with correct answers A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I am having mild pain" "The pain is like a dull ache in my stomach"
"I notice that the pain gets worse after I eat" "The pain makes me feel nauseous" Correct Answer - "The pain is like a dull ache in my stomach"
A client in non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm Extinguish the fire Evacuate the client Confine the fire Correct Answer - Evacuate the client
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Neck vein distention Urine specific gravity 1.010
Rapid Heart rate Blood pressure 144/82 mmHg Correct Answer - Rapid heart rate A nurse has accepted a verbal prescription for "thee tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse
transcribe the dosage of this medication in the client's medical record? .3 mg
0.3 mg 0.30 mg 3/10 mg Correct Answer - 0.3 mg
A nurse is preparing a heparin infusion for a client who was admitted to the facility
with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9%
sodium chloride 250 ml to infuse at 800 units/hour. At what rate should the nurse set the infusion pump? Correct Answer - 8 ml/hour
A nurse is caring for a client who has a prescription for wound irrigation. Which of
the following actions should the nurse take? Wear sterile gloves when removing the old dressing Warm the irrigation solution to 40.5 C (105 F)
Cleanse the wound from the center outward Use a 20 ml syringe to irrigate the wound Correct Answer - Cleanse the wound from the center outward
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as
indicating infiltration? Purulent exudate Warmth Skin blanching Bleeding Correct Answer - Skin blanching A nurse 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? "When descending the stairs, I will first shift my weight to my right leg"
"I should place my crutches 12 inches in front and to the side of each foot"
"As I sit down, I will hold one crutch in each hand" "I will make sure the shoulder rests are snug against my armpits" Correct Answer -
"When descending the stairs, I will first shift my weight to my right leg"
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? Rinse the feeding back with water between feedings
Tell the client to keep the head of the bed elevated at least 30 degrees
Make sure the enteral formula is at room temperature Wipe the top of the formula can with alcohol Correct Answer - Tell the client to keep the head of the bed elevated at least 30 degrees
A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day". Which of the following components of the prescription should the nurse verify with the provider? Medication name Route of administration Medication dose
Frequency of administration Correct Answer - Medication dose A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? "This type of hearing aid does not allow for fine tuning of volume"
"I shouldn't have trouble keeping the hearing aid in place during exercise"
"I expect to hear a whistling sound when I first insert the hearing aid" "I will be sure to remove my hearing aid before taking a shower" Correct Answer - "I will be sure to remove my hearing aid before taking a shower"
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? "Incident report completed"
"Client climbed over the side rails" "Client found lying on the floor"
"Client was trying to get out of bed" Correct Answer - "Client found lying on the floor"
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? Seal unused medications from the facility in a plastic bag Evaluate the client's ability to self administer medications Report an identified discrepancy to The Joint Commission Compare prescriptions with medications the client received while at the facility Correct Answer - Compare prescriptions with medications the client received while at the facility