Iron Man
1. After a client falls out of bed, the nurse completes:
A. a safety event report (incident report).
B. a telephone call to hospital's attorney.
C. a progress note stating event report was completed.
D. a malpractice report.
A. a safety event report (incident report).
What type of bath is preferred to decrease the inflammation after rectal surgery?
A. bed bath
B. tub bath
C. whirlpool bath
D. sitz bath
D. sitz bath
A nurse is initiating a peripheral venous access IV infusion prescribed for a client preoperatively. In what position would the nurse place the client to perform this skill?
A. high-Fowler
B. low-Fowler
C. Sims
D. dorsal recumbent
B. low-Fowler
Which client will have more adipose tissue and less fluid?
A. A woman
B. A man
C. An infant
D. A child
A. A woman
Which body fluid is the fluid within the cells, constituting about 70% of the total body water?
A. extracellular fluid (ECF)
B. intracellular fluid (ICF)
C. intravascular fluid
D. interstitial fluid
B. intracellular fluid (ICF)
A client is very anxious and states, "I am so stressed." What is the reason stress affects the client's safety?
A. Stress increases retention of information.
B. Stress affects interpersonal relationships.
C. Stress increases concern about hazards.
D. Stress tends to narrow the attention span.
D. Stress tends to narrow the attention span.
Which consideration should a nurse prioritize relating to the use of herbs and supplements by a client?
A. potential interactions with drugs
B. the client's cultural background and beliefs
C. the client's previous use of herbal supplements
D. pharmacologic alternatives to herbs and supplements
A. potential interactions with drugs
A nurse is shaving the facial hair of a client confined to bed. What is a recommended guideline for this procedure?
A. Fill bath basin with cool water.
B. Apply shaving cream approximately 1 inch thick.
C. Shave with the direction of hair growth in downward, short strokes.
D. Do not use aftershave or lotion on the area shaved.
C. Shave with the direction of hair growth in downward, short strokes.
A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?
A. It can cause the nasal mucosa to dry in case of high flow.
B. It can cause anxiety in clients who are claustrophobic.
C. It can create a risk of suffocation.
D. It can result in an inconsistent amount of oxygen.
A. It can cause the nasal mucosa to dry in case of high flow.
A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?
A. The client's family members have been donors.
B. The client donates their own blood.
C. The client's blood has been rendered sterile.
D. The client will only need fluids, not blood.
B. The client donates their own blood.
A nurse makes a medication error and fills out an incident report. What will the nurse do with the safety event report once it is filled out?
A. Place it in the client's medical record.
B. Take it home and keep it locked up.
C. Maintain it according to agency policy.
D. Include it with documentation of the error.
C. Maintain it according to agency policy.
Which essential oil can be used during aromatherapy to treat nausea?
A. Lavender
B. Garlic
C. Parsley
D. Ginger
D. Ginger
A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. What should the nurse ask the client to do?
A. Wash hair daily.
B. Use dry shampoo.
C. Use oil-based shampoo.
D. Use anti-lice shampoo.
A. Wash hair daily.
A nurse is preparing to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?
A. discomfort
B. pain
C. minor bleeding
D. infection
D. infection
A nurse is changing a client's peripheral IV dressing. Which step is recommended in this procedure?
A. Observe clean technique to minimize the possibility of contamination.
B. Cleanse the site thoroughly with sterile saline or according to facility policy.
C. Apply chlorhexidine to the site in order to disinfect.
D. Wipe or blot the site dry and allow it to dry completely before covering it.
C. Apply chlorhexidine to the site in order to disinfect.
The older adult client was admitted to the emergency department for accidentally overdosing on a prescribed medication. The client is prescribed several medications that have varying frequencies for administration. The nurse is providing tips to the client to prevent such an occurrence from happening again. What instructions would the nurse provide to the client? Select all that apply.
A. Place pills in a pill dispenser that provides for separate dosing throughout the day.
B. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit.
C. Contact the pharmacist or primary care provider about questions regarding medications.
D. Request large-print medication labels on each of the prescribed medication bottles.
E. Keep discontinued medications in case the health care provider prescribes the medication again.
A. Place pills in a pill dispenser that provides for separate dosing throughout the day.
B. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit.
C. Contact the pharmacist or primary care provider about questions regarding medications.
D. Request large-print medication labels on each of the prescribed medication bottles.
Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agent. What is an appropriate consideration when assisting the client with morning hygiene?
A. Provide the client with an electric shaver.
B. Provide the client with a firm-bristled toothbrush.
C. Do not allow the client to shower.
D. Avoid massaging the client's back with lotion.
A. Provide the client with an electric shaver.
A nurse has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the nurse do?
A. Provide total physical hygiene, including perineal care.
B. Provide total physical hygiene, excluding hair care.
C. Provide supplies and orient the client to the bathroom.
D. Provide supplies and assist with hard-to-reach areas.
D. Provide supplies and assist with hard-to-reach areas.
A 78-year-old client with diabetes needs to have their toenails trimmed. It is important for the nurse to do what?
A. Remove ingrown toenails.
B. Cut the nail straight across.
C. Protect the foot from blisters.
D. Soak the foot in witch hazel.
B. Cut the nail straight across.
While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event?
A. Submerge the end of the chest tube in a container of sterile water.
B. Clamp the tube near the end and also near the insertion point.
C. Place the end of the tube on a sterile surface and seek help promptly.
D. Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit.
A. Submerge the end of the chest tube in a container of sterile water.
After numerous unsuccessful strategies to protect a client, it is determined that an extremity restraint is needed. Which action will the nurse do first?
A. Ensure an order had been obtained from the appropriate practitioner.
B. Explain the reason for the restraint to the client and family.
C. Inspect the restraint for damage, rips, or tears.
D. Apply padding to protect bony prominences.
A. Ensure an order had been obtained from the appropriate practitioner.
The nurse is discussing complementary health alternatives (CHAs) with a client recently diagnosed with mixed connective tissue disorder (MCTD). After setting a goal for reduced musculoskeletal pain through mind–body intervention as well as manipulative and body-based methods, which statement by the client indicates an understanding of how the use of this alternative therapy will be a benefit?
A. "Massage therapy, yoga, and relaxation techniques will help reduce my muscle and joint pain by redirecting the flow of energy through the body thus treating my diagnosis holistically."
B. "Acupuncture and herbal therapy will be useful in treating my diagnosis in separate components, the mind and the body."
C. "Seeing both a chiropractor and health care provider means treating my diagnosis in components because parts of an organism rarely interact or change, but can be manipulated."
D. "The idea behind CHA is that traditional medicine is most effective for chronic illnesses such as mine, but alternative medicine is best for acute illnesses."
A. "Massage therapy, yoga, and relaxation techniques will help reduce my muscle and joint pain by redirecting the flow of energy through the body thus treating my diagnosis holistically."
Which client would be at highest risk for injury to the skin and mucous membranes?
A. 10-day-old infant with no health problems
B. 17-year-old adolescent with asthma
C. 44-year-old adult with hemorrhoids
D. 77-year-old client with diabetes
D. 77-year-old client with diabetes
The nurse is auscultating breath sounds of an infant with respiratory syncytial virus. For which finding will the nurse immediately contact the health care provider?
A. Respiratory rate decrease from 40 to 32 breaths per minute
B. Heart rate decreased from 110 to 100 beats per minute
C. Quiet chest from previous assessment of wheezing
D. An oxygen saturation of 90%
C. Quiet chest from previous assessment of wheezing
A specially trained nurse has inserted a PICC line. What would be done next?
A. Start administration of prescribed fluids.
B. Explain the procedure to the client and family.
C. Place the client on restricted oral fluids.
D. Send the client to the radiology department.
D. Send the client to the radiology department.