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A nurse is giving chance-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?
a) Admitting diagnosis.
b) Breath sounds.
c) Body temperature.
d) Diagnostic results. - correct answerCorrect answer: B.
Breath sounds - 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.
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings
through an open system.
Which of the following actions should the nurse take first?
a) Rinse the feeding bag with water between feedings.
b) Tell the client to keep the head of the bed elevated at least 30°.
c) Make sure the enteral formula is at room temperature.
d) Wipe the top of the formula can with alcohol. - correct answerCorrect answer: B. -
The first action the nurse should take when using the airway, breathing, circulation
approach to
client care is to prevent aspiration of the enteral formula; therefore, the priority
intervention is to keep the head of the
bed elevated at least 30° to prevent reflux of the formula into the esophagus
A nurse is caring for a client who has tuberculosis. Which of the following actions should
the nurse take?
a) Place the client in a room with negative-pressure airflow
b) Wear gloves when assisting the client with oral care.
c) Limit each visitor to 2-hr increments.
d) Wear a surgical mask when providing client care.
,e) Use antimicrobial sanitizer for hand hygiene - correct answerCorrect answer: A, B, E.
- Place the client in a room with negative-pressure airflow is correct. The nurse should
place the
client in a room with negative-pressure airflow to meet the requirements of airborne
precautions. Wear gloves when
assisting the client with oral care is correct. The nurse should wear gloves when
assisting the client with oral care to meet
the requirements of standard precautions, which the nurse must adhere to for all clients
regardless of their diagnosis.
The nurse should wear gloves whenever their hands might come in contact with a
client's bodily fluids, such as saliva,
and the mucous membranes in the mouth. Limit each visitor to 2-hr increments is
incorrect. The nurse does not need to
limit the client's visitors. However, the nurse should limit the client's presence outside
the room and the client should
wear a surgical mask when outside of the room. Wear a surgical mask when providing
client care is incorrect. The nurse
should wear an N95 respirator during client care to meet the requirements of airborne
precautions. Use antimicrobial
sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for
routine hand hygiene when caring
for a client who has tuberculosis. Nurses should also wash their hands with soap and
water when their hands are visibly
soiled.
A nurse is performing a Romberg test during a physical assessment of a client. Which
of the following techniques
should the nurse use?
a) Touch the face with a cotton ball.
b) Apply a vibrating tuning fork to the client's forehead.
c) Have the client stand with their arms at their sides and their feet together.
d) Perform direct percussion over the area of the kidneys. - correct answerCorrect
answer: C - A Romberg test helps identify alterations in balance. The nurse should have
the client stand with
their arms at their sides and their feet together to observe for swaying and a loss of
balance.
To obtain an accurate blood pressure measurement, - correct answerthe nurse should
inflate the cuff 30 mm Hg
beyond the point at which the nurse was last able to palpate the pulse. If the nurse last
palpated the pulse at 92 mm Hg,
then this would be the correct pressure to which the nurse should inflate the cuff.
The nurse has accepted a verbal prescription "for three tenths of a milligram of
levothyroxine IV stat" for a client
, who has myxedema coma. How should the nuse transcribe the dosage of this
medication in the medical record?
a) .3 mg
b) 0.3 mg
c) 0.30 mg
d) 3/10 mg - correct answerCorrect answer: B - The use and placement of a decimal
point can potentially cause a medication error if documented
incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a
decimal point unless a whole
number follows the zero, as in 2.05 mg
A nurse is discussing the use of herbal supplements for health promotion with a client.
Which of the following client
statements indicates an understanding of herbal supplement use?
a) "I can take echinacea to improve my immune system."
b) "I can take feverfew to reduce my level of anxiety."
c) "I can take ginger to improve my memory."
d) "I can take ginkgo biloba to relieve nausea." - correct answerCorrect answer: A.-
Echinacea is taken to promote immunity and reduce the risk of infection. Feverfew is
taken to
promote wound healing and decrease inflammation associated with arthritis. Valerian
and chamomile can be taken to
reduce anxiety. Ginger is taken to relieve nausea and vomiting and aid in digestion.
Ginkgo biloba can be taken to
improve memory and reduce stress. Ginkgo biloba is taken to improve memory and
reduce stress. Ginger can be taken to
relieve nausea and vomiting and aid in digestion.
A nurse is caring for a client who has decreased mobility. Which of the following actions
should the nurse take t
decrease the client's risk of developing plantar flexion contractures?
a) Place a pillow under the client's knees.
b) Position a trochanter roll under each of the client's hips.
c) Advise the client to wear rubber-soled slippers.
d) Apply an ankle-foot orthotic device to the client's feet. - correct answerCorrect
answer: D.- The nurse should use a device to maintain dorsiflexion, such as an ankle-
foot orthotic device or a
foot board placed perpendicular to the mattress.
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of
the following interventions
should the nurse include that is within the RN scope of practice?
a) Insert an implanted port.
b) Close a laceration with sutures.
c) Place an endotracheal tube.