Place the client into the Fowler’s position
31. A nurse is assessing a client who is receiving tube feedings via NG tube. Which of the following findings should the nurse report to the provider?
a.) Potassium 5.5 mEq/L b.) Irritation of nasal mucosa c.) Sodium 144 mEq/L
d.) Loose stools
32. A nurse is caring for a client who consumed 4 oz of juice, 16 oz of milk, 8 oz of coffee, and 200 mL of water over an 8-hr period. Calculate the client’s intake for that 8-hr period using millilters. (nearest whole number) 1oz=30mL
33. A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?
a.) Use proper medical terms when giving instructions to the client.
b.) Offer written instructions in the client’s language
c.) Direct verbal discharge instructions to the interpreter (No, supposed to address the pt) d.) Request that an assistive personnel interpret that instructions for the client
34. A nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?
a.) Don sterile gloves prior to opening sterile dressing supplies
b.) Set up the sterile field above waist level
c.) Consider 5.08cm (2 in) of the sterile field’s border to be contaminated d.) Place the cap of a sterile solution inside the sterile field
35. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube?
a.) Assess the client for a gag reflex
b.) Measure the pH of the gastric aspirate
c.) Place the end of the NG tube in water to observe for bubbling
d.) Auscultate 2.5cm (1 in) above the umbilicus while injecting 15 mL of sterile water
36. A nurse is documenting in a client’s medical record. Which of the following entries should the nurse record? a.) “Incision without redness or drainage”
b.) “Drank adequate amounts of fluid with meals”
c.) “Administered pain medication”
d.) “Oral temperature slightly elevated at 0800”
37. A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take?
a. Press straight down on the container to create a vacuum
b. Wear sterile gloves when emptying the container
c. Reset the container with the drainage port closed
d. Maintain the drain in a dependent position to facilitate drainage
38. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corn
And calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?
a. I can place an oval corn pad over toes that have corns as long as i remove the pad weekly
b. I should soak my feet in warm water daily to soften corns and calluses
c. I can apply lotion to soften calluses as long as i dont put lotion between my toes
d. I should use an over the counter liquid medication to remove corns
39. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?
a. Remove clocks from the clients room
b. Use full length side rails on the clients bed (considered a restraint)
c. Check on the client frequently while he is in the restroom (safety)
d. Encourage physical activity throughout the day to expend energy
40. A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate?
a. Contact
b. Droplets
c. Airborne
d. Protective environment
41. A nurse is planning to use nonpharmacological pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan?
a. Encourage the client to apply a heating pad for 2 hours at a time
b. Apply an ice pack to the clients back for 1 hour
c. Remove distractions from the client’s room (distraction is good for the pt to get mind off of pain)
d. Instruct the client to take deep, rhythmic breaths
42. A nurse is teaching a client how to use an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
a. I will try not to cough after using the spirometer (it’s good to cough up sputum)
b. I will use the spirometer three times a day (3-5x an hour)
c. I will initially hold my breath for 15 seconds (for inhalers)
d. I will seal my lips around the mouthpiece
43. A charge nurse is assigning tasks to nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?
a. Report ABG results to the provider
b. Instruct a client about how to use an incentive spirometer
c. Administer an enteral feeding to a client who has an established gastrostomy tube
d. Monitor the color of a client’s urinary output
44. A nurse is interviewing a family as part of a family assessment. The nurse identifies the family unit as a husband, a wife, and three children. One child is biological from this marriage and the other two are from the wife’s previous marriage. The nurse should identify this as which of the following family forms?
45. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first?
a. Obtain a replacement pump
b. Notify the biomedical department to fix the pump
c. Label the pump with a defective equipment sticker
d. Unplug the pump
46. A nurse is preparing to insert IV catheter for an adult client. Which of the following actions should the nurse take?
a. Choose the most proximal site on the extremity selected (distal first)
b. Apply a cool compress for several minutes before insertion of the IV catheter (warm it)
c. Stroke the extremity for several minutes before insertion of the IV catheter
d. Place the tourniquet below the proposed insertion site (above it)
47. A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching
a. I will place the bed in the lowest position (place at your hip level)
b. I will tighten my abdominal muscles prior to moving
c. I will keep my legs straight to provide more power in the lift (bend)
d. I will twist at the waist while pulling the draw sheet (avoid)
48. A nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report?
a. Frequency of previous vital sign measurement
b. Number of family members who have visited
c. Time of the clients last bath
d. Effectiveness of the last dose of pain medication
49. A nurse is assessing a client’s bowel sounds. Which of the following actions should the nurse take?
a. Listen to the bowel sounds after performing abdominal palpation (inspect, auscultate, percuss palpate)
b. Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes)
c. Place the diaphragm of the stethoscope over each quadrant
d. Ask the client to cough upon auscultation (for lung assessment)
50. A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate?
A. Evaluating healing of an incision
B. Inserting a NG Tube
C. Performing a simple dressing change.
D. Changing IV tubing.
51. A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?
A. HR 105/min
B. BMI 25 kg/m2
C. BP 148/92
D. Glucose 45mg/dl
52. A nurse is assessing a client’s extraocular eye movements. Which of the following actions should the nurse take?
A. Position the client 6.1m(20ft) away from the Snellen chart.
B. Instruct the client to follow finger through the six cardinal position of gaze,
C. Ask the client to cover her right eye during assessment of her left eye.
D. Hold a finger 46cm (18inch) in front of the client’s eye.
58.A nurse is planning care for a client who has prescription of knee-length antibolic stockings. Which of the following actions should the nurse take?
A. Remove the client’s stockings at least once each shift.
B. Roll the top of the client’s stocking down to just below the knee.
C. Seat the client in a chair for 30min prior to applying stockings
D. Measure the length of the client’s leg from the heel to gluteal fold.
59. A nurse is assessing a client’s oculomotor nerve functions. Which of the following actions should the nurse take?
A. Check the client’s pupillary reaction to light
B. Ask the client to read print from the Snellen chart
C. Ask the client to identify diff scents
D. Use cotton to touch the client’s cornea lightly.
60. A nurse is planning to perform ear irrigation on an adult client who has impacted cerumen. Which of the following should the nurse plan to take?
A. Wear sterile gloves while performing irrigation
B. Position the client with the affected side down following irrigation
C. Use cool fluid to irrigate the ear canal.
D. Pull the pinna downward during irrigation.
61. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication are not option for managing pain. Which of the following is an appropriate response by the nurse?
A. Im sure it will work if you just give it a chance?
B. You may take any herbal remedies you bring from home
C. Why do you think pain medication is not going to help you
D. Would you like me to give you a back massage?
62. A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first?
A. Provide the client with contact number for diabetes education specialist.
B. Obtain printed information on insulin self-administration
C. Make a copy of the medication reconciliation from for the client
D. Determine whether the client can afford the insulin administration supplies
63. A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?
A. Allow the client to slide down his outstretched leg.
B. Place his arms around the client to prevent her fall.
C. Remain upright as the client falls toward him
D. Move quickly to a position in front of the client.
64. A nurse is preparing to use the Z-track method to administer iron dextran to a client who has iron-deficiency anemia. The client asks why this method of injection is necessary. Which of the following responses should the nurse make?
A. It decreases the risk of injecting medication into a blood vessel.
B. It delays medication absorption
C. It minimizes tissue irrigation
D. It accelerates medication excretion
65. A nurse is conducting a health assessment for a client who take herbal supplements. Which of the following statement by the client indicates an understand of the use of the supplements?
A. I use garlic for my menopausal symptoms.
B. I use ginger when I get car sick
C. I take ginkgo biloba for headache
D. I take echinacae to control cholesterol
66. A nurse is caring for a client who has C-diff infection Which of the following actions should the nurse take?
A. Give the client chlorhexidine gluconate for hand hygiene.
B. Remove the protective gown first when exiting the client's room
C. Use alcohol-based hand rub when caring for the client
D. Initiate contact precautions when providing client care
67. A nurse is caring for a client who is scheduled for hip surgery in hr. Which of the following actions is the nurse’s priority?
A. Ensure that the client has signed the consent form.
B. Lock the client’s valuable in a safe location
C. Verify that the client’s lab values are in the medical record.
D. Administer the prescribed preoperative sedative.
68. A nurse is caring for a client who has prescription for morphine 5mg IM accidentally administers the whole 10mg from the single dose vial. Which of the following actions should the nurse take first?
A. Complete an incident report
B. Measure the client’s respiratory rate
C. Report the incident to the pharmacy.
D. Notify the client's provider
Already member? Sign In
