CMS Funds B

Question 1

A nurse in an emergency department is assisting in the care of a client.
What findings indicate the client might be malnourished?

1100:

Client arrives to ED with report of nausea, vomiting, and diarrhea for 3 days. Client is febrile.

V/S: 1100:

Temperature 39.2° C (102.5° F)
Pulse rate 118/min
Respiratory rate 18/min
Blood pressure 92/68 mm Hg
Oxygen saturation 95% on room air
Weight 44.9 kg (99 lb)
BMI 1

1110:

Provider at bedside; prescriptions received.

1115:

IV initiated in right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.

1200:

Client appears fatigued with no energy. Hair is thin and sparse. Client is cachectic with flaccid muscle tone. Oriented to person, place, and time. Client is able to move all extremities. Tachycardia and edema to lower extremities present. Respirations are unlabored, and lung sounds are clear. Bowel sounds in all four quadrants are hyperactive, and abdomen is distended. Reports no difficulty with urination. Skin is dry and scaly with bruises on extremities.

Answer 1

-Client is cachectic with flaccid muscle.
Rationale: The client’s lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition.
-Skin is dry and scaly with bruises on extremities
Rationale: The client’s dry, scaly, and bruised skin can be an indication of malnutrition.
- Pulse rate 118/min
Rationale: The client’s tachycardia can be an indication of malnutrition.
-Abdomen is distended.
Rationale: The client’s abdominal distention can be an indication of malnutrition.
-BMI 17
Rationale: A BMI of 17 is considered underweight and can be an indication of malnutrition.

Question 2

A nurse is assisting with the care of a client who is receiving a unit of packed RBCs.

Nurses Notes

0800:

Packed RBCs initiated by the charge nurse through an 18-gauge peripheral IV to infuse over 2 hr.

0815:

Client reports itching and anxiety. Client’s face is flushed and has hives.

Vital Signs

0800:

Blood pressure 112/64 mm Hg
Heart rate 80/min
Respiratory rate 18/min
Temperature 37.1° C (98.8° F)
Oxygen saturation 97% on room air

0815:

Blood pressure 106/54 mm Hg
Heart rate 100/min
Respiratory rate 22/min
Temperature 37° C (98.6° F)
Oxygen saturation 95% on room air

Complete the following sentence:
The client has manifestations of____ as evidenced by the clients____.

Answer 2

The client has manifestations of AN ALLERGIC REATION as evidenced by the clients ITCHING.

Question 3

A nurse is assisting the care of a client who has pancreatitis.

SELECT 3 TASKS the nurse should delegate to an AP.

-document the client vital signs
-collect data about the clients pain level
-transfer the client form a wheelchair to the bed
-measure the clients intake and output
-insert an NG tube for the client.

Nurses Notes

1000:

Client sitting in wheelchair at bedside and states, “I am unable to eat anything without vomiting.” Client reports pain in left upper quadrant of the abdomen that radiates to their back. Bruising noted on the client’s abdomen. Client is pale and diaphoretic. Provider notified; prescriptions received. IV fluids infusing.

Vital Signs

1000:

Blood pressure 96/52 mm Hg
Heart rate 110/min
Respiratory rate 22/min
Temperature 38.4° C (101.2° F)
Oxygen saturation 92% on room air

Prescriptions

1010:

CT scan of abdomen
Insert NG tube, connect to low-intermittent suction
Serum amylase

Answer 3

• Document the client’s vital signs is correct. The nurse should identify that documenting the client’s vital signs is a task that is within an AP’s range of function.
• Measure the client’s intake and output is correct. The nurse should identify that measuring the client’s intake and output is a task that is within an AP’s range of function.
  -Transfer the client from a wheelchair to the bed is correct. The nurse should identify that transferring the client from a wheelchair to the bed is a task that is within an AP’s range of function.

Question 4

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

A. Client reports voiding three times during the night
B. Client reports burning and discomfort with urination.
C. The client’s WBC count is 11,000/mm3 (5,000 to 10,000/mm3).
D. The client’s output was 60 mL for the past 3 hr.

Answer 4

D. The client’s output was 60 mL for the past 3 hr.

RATIONALE: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is a urinary output of 60 mL over 3 hr. This finding represents oliguria and can indicate a decrease in kidney perfusion or function

Question 5

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?

A. Check the pH of the gastric aspirate
B. Observe the color of the gastric aspirate after adding blue dye to the formula
C. Auscultate over the epigastrium
D. Measure the length of the inserted NG tube.

Answer 5

A. Check the pH of the gastric aspirate

RATIONALE: The nurse should check the pH of the gastric contents to verify tube placement. A pH greater than 6 is an indication that the nurse has aspirated respiratory contents or that the tube is in the intestine, and that the nurse should withhold the feeding.

Question 6

The nurse should check the pH of the gastric contents to verify tube placement. A pH greater than 6 is an indication that the nurse has aspirated respiratory contents or that the tube is in the intestine, and that the nurse should withhold the feeding.

A. Support the client’s head with a pillow that maintains cervical flexion.
B. Position the client’s shoulders off the pillow for internal rotation.
C. Place the client’s arms at their sides to keep their elbows extended.
D. Internally rotate the client’s hips by using a trochanter roll.

Answer 6

D. Internally rotate the client’s hips by using a trochanter roll.

RATIONALE: The nurse should place trochanter rolls at the proximal end of each of the client’s legs to maintain a neutral or internal rotation of the client’s hips and to prevent external rotation of the hips, which can cause injury when the client is supine.

Question 7

The nurse should place trochanter rolls at the proximal end of each of the client’s legs to maintain a neutral or internal rotation of the client’s hips and to prevent external rotation of the hips, which can cause injury when the client is supine.

A. Posterior tibial
B. Dorsalis pedis
C. Popliteal
D. Brachial

Answer 7

B. Dorsalis pedis

RATIONALE: The nurse should document palpating the dorsalis pedis pulse on the top of the foot.

Question 8

The nurse should document palpating the dorsalis pedis pulse on the top of the foot.

A. Offer information about alternative therapies to the procedure.
B. Contact a family member to convince the client to change their mind.
C. Tell the client the benefits of the surgery.
D. Notify the charge nurse of the client’s concerns.

Answer 8

D. Notify the charge nurse of the client’s concerns.

RATIONALE: The nurse should notify the charge nurse of the client’s concerns. The charge nurse can then inform the provider that the client requires further explanation of the procedure.

Question 9

The nurse should notify the charge nurse of the client’s concerns. The charge nurse can then inform the provider that the client requires further explanation of the procedure.

A. “This can help prevent nausea.”
B. “This can help prevent pneumonia.”
C. “I should do this every 4 hours.”
D. “I should do this to keep my heart from beating too fast.”

Answer 9

B. “This can help prevent pneumonia.”

RATIONALE: The purpose of turning, coughing, and breathing deeply is to reduce the risk of respiratory complications such as atelectasis, which can lead to pneumonia. This helps to maximize lung expansion and assist with the removal of pulmonary secretions.

Question 10

The purpose of turning, coughing, and breathing deeply is to reduce the risk of respiratory complications such as atelectasis, which can lead to pneumonia. This helps to maximize lung expansion and assist with the removal of pulmonary secretions.

A. 1+ pitting edema
B. 2+ pitting edema
C. 3+ pitting edema
D. 4+ pitting edema

Answer 10

C. 3+ pitting edema

RATIONALE: The nurse should document 3+ pitting edema when there is deep indentation of the tissue, which is about 6 mm.

Question 11

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

A. Count the client’s radial and apical pulses simultaneously with another nurse.
B. Calculate the client’s pulse for 30 seconds and multiply by 2.
C. Assist the client to a side-lying position.
D. Auscultate the area of the client’s chest over the Erb’s point.

Answer 11

A. Count the client’s radial and apical pulses simultaneously with another nurse.

RATIONALE: The nurse should have another nurse count the radial pulse as they count the apical pulse. A pulse deficit occurs when there are differences between the radial and apical pulse rates.

Question 12

A nurse is contributing to a plan of care fora client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

A. Check that the restraint is tied to a fixed frame of the bed.
B. Pad bony prominences on the wrist.
C. Remove the restraint every 4 hr to allow movement.
D. Tie the restraint with a knot that will tighten when pulled.

Answer 12

B. Pad bony prominences on the wrist.

RATIONALE: The nurse should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client’s skin.

Question 13

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an AP?

A. Ensure a client can use crutches before discharge.
B. Check a client’s ability to swallow following a stroke.
C. Obtain a client’s pain rating prior to physical therapy.
D. Assist a client to get out of bed after a breathing treatment.

Answer 13

D. Assist a client to get out of bed after a breathing treatment.

RATIONALE: The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP’s range of function.

Question 14

A nurse is collecting data from a client who is 2 days post-op following a colostomy placement. Which of the following findings should the nurse report to the provider?

A. A purple-colored stoma
B. Protrusion of the stoma
C. A small amount of bleeding from the stoma
D. Intestinal gas in the pouch

Answer 14

A. A purple-colored stoma

RATIONALE: The stoma should be reddish-pink and moist. A purple-colored stoma is an indication of poor circulation, and the nurse should report this finding to the provider immediately.

Question 15

A nurse is reviewing the medical record of a female client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess?

A. Urine specific gravity 1.05 (1.005 to 1.03)
B. Hematocrit 49% (37% to 47%)
C. Urine pH 4.4 (4.6 to 8)
D. BUN 8 mg/dL (10 to 20 mg/dL)

Answer 15

D. BUN 8 mg/dL (10 to 20 mg/dL)

RATIONALE: A BUN of 8 mg/dL is below the expected reference range of 10 to 20 mg/dL. With fluid volume excess, the nurse should expect the client’s BUN to be below the expected reference range due to hemodilution.

Question 16

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

A. The client leans on the crutches for support while standing still.
B. The client advances the unaffected leg first while climbing stairs.
C. The client stands 5 cm (2 in) from the front of a chair before sitting.
D. The client bears weight on their axilla while standing in the tripod position.

Answer 16

B. The client advances the unaffected leg first while climbing stairs.

RATIONALE: When ascending stairs, the client should first advance the unaffected leg.

Question 16

A nurse is contributing to the plan of care for a client who has prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

A. Check for capillary refill proximally to the elastic bandages every 12 hr.
B. Compare the client’s pedal pulses bilaterally every 4 hr.
C. Place the client’s legs in a dependent position for 30 min before applying the elastic bandages.
D. Remove the elastic bandages every other day to inspect the skin.

Answer 16

B. Compare the client’s pedal pulses bilaterally every 4 hr.

RATIONALE: The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on their lower extremities.

Question 17

A nurse is preparing to obtain a client’s vital signs. Which of the following actions should the nurse take then washing their hands?

A. Rinse their forearms with running water before applying soap.
B. Hold their hands above elbow level while washing and rinsing.
C. Generate a lather by rubbing their hands together vigorously for 5 seconds.
D. Turn off the faucet with a clean paper towel after drying hands.

Answer 17

D. Turn off the faucet with a clean paper towel after drying hands.

RATIONALE: If the nurse’s hands are wet or the paper towel is wet when they turn off the faucet, they increase the risk of transferring micro-organisms from the faucet back to their hands.

Question 18

A nurse is preparing to administer a medication to a preschooler and must convert the child’s weight from pounds to kilograms. The child weighs 30lb. How many kilograms does the child weigh?
( round to the nearest tenth.)

Answer 18

13.6 kg

** remember: 1lb / 2.2kg **

Question 19

A nurse is caring for a client who is postop following a mastectomy. The client states, “I can barely look at myself in the mirror.” the Nurse should identify that the client is experiencing which of the following?

A. Complicated grief
B. Maturational loss
C. Disenfranchised grief
D. Actual loss

Answer 19

D. Actual loss

RATIONALE: The nurse should identify that the client’s comments indicate an actual loss, which is a loss that occurs when the person can no longer feel, see, hear, or know an object, another person, or a part of themselves, such as the loss of a body part.

Question 20

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

A. Heart rate 89/min
B. Pink mucous membranes
C. Pallor with scaly skin
D. Body mass index 23

Answer 20

C. Pallor with scaly skin

RATIONALE: The nurse should identify that pallor along with scaly skin can indicate malnutrition. The skin should be smooth and have the same hue as other areas of sun-exposed skin in clients who are well-nourished.

Question 21

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

A. “What types of foods have you been eating?”
B. “Are you using stool softeners or laxatives?”
C. “Have you been passing gas?”
D. “Have you had small liquid stools?”

Answer 21

D. “Have you had small liquid stools?”

RATIONALE: Using the nursing process, the first action the nurse should take is to collect data from the client to determine if the client has any findings consistent with a fecal impaction. Therefore, the first question for the nurse to ask is if the client has had any small liquid stools, which can indicate that there is seepage of liquid feces around the impacted mass.

Question 22

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following finding indicates hypomagnesemia?

A. Bone pain
B. Drowsiness
C. Bowel hypomotility
D. Positive Chvostek’s Sign

Answer 22

D. Positive Chvostek’s Sign

RATIONALE: To elicit Chvostek’s sign, the nurse should tap the client’s facial nerve near the ear. If the client’s facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels.

Question 23

A nurse is caring for a client who has just die and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

A. The client’s body should be placed on the floor.
B. The client’s oldest child will bathe the body.
C. The client’s face should be turned toward Mecca.
D. The client’s body will be adorned with amulets.

Answer 23

C. The client’s face should be turned toward Mecca

RATIONALE: Following death, a common practice of the Islamic faith is to turn the face of a deceased person toward Mecca.

Question 24

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? A. Art therapy B. Tai chi C. Guided imagery D. Biofeedback

Answer 24

C. Guided imagery RATIONALE: Guided imagery is a technique that can produce physical changes in the body, such as decreasing pain levels, by concentrating on a visualization of a pleasurable memory

Question 25

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make? A. "I will have the nursing staff check on you frequently during the night." B. "You are right to be afraid. This is a new place for you." C. "I will give you your prescribed sleeping medication to help you fall asleep." D. "Describe your concerns about sleeping to me."

Answer 25

D. "Describe your concerns about sleeping to me." RATIONALE: This statement is open-ended and allows for further communication. This addresses the client's concerns and builds trust.

Question 26

A nurse is assisting with the care of a client who has prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy. A. Eggs B. Latex C. Seafood D. Bee Stings

Answer 26

B. Latex RATIONALE: Nurses use products containing latex, including gloves, tourniquets, and IV tubing, to deliver IV therapy. Clients who have an allergic reaction to latex can have a wide range of manifestations, such as itching and hives, or a more serious reaction, such as dyspnea or laryngospasm.

Question 27

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following action should the nurse plan to take? A. Administer an analgesic 30 min before starting the procedure. B. Hold the syringe 5 cm (2 in) above the upper end of the wound. C. Place the irrigation solution in a basin of cool water. D. Perform the wound irrigation with a 10-mL syringe with an angiocatheter.

Answer 27

A. Administer an analgesic 30 min before starting the procedure. RATIONALE: The nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation procedure.

Question 28

A nurse is caring for a group of client in a long-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these client? (SATA) - Place immunocompromised clients in the same room. - Wash hands after removing gloves. Use antimicrobial hand gel after refilling a client's water pitcher. - Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. - Administer a prophylactic dose of antibiotics prior to discharge.

Answer 28

-Wash hands after removing gloves. -Use antimicrobial hand gel after refilling a client's water pitcher. -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

Question 29

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality? A. Sharing the client's prognosis with a member of the client's family B. Discussing the client's status with a member of the spiritual support team C. Collaborating with a nurse from another unit about the client's care D. Providing client information to another nurse at change of shift

Answer 29

D. Providing client information to another nurse at change of shift. RATIONALE: The nurse can share information with other staff who are caring for the client because it is essential to maintaining continuity of care, and does not violate the client's confidentiality. The nurse should only share information about the client with those directly involved in the client's care.

Question 30

A nurse is assisting with the admission of a client who has brought their medication to the facility. Which of the following actions should the nurse take? A. Allow the client to continue taking the medications as they did at home. B. Take the medications from the client and discard them. C. Compare the medications the provider has prescribed with the client's medications from home. D. Place the medications in the medication cart and administer them as the client took them at home.

Answer 30

C. Compare the medications the provider has prescribed with the client's medications from home. RATIONALE: During admission, the nurse should compare the medications that the provider has prescribed with the medications that the client is taking at home to decrease the risk of medication error. The nurse should include this information in the client's medical record as a resource for other health care personnel.

Question 31

A nurse is caring for a client who has a prescription for a potassium supplement. the client tells the nurse the the pill is too large to swallow and refuses to take it. The nurse offers to break the pull into two smaller pieces. The nurse is demonstrating which of the following ethical principles? A. Autonomy B. Beneficence C. Justice D. Nonmaleficence

Answer 31

B. Beneficence RATIONALE: The nurse is demonstrating beneficence by acting in the client's best interest to make it possible for the client to swallow the medication.

Question 32

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates and understanding of the teaching? A. "I will be sure to keep the crutch tips dry." B. "I will hold a crutch in each hand when sitting down." C. "I will place my weight on my underarms." D. "I will lead with my right leg when going up stairs."

Answer 32

A. "I will be sure to keep the crutch tips dry. RARTIONALE: The nurse should instruct the client to inspect the crutch tips frequently and keep them dry at all times to decrease the risk for slipping.

Question 33

A nurse is planning care fora group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? A. Administration of an enema B. Performance of a paracentesis C. Insertion of an indwelling urinary catheter D. Placement of an NG tube

Answer 33

B. Performance of a paracentesis. RATIONALE: The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis.

Question 34

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? A. Provide an artificial voice box. B. Avoid using facial gestures. C. Speak to the client in a louder voice. D. Ask the client close-ended questions.

Answer 34

D. Ask the client close-ended questions. RATIONALE: Clients who have aphasia can have difficulty forming words. Therefore, the nurse should ask the client questions that can be answered with a "yes" or "no" because the client can respond to these close-ended questions by shaking or nodding their head.

Question 35

A nurse is contributing to the plan of care for a client who is dying? Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (SATA) - Keep the family updated about the client's status. - Suggest that family members return home at night to allow the client to rest. - Encourage the family to comb the client's hair. - Tell the client's family what to expect as the client's death nears. - Ask the family to encourage the client to eat.

Answer 35

- Keep the family updated about the client's status. - Encourage the family to comb the client's hair. - Tell the client's family what to expect as the client's death nears.

Question 36

A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take? A. Perform a bladder scan. B. Cleanse the meatus. C. Provide perineal care. D. Lubricate the catheter.

Answer 36

A. Perform a bladder scan. The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the nurse should evaluate the bladder contents before performing an invasive procedure. A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations.

Question 37

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? A. Young adults should receive a dental assessment every 6 months. B. Young adult males should have a testicular examination every 5 years. C. Young adult females should have a routine physical examination every 4 years. D. Young adults should receive a tuberculosis skin test every 3 years.

Answer 37

A. Young adults should receive a dental assessment every 6 months. RATIONALE: The nurse should include the recommendation for young adults to receive a dental assessment twice per year.

Question 38

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? A. Place the client's medication record on the bedside table while ambulating the client. B. Give report about the client's status while standing at the nurses' station. C. Speak with the client about their condition after visitors have left. D. Place a message board in the client's room to post dietary information.

Answer 38

C. Speak with the client about their condition after visitors have left. RATIONALE: The nurse should ensure a private environment before discussing the client's condition with them.

Question 39

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? A. "Keep your feet close together." B. "Tighten your stomach muscles." C. "Straighten your knees." D. "Bend at your waist.

Answer 39

B. "Tighten your stomach muscles." The nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back.

Question 40

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? A. "The reduced muscle tone has relaxed the jaw muscles." B. "That happens when a person gets close to death." C. "I can apply a chin strap to help hold the mouth closed." D. "You shouldn't worry about that at this time."

Answer 40

A. "The reduced muscle tone has relaxed the jaw muscles." RATIONALE: Prior to death, decreased muscle tone causes jaw muscles to relax, resulting in an open mouth.

Question 41

A nurse is caring for a post op client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an AP? A. Apply thromboembolic stockings. B. Monitor the circulation in all four extremities. C. Record the condition of the client's skin. D. Reinforce teaching about performing range-of-motion exercises

Answer 41

A. Apply thromboembolic stockings. The application of thromboembolic stockings is within the range of function of an AP and does not require further data collection by the nurse.

Question 42

a nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment? A. "Perform muscle relaxation before bedtime." B. "Exercise vigorously 1 hour prior to going to bed." C. "Drink a cup of hot chocolate at bedtime." D. "Change the time you go to sleep each day."

Answer 42

A. "Perform muscle relaxation before bedtime." The nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep.

Question 43

A nurse is contributing to the plan of care for a client who has a positive throat culture for step. Which of the following intervention should the nurse recommend to be included in the plan of care? A. Place the client in a room with another client who has pharyngitis. B. Ensure that the client wears a surgical mask during transportation throughout the facility. C. Limit the client's visitors to visitations of 30 min. D. Provide the client a room with negative-pressure airflow of six air exchanges per hour.

Answer 43

B. Ensure that the client wears a surgical mask during transportation throughout the facility. Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room.

Question 44

A nurse is providing care to four client in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? A. "I might file a lawsuit because of how my surgery went." B. "Please don't tell my doctor, but I am taking my partner's oxycodone." C. "Please don't get me out of bed this morning. It hurts too much." D. "I don't want to take my medicine. It makes me sick to my stomach."

Answer 44

B. "Please don't tell my doctor, but I am taking my partner's oxycodone." This situation poses an ethical dilemma for the nurse because there is a conflict between what the client is asking of the nurse and the nurse's responsibility to protect the client from harm during hospitalization.

Question 45

A nurse is caring for a client who is post op and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (SATA) - Full bounding pulse - Cool extremities - Moist crackles in the lungs - Orthostatic hypotension - Flat neck veins

Answer 45

- Cool extremities - Orthostatic hypotension - Flat neck veins

Question 46

A charge nurse smells smoke, enters the visitors restroom and sees flames in the trash can. What is the sequence of actions that the nurse should take?

Answer 46

Evacuate the client from the area. PULL THE LEVER close the fire doors PUT THE FIRE OUT

Question 47

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? A. Sit beside the client. B. Speak slowly and loudly to the client. C. Dim the lights in the client's room. D. Choose a private room for the interview.

Answer 47

D. Choose a private room for the interview. The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying.

Question 48

A nurse had delegated various client care tasks to the ap on the care team. Which of the following action by the AP should the nurse identify as correct? A. Using hand sanitizer to cleanse their hands of spilled food from a client's meal tray B. Setting aside their gown for future use in the room of a client who has a wound infection C. Removing their gloves after exiting a client's room D. Donning a mask to measure the vital signs of a client who has pertussis

Answer 48

D. Donning a mask to measure the vital signs of a client who has pertussis Caring for clients who have pertussis requires droplet precautions. Therefore, the AP should wear a mask when within 1 m (3.3 feet) of the client.

Question 49

A nurse working in a community clinic is talking with an older adult client who states that their life has no purpose. The nurse should identify that the client is in which stage of Erikson's Theory of Psychosocial Development? A. Ego integrity vs. despair B. Generativity vs. self-absorption C. Identity vs. role confusion D. Intimacy vs. isolation

Answer 49

A. Ego integrity vs. despair The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. The nurse should assist the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations. Supporting the client's ego integrity will help the client cope with the challenges of aging

Question 50

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the clients religious preferences? A. "Do you receive Holy Communion?" B. "Do you follow a kosher diet?" C. "Do you consume pork products?" D. "Do you oppose receiving a blood transfusion if it is needed?"

Answer 50

"C. Do you consume pork products?" Some clients who practice Islam do not consume pork or alcohol.

Question 51

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? A. A client who has pneumonia B. A client who has measles C. A client who has pertussis D. A client who has MRSA

Answer 51

B. a client who has measles The nurse should initiate airborne precautions for a client who has measles.

Question 52

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation? A. Completion of an incident report B. Name of the nurse certifying the client's death C. Release of personal belongings form D. One client identifier at the client's time of death

Answer 52

C. Release of personal belongings form The nurse should document the release of the client's personal belongings form and the articles the nurse gave to the family or guardian.

Question 53

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? A. 1 cup of cantaloupe B. 1 large potato C. 4 oz banana chips D. 1 cup of applesauce

Answer 53

D. 1 cup of applesauce The nurse should determine that applesauce is the best food choice because 1 cup of applesauce contains 184 mg of potassium per serving. Therefore, the client's food choice of applesauce demonstrates an understanding of the teaching.

Question 54

A nurse is assisting in the admission of a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The nurse is collecting data from the client’s medical record. Which of the following interventions should the nurse expect? - Wear a mask within 1 m (3 feet) of the client. - Request a prescription for an antibiotic medication. - Place the client in a negative airflow room. - Apply a mask on the client when the client leaves their room. - Initiate droplet precautions. - Apply oxygen at 2 L/min via nasal cannula. Nurses Notes 1000: Client reports sore throat, productive cough with yellow-colored mucus, and fever for past 3 days. Client has swollen lymph nodes. Client also reports on headache that "won't go away." Client's face is flushed and is diaphoretic. Throat culture and blood work obtained as prescribed. Vital Signs 1000: B/P 132/68 mm Hg Heart rate 99/min Respirations 20 /min Temperature 38.3° C (101.1 F) Oxygen saturation 96% on room air Diagnostic Results 1100: Positive throat culture for streptococci bacteria (negative)

Answer 54

- Wear a mask within 1 m (3 feet) of the client. - Request a prescription for an antibiotic medication. - Apply a mask on the client when the client leaves their room. - Initiate droplet precautions.

Question 55

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. A nurse is collecting data from the client. Which of the following actions should the nurse take? - Place a pressure dressing over the IV site. - Ask an RN to start a new IV in the client's left hand. - Stop the IV infusion. - Elevate the client's left arm. - Apply heat to the client's left hand. Nurses Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing is dry and intact. IV site is without redness or swelling. IV fluid is infusing well. Day 2: IV site is edematous. Skin surrounding catheter site is taut, blanched, and cool to touch. IV fluid is not infusing.

Answer 55

- Stop the IV infusion. - Elevate the client's left arm. - Apply heat to the client's left hand.

Question 56

A nurse is caring for a client who reports difficulty sleeping and is interested in trying an herbal supplement. which of the following should the nurse recommend to promote sleep? A. ginger B. valerian C. echinacea D. feverfew

Answer 56

B. valerian Valerian is an herbal supplement that can help control restlessness, mild anxiety, and sleep disorders. It can also help lower blood pressure and ease the discomfort of menstrual cramps.