A nurse is obtaining a health history from a client. The nurse should recognize which of the following data as placing the client at higher risk for osteoporosis?
The client has a sedentary lifestyle.
A nurse is teaching an older adult who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity would the nurse recommend?
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Walking briskly because weight bearing exercises are essential for maintaining bone mass which will prevent osteoporosis.
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A nurse is performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?
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A mole with an asymmetrical appearance
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A nurse is teaching a client and his family how to care for the client's tracheostomy at home. What instructions should the nurse include in the teaching?
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Use tracheostomy covers when outdoors
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A nurse is reviewing a client's medication prescription that reads, " digoxin 0.25 by mouth everyday". Which of the following components of the prescription should the nurse verify with the provider?
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Medication Dose
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In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.
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A nurse is preparing a heparin infusion for a client who was admitted to the facility with DVT. The prescription reads:25,000 units of heparin in 0.9% sodium chloride 250ml to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
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8 mL/hr.
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800 X 250= 200,000
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200,000 / 25,000= 8
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A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
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A client who is unaware of her recent cancer diagnosis ask the nurse if she has cancer, and the nurse responds affirmatively.
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Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.
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A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
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Practice sessions
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Practice sessions require psychomotor skills when learning
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A nurse is planning strategies to manage time effectively for client care. What strategies should the nurse implement?
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Use the planning step of the nursing process to prioritize client care delivery
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A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following nurse implement to prevent infection?
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Applying a transparent dressing over the IV insertion site and securement device
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A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
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Cleanse the wound from the center outward
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A nurse is caring for a client who has dementia. What intervention should the nurse take to minimize the risk for injury to the client?
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Use a bed exit alarm system
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A nursing is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
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When descending stairs, I will first shift my weight to my right leg.
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To descend stairs, the client should first shift his body weight to his right, unaffected leg.
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A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120mL of fluid?
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In the context where a nurse is calculating a client's fluid intake over the past 8 hr, the item that corresponds to 120 mL of fluid would be 8 oz of ice chips. Here's why: typically, 1 US fluid ounce is equivalent to approximately 30 ml. Therefore, 8 fluid ounces would be approximately 240 mL.
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A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?
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Check the cord routinely for frays or tearing
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Consider purchasing a generator for power backup
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Observe for signs of hypoxia
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Keep the unit 10ft away from open flames
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A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
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Assess the client for orthostatic hypotension
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The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.
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A nurse is planning to insert a peripheral IV catheter for an older adult client. What action should the nurse plan to take?
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Place the client's arm in a dependent position
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In a dependent position the vein will dilate d/t gravity
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A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching?
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Establish the client's learning needs
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A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?
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Have the client stand with their arms at their sides and their feet together.
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The Romberg test helps identify alterations in balance. The nurse is looking for swaying and a loss of balance.
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A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
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Skin blanching
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Skin blanching, edema, and coolness are all signs for infiltration.
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A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
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Breath sounds
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When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.
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A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh length sequential compression sleeves. Which of the following actions should the nurse take?
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Make sure two fingers can fit under the sleeves
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The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate
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A nurse preparing to provide tracheotomy care for a client. Which of the following actions should the nurse plan to take?
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Wear clean gloves while cleaning the inner cannula
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A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?
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Instruct the client to push the button more frequently
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The client should be encouraged to use the PCA pump before the pain becomes severe, as this will provide better pain control and reduce the risk of side effects
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A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
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Endotracheal suctioning
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If a client requires endotracheal suctioning, it is likely due to respiratory distress or compromised airway clearance. Ensuring a patent airway and maintaining adequate oxygenation is the top priority, making endotracheal suctioning the first procedure to be performed.
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A nurse manager overhears a nurse telling a client. "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?
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Assault
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Assault occurs when one person intentionally threatens or causes another person to fear that they will be touched without their consent. In this situation, the nurse is threatening to administer medication by injection (an unwanted touch) as a consequence for not swallowing pills.
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A nurse is preparing to administer several medications via an NG tube to a client who is receiving continuous tube feeding. Which of the following actions should the nurse take?
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Flush the NG tube with 5 mL of sterile water for irrigation prior to administration.
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Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.
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A nurse is obtaining a health history from a client. The nurse should recognize which of the following data as placing the client at higher risk for osteoporosis?
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The client has a sedentary lifestyle.
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Sedentary lifestyle, lack of weight-bearing exercise, and decreased physical activity are risk factors for osteoporosis. A sedentary lifestyle is defined as a lifestyle that involves a lot of sitting and lying down, with very little to no exercise
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A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?
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"Walk for 30 minutes three to five times each week."
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Weight-bearing exercises, such as walking, are beneficial for preventing osteoporosis. Weight-bearing activities stimulate bone formation and help maintain bone density. Regular walking for 30 minutes, three to five times per week, can contribute to overall bone health and reduce the risk of osteoporosis.
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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"
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Pad bony prominences before applying the restraints
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Ensure that the clients bed in in the lowest position
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Ass skin temperature and color before applying the restraints
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