Oh Shoot
A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?
A. Gloves
B. Goggles
C. Gown
D. Mask
D. Mask
The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 3 feet of the client.
A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?
A. Allow the AP to deliver the food tray to the client
B. Call dietary department and ask for a kosher diet.
C. Replace the nonfat milk with apple juice
D. Explain to the client that he needs the protein in the milk and beef
B. Call dietary and order a Kosher diet tray
Cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who practice the Orthodox Jewish faith do not eat meat and dairy together.
A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the client's use of a cane?
A. "When the client moves, he should move the cane forward first"
B. "The client should hold the cane on the weak side of his body"
C. "The grip should be level with the client's waist"
D. "The client should first move the strong leg, then the weak one"
A. When the client moves, he should move the cane forward first.
First move the cane forward 12 inches, then move the weak leg even with the cane, move his strong leg forward and ahead of the cane and his weak leg.
Hold the cane on the strong side, the grip should be level with the trochanter of the femur. Bend of the arm 30 degrees.
A nurse is caring for a client who reports constant leakage of small amounts of urine and a bladder that is distended and palpable. The should associates these findings with which of the following incontinence?
A. Stress Incontinence
B. Urge Incontinence
C. Overflow Incontinence
D. Reflex Incontinence
Overflow - pressure of urine in an overfull bladder overcomes sphincter control
Stress - loss of urine with physical exertion (laughing..)
Urge - strong desire to urinate
Reflex - neurologic dysfunction and occurs with no warning signs
1. A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse?
A. Speak using his usual tone of voice
B. Stand directly in front of the client
C. Rephrase statements the client does not hear
D. Determine if the client uses hearing aids
2. How would the nurse educate the client to clean his hearing aids?
1. D. Determine if the client uses hearing aids.
The nurse should always start by using the nursing process; assessment.
2. Hearing aids: use a soft cloths to remove cerucem and other debris, never immerse them in water. soap and water
A nurse is preparing to administer amoxicillin 350mg PO. Available is amoxicillin 250mg/5mL. How many mL should the nurse administer? Round to the nearest whole number.
7mL
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?
A. Abrasion
B. Contusion
C. Laceration
D. Puncture
Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged and irregular. Lacerations are often considered contaminated wounds because of the introduction of bacteria or debris that can be in the wound.
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multi drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
A. Ask the x-ray technician to come to the client's room to obtain a portable x-ray
B. Have the client wear a mask
C. Notify the x-ray department that the client requires airborne precautions
D. Wear a filtration mask and gloves during transport
B. Have the client wear a mask.
When a client who has a communicable disease must leave the room, it is important to protect others who the clients come in contact with. Having the client wear a mask protects others. The question is asking what necessary procedures does the nurse need to take when taking the client outside the room.
A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following foods is a good source of high-quality protein?
A. Soybeans
B. Grains
C. Legumes
D. Green vegetables
A. Soybeans
Soybean products are high-quality, or complete sources of protein. They contain all nine essential amino acids required for growth and maintenance of the body.
A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply?
A. Transparent dressing
B. Wet-to-dry glaze dressing
C. Hydrogel dressing
D. Alginate dressing
A. transparent dressing
involves only the epidermal skin, protects the skin from moisture and bacteria while allowing oxygen to reach the skin.
wet-to-dry dressing is to remove necrotic tissue from a wound
hydrogel = rehydrates the bed of the wound and promotes autolytic debridement, use for stage II - IV pressure ulcers
alginate = stage II - IV that have moderate to heavy drainage
A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?
A. Limit the client's fluid intake in the evening
B. Obtain a bedside commode for the client's use
C. Leave a nightlight on in the client's room
D. Put the side rails up and tell the client to call the nurse before voiding
Leave a nightlight on in the client's room.
Answer Rationale:
This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?
A. "Are there any specific factors that you think are affecting your ability to sleep?"
B. "Can you describe your bedtime routine to me?"
C. "Do you have a difficulty staying awake when you are driving?"
D. "When did you begin to have trouble sleeping?"
A nurse is preparing to administer digoxin 12mcg/kg/day PO to divide equally every 12 hr to a school-age child who weighs 66lb. Available is digoxin elixir 0.05mg/mL. How many mL should the nurse administer per dose?
3.6 mL
When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document adventitious breath sounds as?
Wheezes - could be asthma
A nurse is assisting with the admission of a child who has measles. Which of the following isolation precautions should the nurse initiate?
Airborne - The nurse should initiate airborne precautions, it is transmitted via droplet <5 microns. The should place the child in a negative pressure air flow room and wear a N95 mask when providing care.
A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving a continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
A. Observe the client's respiratory status
B. Elevate the head of the client's bed 30-45 degrees.
C. Monitor intake and output every 8 hours
D. Check residual volume every 4-6 hours
B. Elevate the head of the client's bed 30-45 degrees. High risk for aspiration, keeping the head of the bed up promotes gastric emptying and reduce the risk of aspiration.
The remainder answer are all correct, but not the priority.
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
A. Place the wheelchair at a 90 degree angle to the bed
B. Lock the wheels of the bed and the wheelchair
C. Acquire the help of several people to lift the client
D. Elevate the bed to a position of comfort for the nurse
B. Prevent an injury, always lock the wheelchair.
Place the wheelchair closest to the bed as possible to prevent a fall, there is no indication that the client is so weak that the staff must lift him. if the client requires lifting, always use an assisted device and extra staff for assistance. when assisting the client out of the bed, put it in the lowest position.
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
A. Urine output of 175mL in the past 8 hours
B. Urine output 2200 mL in the past 24 hour
C. First voided urine in the morning has a strong odor
D. Urine is cloudy after sitting in the urinal for 6 hours
Urine output of175 mL in the past 8 hr - The nurse should notify the provider if the client’s urinary output is less than 30 mL/hr. This finding indicates a fluid imbalance, decreased circulating fluid volume, and possibly inadequate renal perfusion.
Urine is usually more concentrated in the morning and has a stronger odor. The nurse does not need to notify the provider of this finding.
A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?
The left second intercostal space
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that a nurse the wear gloves? Select all that apply
A. Emptying urine from an indwelling urine collection bag?
B. Providing oral care
C. Changing an stony pouch
D. Delivering a food tray to a client who has AIDS
E. Placing oral medication tablets into a client's hand
A, B, C
Do not need to wear gloves delivering a food tray to a client with AIDS and giving an oral medication
A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?
A. Attach a humidifier bottle
B. Hyperoxygenate the client before they eat and remove the nasal cannula while they eat
C. Secure the oxygen tubing to the bed sheet near the client's head
D. Apply petroleum jelly to the nares as needed to soothe mucous membranes
Attach a humidifier bottle to the base of the flow meter. Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.
The nurse should maintain sufficient slack and secure the oxygen tubing to the client’s clothing. The nurse should apply water-soluble lubricant, not petroleum jelly, as needed to soothe the mucous membranes.
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
A. Suction 2-3 times with a 60 second pauses between passes
B. Perform chest physiotherapy prior to suctioning
C. Lubricate the suction catheter tip with sterile saline
D. Hyperventilate the client on 100% oxygen prior to suctioning
A. Suction 2-3 times with a 60 second pause
Copious secretions will require more than 1 pass, 60 second pause will help prevent hypoxia.
Chest physiotherapy will mobilize secretions, C & D has no effect on removing secretions.
A nurse is developing an education program for a community group about dietary intake of vitamins and minerals in the diet. The nurse should include which of the following foods as sources of vitamin C? (Select all that apply.)
A. Green pepper
B. Orange
C. Cabbage
D. Strawberries
E. Milk
A,B,C,D
MILK VIT B12, B6
A nurse is assessing a client who is experiencing complications d/t immobility. Which of the following findings should the nurse expect? Select all that apply
A. Contractures of the extremities
B. Polyuria
C. Diarrhea
D. Crackles in the lungs
E. Pressure ulcers
Contractures- disuse of muscles and joint
Crackles in the lungs- d/t mucous collecting in the dependent airways
Pressure ulcers- d/t increase pressure on the skin and bony prominences affects tissue metabolism
A nurse is teaching a client who has constipation. Which for the following are causes of constipation? Select all that apply
A. Excessive laxative use
B. Ignoring the urge to defecate
C. Inadequate fluid intake
D. Increased fiber intake
E. Increased activity
A, B, C.
chronic use of laxatives cause decreased muscle tone and become less responsive to stimulation by laxatives. ignoring the urge to defecate can disrupt the regular bowel habits. inadequate fluid intake is correct, restrict food to pass through
A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team?
A. Occupational Therapist
B. Registered Dietitian
C. Social Worker
D. Speech pathologist
Occupational therapist
An occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding.
A social worker coordinates community services to assist the client with meal procurement or equipment to help the client prepare meals.
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraints. Which of the following interventions should be included in the client's care plan? Select all that apply
A. Document restraints checks and client status every 2 hr.
B. Educate the clients family about restraints use
C. Obtain the provider's prescription renewal every 72 hours
D. Implement passive range of motion exercises
E. Release the restraint and reposition the client every 4 hours
A, B, D
providers prescription renew every 24 hrs
every 2 hrs for repositioning the client
A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. Prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate. The client has an IV of D5½ NS running at 75 mL/hr from 0700 until 1200. The IV runs at 30 mL/hr from 1200 to 1500. At 1500, the client has 6 oz juice. How many mL should the nurse document as the client's intake for the shift?
1005 mL
Correct Answer Rationale:
First, determine the amount of intake for each source.
Sodium diatrizoate and meglumine diatrizoate: 12 oz
1 oz = 30 mL
12 oz x 30= 360 mL
D5½ NS IV:
75 mL/hr from 0700 until 1200: 75 mL/hr x 5 hr = 375 mL
30 mL/hr from 1200 until 1500: 30 mL/hr x 3 hr = 90 mL
Total IV intake = 90 mL + 375 mL = 465 mL
Juice: 6 oz
1 oz = 30 mL
6 oz x 30 = 180 mL
Total the amounts: 360 mL + 465 mL +180 mL = 1,005 mL
A nurse has just finished a wound irrigation for a client who requires contact precautions. In which order will the nurse remove her personal protective equipment?
Gloves, gown, face shield, and mask
Most contaminated item first
A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advice the clients to avoid when taking their prescriptions?
A. Carbonated beverages
B. Milk
C. Orange Juice
D. Grapefruit Juice
D. grapefruit juice
High rate of food-drug interaction between grapefruit juice and medications frequently especially lipid-lowering agents. Specific enzymes in the intestinal tract can decrease the rate at which mediations enter the systemic circulation. this could allow a larger amount of these drugs to reach the bloodstream, resulting in increased drug levels and possibly toxicity
A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?
A. Increased insulin production
B. Decreased RBC production
C. Decreased sodium excretion
D. Increased calcium excretion
D. prolonged immobility leads to breakdown of bone tissue, this results in increased calcium excretion.
insulin production - does not affect mobility
RBC production - does not affect mobility, but it can increased the risk of thrombus formation
sodium excretion - electrolyte imbalances
A nurse is assessing a client and discovers the infusion pump with the client’s total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?
A. Excessive thrist and urination
B. Shakiness and diaphoresis
C. Fever and chills
D. Hypertension and crackles
Shakiness and diaphoresis
When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?
A. Complete a neurological check
B. Administer the prescribed PRN antihypertensive medication
C. Increase the client's fluid intake
D. Hold the client's evening dose of digoxin.
Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being.
A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?
A. Placing a sterile dressing 2inches from the border of the sterile field
B. Holding a sterile item at just above waist level
C. Opening a sterile package over the middle of the sterile field
D. Opening the sterile tray by first unfolding the flap the farthest from his body
C. Should never reach over the sterile field, the nurse should place the object on the field approaching the field from an angle
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)
A. More difficulty seeing due to a greater sensitivity to glare
B. Decreased cough reflex
C. Decreased bladder capacity
D. Decreased SBP
E. Dehydration of intervertebral discs
A,B,C,E
More difficulty seeing due to a greater sensitivity to glare is correct. Older adults have an increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and alterations in color perception.
Decreased cough reflex is correct. Older adults have a decreased cough reflex, increased airway resistance, fewer alveoli, and a greater risk for respiratory infections.
Decreased bladder capacity is correct. Older adults have a decreased bladder capacity and a reduction in renal blood flow.
Decreased systolic blood pressure is incorrect. Older adults have increased systolic blood pressure, thickening of blood-vessel walls, and decreased peripheral circulation.
Dehydration of intervertebral discs is correct. Older adults have dehydration of intervertebral discs, decreased muscle strength and mass, and decalcification of bones.