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?

Change the pt position every 4 hours

Apply petroleum base ointment in the red area

Assess the red area for blanching

Use friction when cleansing the client's skin

Assess the red area for blanching

A nurse is teaching a client who had an enucleation about care of an artifical eye. Which of the following information should the nurse include in the teaching? (select all that apply )

Store the artificial eye in the label container filled with 0.9 % sodium chloride irrigation

Remove from the artificial eye by retracting the upper eyelid

Apply pressure just below artificial eye to break the suction

Clear the artificial eye with hydrogen peroxide before storing

Retract the upper and lower lids to reinsert the artificial eye

Apply pressure just below artifical eye to break the suctioN

Retract the upper and lower lids to reinsert the artifical eye

A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first?

Determine areas of resonance across the abdomen using a systemic approach

Expose the client's abdomen to look for changes in appearance

Perform abdominal palpation by pressing gently with the finger pads

Use the diaphragm of the stethoscope to listen for bowel sounds

Expose the client's abdoment to look for changes in appearance

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?

Determine the client's reading ability

Review the use of an artifical larynx

With the client schedule a support session

For the client explain the techniques of esophageal speech

For the client explain the techniques of esophageal speech

A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply)

I will use the bars when getting in and out of the bath tub

I need to check my medications for expiration dates

I need to have a fire escape plan with my family

I will apply tape over frayed areas of electrical cords

I need to set my hot water heater to 140 degrees Fahrenheit

I will use the bars when getting in and out of bath tub

I need to check my medications for expirations dates

I need to have a fire escape plan with my family

A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?

Offer pain medication

Palpate the abdomen

Auscultate bowel sounds

Adminsiter an antiemetic

Ausculate bowel sounds

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 dressing?

Dry Gauge

Transparent

Calcium alginate

Hydrogel

Transparent

A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?

I can apply lotion to soften the calluses as long as I don't put lotion between my toes

I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly

I should soak my feet in warm water daily to soften corns calluses

I should use an over the counter liquid medication to remove corns

I can apply lotion to softne the calluses as long as I don't put lotion between my toes

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?

Tie the restraints to the side rail

Secure restraints with a square knot

Remove one restraint at a time

Remove the restraints every 3 hours

Remove one restraint at a time

A nurse is admitting a client who has a clostridium diff infection. Which of the following actions should the nurse take? Select all that apply

Use an N95 respirator while providing client care

Wear a gown and gloves when providing client care

Assign the client to a private room with positive air flow

Wash hands with soap and water after contact with the client

Ensure the client does not receive fresh fruit

Wear a gown and gloves when providing client care

Assign the client to a private room wiht positive air flow

Wash hands with soap and water after contact with the contact

A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care?

Schedule the client as the first surgical procedure of the day

Cleanse the stoppers with primidone iodine for withdrawing medication

Remove the stop stocks from iv tubing

Ensure the gloves in the surgical suite are powdered gloves

Schedule the client as the first surgical procedure of the day

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?

The client's belief that his needs will be met through education

The nurse explaining the need for education to the client

The client seeking family apporval by agreeing to a teaching plan

The nurse's empathy about the client having to self- inject

The client's belief that his needs will be met through education

A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?

Heat the formula to 105 degrees Fahrenheit

Flush the tubing with 10 ml of water every 2 hours

Change the tubing every 72 hours

Aspirate residual vilume every 4 hours ( every 4-8 hours is correct)

Aspirate residual volume every 4 hours

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?

The client picks up the walker with each step

The client stoops slightly forwars when moving the walker

The client stands with her elbows slightly flexed while holding the walker

The client moves the walker ahead 10 inches with each step

The slient stands with her elbows slightly flexed while holding the walker

A nurse us caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her restraints. The nurse should identify that the AP is committing which of the following torts?

Libel

Defamation of character

Assault

Battery

Assault

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?

Stabilize the vein by applying traction above the insertion site

Engorge the vein by placing the arm in the dependent position

Use friction at the insertion site to increase venous distention

Leave the tourniquet on for 30 to 60 seconds after initial insertion

Engorge the vein by placing the arm in the dependent position

A nurse us 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?

Prepare the client for central venous line

Change the PN and fat emulsion separately

Obtain a random blood glucose daily

Prepare the client for central venous line

A nurse is caring for a client who is schedule while witnessing the client signature. While the client is saying I trust the doctor, but I dont understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take?

Provide broochures about the procedure

Notify the provider

Complete an incident report

Describe the surgery to the client

Notify the provider

A nurse is caring for a client who 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. The situation respects which of the following torts?

False imprisonment

Invasion of privacy

Assault

Negligence

False Imprisonment

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?

Use the television to mask external noises

Listen to soft music before lying down

Exercise just pior to bedtime

Listen to soft music befire lying down

A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take?

Place an activated tuning fork in the middle of the clients forehead

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?

Eat a light carbohydrate snack before bedtime

Exercise 1 hour before bedtime

Drink a cup of cocoa before bedtime

Take a 30 min nap daily

Eat a light carbohdrate snack before bedtime

A nurse is teaching in a group of newly licensed nurses about the braden scale. Which of the following responses by the newly licensed nurse indicates understanding in the teaching?

Each elements has a range 1 to 5 points

The higher the score the higher the pressure ulcer risk

The clients age is part of the measurement

The scale measures six elements

The scale measure six elements

A nurse is planning care for a client who is schedule for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
Ensure the client is free of metal objects

Administer 240 ml contrast before the procedure

Monitor the client for pain in the suprapubic region

assist the client with a bowel cleansing

Ensure the client is free of metal objects

A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest. Which of the following should the nurse take to obtain the sample?

The pad of the finger tip

The lateral aspect of the finger

The pinna of the ear

The side of the wrist

The lateral aspect of the finger

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?

Provide the client with a contact number for a diabetes education specialist

Make a copy of the medication record of the reconciliation for the client

Determine whether the client can afford the insulin administration supplies

Obtain printed information about self administration

Determine whether the client can afford the insulin administration supplies

A nurse is teaching about home safety with a client. Which of the following insrtuctions should the nurse include?

Use electrical tape to secure extension cords next to base boards on the floor

Replace carpet floors with tiles

Unplug electronics by grasping the cord

To use fire extinguisher, aim high at the top of the flames

Use electrical tape to secure extension cords next to the base boards on the floor

A nurse is caring for a client who has restraint to each extremity. Which of the following assessment should the nurse perform first?

Elimination needs

Comfort level

Peripheral pulse

Skin integerity

Peripheral Pulse

A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take?

Cotton tip applicator to clean the inside of the cannula

Soak the outer cannula in warm soapy tap water

Cleanse the skin around the stoma with normal saline

Secure the tracheostomy ties to allow one finger to fit snuggly underneath

Secure the tracheostomy ties to allow one finger to fit snuggly underneath

Nurse is providing teaching to a client who is self administer an ophtalmic solution. Which of the following statements by the client indicates understanding of the teaching?

I will keep my eyes closed for 5 mins after inserting drops

I will insert the drops in the center of the eye

I will press the inner corner of my eyes after insert drops

I will raise my eye lid up while looking down and insert drops

I will press the inner corner of my eye after insert drops

A nurse in a long term care facility is planning care for 4 clients. Which of the following client's is at greatest risk of developing a pressure ulcer?

A client who is incontinent of urine 1 to 2 times a day

A client who is receiving enteral tube feedings

Client who requires assistance to transfer from the bed to a chair

Client who is unrepsonsive to pain stimuli

Client who is unresponsive to pain stimuli

A nurse is assessing a client's bowel sounds. Which if the following actions should the nurse take?

Listen to bowel sounds after performing abdominal palpation

Place diaphragm of stethoscope over each quadrant

Ask client to cough upon auscultating

Auscultate for 2 mins to determine if bowel sounds are active

Place diaphragm of stethoscope over each quadrant

Hyperosmolar Syndrome Symptoms

Dry Mouth

Phlebitis Symptoms

Erythema is present following the route of the vein

Finger pulse oximeter is not working

Patient's

normal 13.5 - 17.5

Patient's Hemoglobin is 10