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Homework answers / question archive / Rivier UniversityNURSING MISC 1)A nurse is teaching an assistive personnel about using proper body mechanics to prevent injury
Rivier UniversityNURSING MISC
1)A nurse is teaching an assistive personnel about using proper body mechanics to prevent injury. Which of the following actions by the AP indicates an understanding of the teaching?
A. The AP extends his pelvis outward when reaching for an object.
B. The AP keeps the object he is lifting close to his body
C. The AP bends at the waist when lifting an object.
D. The AP relaxes his abdominal muscles when reaching for an object.
2. A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the nurse wear a face shield?
A. Changing the brief of an older adult client who has clostridium difficile infection
B. Suctioning a client’s tracheostomy tube
C. Emptying an indwelling urinary catheter bag
D. Inserting an IV catheter for a client who has peritonitis
3. A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?
A. I will insert the drops in the center of each eye
B. I will raise my eyelid up while looking down to insert the drops
C. I will keep my eyes closed for 5 minutes after inserting the drops.
D. I will press the inner corner of my eyes after I insert the drops
4. 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 about if he asks how he is going to die.” Which of the follow is an appropriate response by the nurse?
A. “Lets talk more about your dad’s condition”
B. “I think you should talk about this with the hospice nurse
C. “Try to help your dad enjoy this time as much as he can”
D. “The social worker will help you answer those questions”
5. A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?
A. Flush the tubing with 10 mL of water every 2 hr. B. Aspirate residual volume every 4 hr.
C. Change tubing set every 72 hr.
D. Heat the formula to 40.5 C (105 F)
6. A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statements by the client’s partner indicates a maladaptive coping?
A. “I don’t understand why he can’t get better and return to work” B. “I don’t know if I will be able to meet his physical needs”
C. “I am going to ask my daughter to come and stay for a week”
D. “I cook for him at home and work hard to prepare nutritious meals”
7. A nurse is providing discharge teaching to a client who does not speak the language as the nurse. Which of the following actions should the nurse take?
A. Offer written instructions in the client’s language. B. Direct verbal discharge instructions to the interpreter
C. Use proper medical terms when giving instructions to the client
D. Request that assistive personnel interpret the instructions for the client
8. A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?
A. Comfort Level B. Peripheral pulses
C. Elimination needs
D. Skin Integrity
9. A nurse is caring for a client who is agitated and threating to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?
A. False Imprisonment
B. Negligence
C. Invasion of privacy
D. Assault
10. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client’s plan of care?
A. Remove the stopcocks from IV tubing
B. Ensure the gloves in the surgical suite are powered gloves
C. Schedule the client as the first surgical procedure of the day
D. Cleanse the stoppers with povidone-iodine before withdrawing medication
11. A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medication for treatment instead of the medication prescribed by her provider. Which of the following is an appropriate response by the nurse?
A. “I can arrange a referral to a practitioner of traditional Chinese medicine”
B. “You should try the prescribed medication before choosing before choosing an alternative” C. “You should ask your provider if she recommends traditional Chinese medicine”
D. “The FDA regulates traditional Chinese medicine
12. A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
A. Assist the client with a bowel cleansing
B. Ensure the client is free of metal objects
C. Monitor the client for pain in the suprapubic region
D. Administer 240 mL (8 oz) of oral contrast before the procedure
13. A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?
A. Apply cornstarch to the client’s arm
B. Arrange for an alternating pressure mattress.
C. Reposition the client every 4 hr.
D. Request a prescription for an indwelling urinary catheter
14. A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate action by the nurse?
A. Discontinue the drainage system when it becomes full
B. Ensure the drainage suction is set on high pressure
C. Measure drainage by emptying into a graduated cylinder
D. Check the volume of the drainage every 24 hr.
15. A nurse in a long-term care facility is assessing a client. Which of the following findings should the nurse recognize as an indication of a fecal impaction?
A. No bowel movement for 48 hr. B. Seepage of liquid stool
C. hypoactive bowel sounds
D. Persistent heartburn
16. A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?
A. Place the client in a negative airflow room
B. Wear a mask when working within 3 feet of the client
C. Administer metronidazole
D. Don protective eyewear before entering the room
17. A nurse a client’s room and discovers a smoldering fire in the drapes. After moving the client to a safe location, which of the following actions should the nurse take next?
A. Pull the fire alarm
B. Turn off any electrical equipment in the room
C. Use an extinguisher to put out the fire
D. Close the doors to client’s room
18. 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 the baseboards on the floor.”
C. “To use a fire extinguisher, aim high at the top of the flames.”
D. “Replace carpeted floors with tile.”
19. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on client’s who are confused. Which of the following instructions should the staff nurse include?
A. Check on the client frequently while he is in the restroom
B. Remove clocks from the client’s room
C. Encourage physical activity throughout the day to expand energy D. Use full length side rails on the client’s bed
20. 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 handoff report?
A. Number of family members who have visited
B. Time of the client’s last bath
C. Effectiveness of the last does of pain medication
D. Frequency of previous vital sign measurement
21. A nurse is preparing to transfer a client who is partially weight-bearing from the bed to the chair. Which of the following actions should the nurse take?
A. Have client bear weight on her stronger side
B. Position the chair next to the bed at a 90 angle.
C. Keep his knees straight when moving the client
D. Stand with his feet together when lifting the client
22. A nurse is assessing a client who is immobile and notices a red area over the client’s coccyx. Which of the following actions should the nurse take?
A. Change the client’s position every 4 hr.
B. Use friction when cleansing the client’s skin
C. Apply a petroleum-based ointment to a red area D. Assess the red area for blanching
23. A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? (Select all that apply)
A. Wear a gown and gloves when providing client care.
B. Wash hands with soap and water after contact with the client
C. Ensure the client does not receive fresh fruits
D. Use an N95 respirator when providing client care
E. Assign the client to a room with positive airflow.
24. 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?
A. “I need to check my medications for expiration dates” B. “I will apply tape over frayed areas of electrical cords”
C. “I need to set my hot water heater to 140 degrees Fahrenheit” D. “I will use the grab bars when getting in and out of the bathtub” E. “I need to have a fire escape plan with my family”
31. 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. Place the cap of a sterile solution inside the sterile field.
D. Consider 5.08 cm (2 in) of the sterile field's border to be contaminated.
32. A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin- resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. I will place the client in a private room.
B. I will wear an N95 respirator mask when caring for the client.
C. I will remove my gown before my gloves after providing client care.
D. I will tell the client's visitors to wear a mask when they are within 3 feet of the client
33. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?
A. Use a cotton tip applicator to clean inside the inner cannula.
B. Secure the tracheostomy ties to allow one finger to fit snugly underneath.
C. Soak the outer cannula in warm, soapy tap water.
D. Cleanse the skin around the stoma with normal saline.
34. A charge nurse is monitoring the documentation of medications by a newly licensed nurse. The charge nurse should intervene if the newly licensed nurse uses which of the following abbreviations?
A. IM
B. q4h
C. stat D. qd
35. A nurse is conducting a weber test on a client. Which of the following is an appropriate action for the nurse to take?
A. Whisper a series of words softly into one ear.
B. Hold an activated tuning fork against the client's mastoid process
C. Deliver a series of high-pitched sounds at random intervals.
D. Place an activated tuning fork in the middle of the client's forehead.
36. A nurse is teaching an older 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 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 can apply lotion to soften calluses as long as I don’t put lotion between my toes
C. I should use over-the-counter liquid medication to remove corns
D. I should soak my feet in warn water daily to soften corns and calluses
37. 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 remove my antiembolic stockings while I am in bed.
B. I will have my partner help me change positions every 4 hours. C. I will perform ankle and knee exercises every hour.
D. I will hold my breath when rising from a sitting position.
38. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
A. Case manager
B. Client care provider
C. Client advocate
D. Client educator
39. To nurse is planning to obtain a blood sample from a client for a capillary blood glucose test. Which of the following sites should the nurse plan to select to obtain to obtain the sample?
A. The pad of the fingertip
B. The side of the wrist
C. The pinna of the ear
D. The lateral aspect of the finger
40. A nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?
A. Have a colonoscopy every 3 years.
B. Have a fecal occult blood test every 2 years.
C. Limit intake of dietary fiber. D. Reduce intake of red meats
41. A nurse is preparing change-of-shift report after the night using the I-SBAR communication tool. Which of the following data should the nurse include reporting background information?
A. Code status: do-not-resuscitate
B. Pain rating of 5 on a scale from 0 to 10 C. Start first dose of penicillin at 1200
D. Blood pressure 160/92 mm Hg
42. A nurse is preparing to apply a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse plan to take?
A. Allow 2.5 to 5 cm (1 to 2 in) between the end of the catheter and the tip of the penis.
B. Keep foreskin in a retracted position after application of the catheter.
C. Place adhesive tape directly on the penis.
D. Change the condom catheter every 3 days.
43. A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy?
A. The cephalic vein in the left distal forearm.
B. The radial vein on the left wrist.
C. The cephalic vein on the back of the right hand.
D. The basilic vein in the right antecubital fossa
44. A nurse is teaching a client how to perform breast self-examination(BSE). Which of the following instructions should the nurse include?
A. Squeeze the nipple to look for discharge.
B. Perform BSE 1 week prior to the onset of menses.
C. Palpate in horizontal motion from the outer breast towards the nipple.
D. Wash and dry each breast prior to palpation
45. A nurse is preparing to administer a medication to a client by the intradermal route. After applying gloves and cleaning the site with an antiseptic swab, in what order should the nurse take the steps below to administer the medication? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A. Withdraw the needle
B. Insert the needle at a 15 degree angle
C. Use the nondominant hand to stretch the skin.
D. Activate the needle safety device.
E. Inject the medication Answer: C, B,E,A.D
46. A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
A. The client turns his head against resistance.
B. The client's tongue is in a midline position.
C. The client's pupils constrict in response to light. D. The client has a symmetrical smile.
47. A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take?
A. Place the bell of the stethoscope on 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. Follow a systematic pattern from side-to-side moving down the client's chest
48. 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 B. Place the diaphragm of the stethoscope over each quadrant
C. Auscultate for 2 min to determine if bowel sounds are absent
D. Ask the client to cough upon auscultation.
49. A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?
A. Musculoskeletal weakness
B. Left lower extremity tenderness.
C. Increased heart rate during physical activity.
D. Loss of appetite
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. Changing IV tubing.
C. Inserting a nasogastric tube.
D. Performing a simple dressing change
51. A nurse is reviewing client confidentially with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPAA?
A. Teaching the client discharge instructions with his partner present.
B. Giving a telephone report to a surgical nurse when sending the client to the surgical suite. C. Discussing the client's transfer to a long term care facility with a nurse from another unit.
D. Faxing medical information to the client's provider's office.
52. A nurse in a long-term care facility is planning care for four clients. Which of the following clients is at greatest risk for developing a pressure ulcer?
A. A client who is incontinent of urine one to two times during the day
B. A client who requires assistance to transfer from a bed to chair
C. A client who is receiving enteral tube feedings
D. A client who is unresponsive to a painful stimulus
54. a nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?
56. a nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings?
57. a nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?
58. a nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?
59. a nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?
60. a nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following images indicates the proper method of cleaning a wound site?
61. a nurse is caring for a client who reports a pain level of 5 on a scale of 0- 10. The client informs the nurse that pain medications is not an option for managing pain. Which of the following is an appropriate response by the nurse?
62. a nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?
63. a nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears an assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?
64. a nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take?
65. a nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?
66. a nurse is caring for a client who is schedule for surgery while witnessing the client signature. While the client is saying I trust my doctor, but I don’t understand what he meant when he said he’ll reset my intestines. Which of the following actions should the nurse take?
67. a nurse Is caring for a client who is 6 hours postoperative abdominal surgery and who is having difficulty voiding. Which of the following actions should the nurse take?
68. an adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest?
69. a nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching?
70. a nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?
71. a nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first?
72. a nurse is caring for a client who has a new prescription of inserting a NG tube. Which of the following is the most reliable method for evaluating tube placement?
73. nurse is caring for a client who is prescribed a special diet the client is concerned that he does not have the resources to purchase the food he needs to adhere to. The nurse should notify which of the following members of the health care team?
