ATI RN FUNDAMENTALS PROCTORED EXAM QBANK QUESTIONS & ANSWERS 100% VERIFIED

BEST 2023 UPDATE ATI RN FUNDAMENTALS PROCTORED EXAM QBANK QUESTIONS & ANSWERS 100% VERIFIED 1- 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? A) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization. 2- 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? a. medication name b. route of administration c. medication dose d. frequency of administration 3- A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. a client who has a history of physical abuse b. a client who has a permanent pacemaker c. a client who has ulcerative colitis d. a client who has asthma 4- A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment 5- A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the client in the semi-Fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it 6- A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.) A) Narrowed arterial lumen B) Distended jugular veins C) Impaired ventricular contraction D) Asynchronous closure of the aortic and pulmonic valves 7- A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A) Ask the client to consider a direct donation. B) Withhold the blood transfusion. C) Request a consultation with the ethics committee. D) Ask the client's family to intervene. 8- A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. client flow sheet b. acuity ranges c. current medications d. incident reports 9- A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A) Erythema on pressure points B) Lower-extremity pulse strength of 2+ C) Fluid intake of 3,000 mL per day D) A bowel movement every other day 10- 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 psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions 11- 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? A) "I'm having mild pain." B) "The pain is like a dull ache in my stomach." C) "I notice that the pain gets worse after I eat." D) "The pain makes me feel nauseous." 12- 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. D) Initiate an enteral feeding through a gastrostomy tube. 13- A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fore 14- 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" 15- 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? A) "incident report completed" S - The Marketplace to Buy and Sell your Study Material B) "client climbed over the side rails" C "client found lying on the floor" D) "client was trying to get out of bed" 16- A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? A) touch the face with a cotton ball B) apply 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 17- 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? A) "When descending stairs, I will first shif t my weight to my right leg." B) "I should place my crutches 12 inches in front and to the side of each foot." C) "As I sit down, I will hold one crutch in each hand." D) "I will make sure the shoulder rests are snug against my armpits." 18- A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? A) dissolve each medication in 5 mL of sterile water B) draw up medications together in the syringe C) push the syringe plunger gently when feeling resistance D) flush the tube with 15 mL of sterile water 19- A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week 20- A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. assign a staff member to feed the client b. provide small handled utensils for the client c. thicken liquids on the client's tray d. arrange food in a consistent pattern on the client's plate 21- A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? a. "You should have an eye exam every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should have a fecal occult blood test every 2 years" d. "You should receive a pneumococcal immunization every 10 years" 22- 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? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg 23- A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A) Auscultate lung sounds. B) Measure urine output. C) Monitor blood pressure readings. D) Monitor serum electrolyte levels. 24- A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. place a pillow under the client's knees b. position a trochanter toll 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 25- A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap 26- A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A) Ensure sterilization of nondisposable items with ethylene oxide. B) Wrap monitoring cords with stockinette and tape them in place. C) Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. D) Wear hypoallergenic latex gloves that contain powder. B) Wrap monitoring cords with stockinette and tape them in place. 27- A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins 28- A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A) Place the client in highFowler's position. B) Increase the client's intake of carbohydrates. C) Massage reddened areas with unscented lotion. D) Have the client use a trapeze bar when changing position. 29- A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? A) instruct the family to refrain from pushing the button for the client while she is asleep B) inform the client that because she is on PCA, vital signs will be taken every 8 hours C) teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10 D) increase the basal rate and shorten the lock-out interval time if the client's pain level is too high 30- A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowel sounds are present on auscultation d. the client reports relief of nausea 31- A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following should the nurse identify as a potential indication of elder abuse? a. the caregiver is the client's financial power of attorney b. the client is in a wheelchair with the wheels locked c. the client reports receiving a full bath twice each week d. the caregiver insists on remaining in the room 32- 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? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the client for orthostatic hypotension d. apply gait belt to the client 33- A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a. wrap blankets around all 4 sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside 34- The 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? select all that apply. a. check the cord routinely for frays and tearing b. keep the unit at least 1.2 m (4 feet) away from a gas stove c. consider purchasing a generator for power backup d. observe for signs of hypoxia d. select synthetic clothing and bedding 35- 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 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol 36- A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a. "we can talk about advance directives, and I can also give you some brochures about them" b. "you should set up a time to talk with your provider about that" c. "let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" d. "why do you want to discuss this without your partner here to plan this with you?" 37- A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea 38- A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound. 39- A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution d. have family members wear a gown and gloves when visiting 40- A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine" b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly" 41- A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine" b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly" 42- A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of the steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle c,a,d,b 43- A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic 44- A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative airflow pressure 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 45- A 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 nurse transcribe the dosage of this medication in the client's medical record? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg 46- A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? a. the newly licensed nurse places the cap of a bottle of sterile solution on the sterile field b. the newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field c. the newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring d. the sterile field is positioned at the level of the newly licensed nurse's waist 47- 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? a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b. a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes c. a client who has a DNR order has a cardiac arrest, and the nurse does not perfrom CPR despite requests from the client's family d. a client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse previously promised to administer 48- A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. describe the procedure to the client b. witness the client's signature on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure 49- A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b. a nurse asks a nurse from another unit to assist with documentation for a client c. a nurse who is caring for a client returns a call to a person appointed in the health care proxy to discuss the client's care d. a nurse discussed a client's status with the physical therapist who is caring for the client. 50- A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? a. "most people are happy when their children grow up and leave home" b. "you should be proud that your children are becoming independent" c. "maybe you should consider why you are feeling useless" d. "people in middle adulthood often find satisfaction in nurturing and guiding young people" 51- A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a. "drink a cup of hot cocoa before bedtime" b. "maintain a consistent time to wake up each day" c. "exercise 1 hour before going to bed" d. "watch a television program in bed before going to sleep" 52- 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? a. purulent exudate b. warmth c. skin blanching d. bleeding 53- A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." b. "beginning at age 60, you should have a colonoscopy" c. " you should have a fecal occult blood test every year" d. "the recommendation is to have a sigmoidoscopy every 10 years' 54- A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. "what could i have done to deserve this illness?" b. "I blame medical science for not curing me" c. "where is my daughter at a time like this? d. "will i ever begin to feel in charge of my life again?" 55- A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. use resuscitation bag with 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction catheter in water soluble lubricant d. adjust the wall suction apparatus to pressure of 170 mmHg 56- 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? a. "this type of hearing aid does not allow for fine tuning of volume" b. "I shouldn't have trouble keeping the hearing aid in place during exercise c. "I expect to hear a whistling sound when I first insert the hearing aid" d. "I will be sure to remove my hearing aid before taking a shower" 57- A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. walking briskly b. riding a bicycle c. performing isometric exercise d. engaging in high-impact aerobics 58- 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 info is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temperature d. diagnostic test results 59- 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/hr. At what rate should the nurse set the infusion pump? round to the nearest whole number 8 Ml/hr 60- A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? a. urine has an unusual odor b. urine specific gravity is 1.035 c. bladder scan shows 525 mL of urine d. urine is positive for ketones ATI RN Fundamentals Proctored Focus Exam A nurse educator is reviewing w/a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse & respiratory rate A, B, E Rational: Edema and pain and tenderness is localized A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent care center." D. "If I am felling stressed, I will remind myself that this is something I should expect." B. "It is important to schedule routine health care visits even if I'm feeling well." Rational: Routine health screenings are important at any age A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between & being responsible for 2 generations C. Devoting a great deal of time to establishing an occupation Rational: Exploring and establishing career options & establishing oneself is important developmental task in a young adult A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, & now I'm supposed to know what to do." D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father." C. "I don't even know who I am yet, & now I'm supposed to know what to do." Rational: Applying Erikson stages of development, knowing oneself is done in adolescence, and this requires the most urgent help A nurse is reviewing safety precautions w/a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all. A. Install bath rails & grab bars in bathrooms B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home B, C, D Rational: A is recommended for older adults and E as well for risk of falls A nurse is reviewing the CDC's immunization recommendations w/a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all. A. Human papillomavirus B. Measles, mumps, rubella C. Varicella D. Haemophilus influenzae type b E. Polio A, B, C Rational: D is not for after 18 months of age and polio is also given as a child and not usually beyond 18 yrs old A nurse is caring for an 82-yr-old client in the ER who has an oral body temp of 38.3 C (101 F), a pulse rate of 114/min, & a RR of 22/min. He is restless & his skin is warm. Which of the following are appropriate nursing interventions for this client? Select all. A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to limit activity & rest D. Allow the client to shiver to dispel excess heat E. Assist the client w/oral hygiene frequently A, C, E Rational: The nurse should prevent shivering & encourage the client to increase fluids. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth & lips. A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A. "Don't measure the client's temp rectally." B. "Count the client's radial pulse for 30 sec & multiply by 2." C. "Don't let the client know you are counting her respirations." D. "Let the client rest for 5 mins before you measure her BP." A. "Don't measure the client's temp rectally." Rational: The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this way increases the risk for bleeding. A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe 1 full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count & report any signs the client demonstrates A, B, C Rational: As for D, this is if the rate is irregular after initial count, for E, sighs are expected & don't need to be reported A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive med B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety med D. Return in 30min to recheck the client's BP B. Ask the client if she is having pain Rational: Perform a pain assessment would be the appropriate action to take next A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? 16/min Rational: The pulse deficit is the difference between the apical & radial pulse rates. 84-68=16 A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following info should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. One stool specimen is sufficient for testing C. A red color change indicates a positive test D. The specimen cannot be contaminated D. The specimen cannot be contaminated Rational: The stool specimens cannot be contaminated with water or urine A nurse is talking w/a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni & cheese B. Fresh fruit & whole wheat toast C. Rice pudding & ripe bananas D. Roast chicken & white rice B. Fresh fruit & whole wheat toast Rational: A high-fiber diet promotes normal bowel elimination A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all. A. Bradycardia B. Hypotension C. Fever D. Poor skin turgor E. Peripheral edema B, C, D Rational: fever=caused by dehydration tachycardia not bradycardia hypotension because of decreased BP from dehydration fluid overload=peripheral edema A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all. A. Warm the enema prior to instillation B. Position the client on the left side w/the right leg flexed forward C. Lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 2 inches E. Hang the enema container 24 inches above the client's anus A, B, C Rational: D is the appropriate length of insertion for a child, 3-4 for an adult. 24 inches is too high & will cause it to run to fast & possible painful distention of the colon, 18 inches is the recommended height While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have the client hold his breath briefly B. Discontinue the fluid instillation C. Remind the client that cramping is common at this time D. Lower the enema fluid container D. Lower the enema fluid container Rational: This will slow the rate of instillation & relieve some discomfort A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the following problems is the client at risk for developing? A. Stasis of secretions B. Muscle atrophy C. Pressure ulcer D. Fecal impaction Answer: C Rational: Unrelieved pressure over a bony prominence for too long increases the risk of a pressure ulcer, sitting will help prevent stasis of secretions B and D-these are from prolonged bed rest A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? A. Encourage isometric exercises B. Suction Q8 hr C. Give low-dose heparin D. Promote incentive spirometer use Answer: D. Promote incentive spirometer use Rational: helps keep airways open and prevent atelectasis, this strengthens skeletal muscles Bthis is not indicated, C-helps prevent thrombus formation A nurse is caring for a client who is postop. Which of the following nursing interventions reduce the risk of thrombus development? Select all. A. Instruct the client not to use the Valsalva maneuver B. Apply elastic stockings C. Review lab values for total protein level D. Place pillows under the client's knees & lower extremities E. Assist the client to change position often B, E Rational: A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching? A. "This device will keep me from getting sores on my skin." B. "This thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape." B. "This thing will keep the blood pumping through my leg." Rational: sequential pressure devices promote venous return in the deep veins of the legs & thus help prevent thrombus formation. To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all that apply. A. Hold the cane on the right side B. Keep 2 points of support on the floor C. Place the cane 15in in front of the feet before advancing D. After advancing the cane, move the weaker leg forward E. Advance the stronger leg so that it aligns evenly w/the cane A, B, D Rational: C-the client should place the cane 6-10 inches in front before advancing not 15 E-the client should advance the stronger leg past the cane not aligned w/it A nurse is assessing the pain level of a client who has come to the ER reporting severe abd. pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following? A. Presence of associated symptoms B. Location of the pain C. Pain quality D. Aggravating & relieving factors A. Presence of associated symptoms Rational: this is a common symptom people have when experiencing pain A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by: A. asking what precipitates the pain B. questioning the client about the location of the pain C. offering the client a pain scale to measure his pain D. using open-ended questions to identify the situation C. offering the client a pain scale to measure his pain Rational: pain scale can measure the amount and intensity of the pain A nurse is obtaining history from a client who has pain. The nurse's guiding principle throughout this process should be that: A. some clients exaggerate their level of pain B. pain must have an identifiable source to justify the use of opioids. C. objective data are essential in assessing pain D. pain is whatever the client says it is D. pain is whatever the client says it is Rational: the client is the best source of information in their pain, it is a subjective experience A nurse is caring for a client who is receiving morphine via a PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping." C. "I should tell the nurse if the pain doesn't stop after I use this device." Rational: The client should let the nurse know if not receiving adequate pain control, so they can reevaluate the pain control plan A nurse is monitoring a client who is receiving opioid analgesia for adv effects of the med. Which of the following effects should the nurse anticipate? Select all. A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea C, D, E Rational: Urinary retention, not incontinence is an adverse effect of these meds as well as constipation, not diarrhea. A nurse is assessing a client who takes haloperidol (Haldol) for the tx of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)? Select all. A. Orthostatic hypotension B. Fine motor tremors C. Acute dystonias D. Decreased level of consciousness E. Uncontrollable restlessness B, C, E Rational : A and D are adverse effects, but not EPS A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutunin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all. A. Take frequent sips of water B. Wear sunglasses when exposed to sunlight C. Use a soft toothbrush when brushing teeth D. Take the medication w/an antacid E. Urinate prior to taking the med A, B, E Rational: side effects of this med include: dry mouth, photophobia, and urinary retention A nurse is reviewing the reported meds of a client who was recently admitted. The meds include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine hydrochloride toxicity C. Decreased risk of adv effects of cimetidine D. Increased therapeutic effects of imipramine hydrochloride B. Increased risk of imipramine hydrochloride toxicity Rational: med that decreases the metabolism of a 2nd med increases the serum level of the 2nd med, increasing risk for toxicity A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk med for the control of seizures. Which of the following statements by the nurse is appropriate? A. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus." B. "This med has evidence indicating that it is safe to take during pregnancy & will not harm the fetus." C. "This med cannot be taken during pregnancy because the risk outweighs the potential benefits." D. "This med hasn't been studied in pregnant women but is believed to be safe for the fetus." A. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus." Rational: Category D meds are known to cause harm to fetuses, however the use during pregnancy may be warranted based on potential benefits. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam (Valium). Prior to administering the med, which of the following actions is the highest priority? A. Teaching the client about the purpose of the med B. Administering the med to the client at the prescribed time C. Identifying the client's med allergies D. Documenting the client's anxiety level C. Identifying the client's med allergies Rational: The greatest risk to the client is an allergic reaction to the med A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer? (round to nearest tenth) 0.3 mL A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15min. The nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole number) 400 mL/hr A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (round to nearest whole number) 83 gtt/min A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention? A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down & rest after meals. B. Instruct the client to tuck her chin when swallowing. Rational: Tucking when swallowing allows food to pass down esophagus more easily. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve? A. Fat B. Protein C. Glycogen D. Carbohydrates D. Carbohydrates Rational: Carbs provide glucose A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup C. Vanilla custard Rational: low-residue diets are low in fiber and easy to digest: dairy products especially A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate her BMI & determine whether this client is obese based on her BMI. BMI=30 Rational: above 30 equals obese so yes. A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info should the nurse include? Select all. A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins & minerals as younger adults do C. Many older men & women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbs A, B, C Rational: D-they need fewer calories not more E-they need more carbs & fiber A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is a 10 on a scale of 0-10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine (Demerol) 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO C. Morphine 2 mg IV Rational: IV morphine is the best because the onset is rapid and absorption to the blood is immediate, which is adequate for a client with a 10 pain severity A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching? A. "I can open the capsule w/the beads in it & sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding." C. "The pills w/the coating on them can be crushed." D. "I will eat 2 crackers w/the pain pills." D. "I will eat 2 crackers w/the pain pills." Rational: this will prevent N&V from the narcotic A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? A. "Flush the tube before & after each med." B. "Administer your meds w/your enteral feeding." C. "Administer tablets through the tube slowly." D. "Mix all the crushed meds prior to dissolving in water." A. "Flush the tube before & after each med." Rational: The client should flush the tube w/15-30 mL of water to prevent clogging of the tube A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effect? A. "Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds." B. "Some meds may have to be administered by a non-enteral route to avoid inactivation as they travel through the liver." C. "Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity." D. "Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring." B. "Some meds may have to be administered by a non-enteral route to avoid inactivation as they travel through the liver." Rational: first pass deals with the liver A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique? A. "I will straighten my ear canal by pulling my ear down & back." B. "I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal." B. "I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops." Rational: The client should apply gentle pressure w/the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal. A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take? A. Offer to assist the client needing the bedpan. B. Administer the injection prepared by the other nurse C. Prepare another syringe & administer the injection D. Tell the client needing the bedpan she will have to wait for her nurse A. Offer to assist the client needing the bedpan. A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all. A. 0905 B. 0825 C. 1000 D. 0840 E. 0935 A, D Rational: 30min time frame for meds A nurse is working w/a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention? A. Taking all meds out of the unit-dose wrappers before entering the client's room B. Checking w/the provider when a single dose requires administration of multiple tablets C. Administering a med, then looking up the usual dosage range D. Relying on another nurse to clarify a med prescription B Checking w/the provider when a single dose requires administration of multiple tablets Rational: this could indicate a possible error so it should be checked w/the provider A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all. A. "I will observe for med side effects." B. "I will monitor for therapeutic effects." C. "I will prescribe the appropriate dose." D. "I will change the dose if adverse effects occur." E. "I will refuse to give a med if I believe it is unsafe." A, B, E A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to take that med. I do not want one more pill." Which of the following responses by the nurse is appropriate in this situation? A. "Your physician prescribed it for you, so you really should take it." B. "Well, let's just get it over w/quickly then." C. "Okay, I'll just give you your other meds." D. "Tell me your concerns w/taking this med." D. "Tell me your concerns w/taking this med." A nurse is assessing a client who has an acute resp. infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all. A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Pallor A, B, E Rational: C and D are late manifestations of hypoxemia. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases B. Assist the client to Fowler's position Rational: Fowler's facilitates better breathing A nurse is preparing to preform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all. A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis, Q2-3 hours C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Limit suctioning to 2-3 attempts A, D, E Rational: B-Suctioning is not w/out risk so it should be done as needed, not routinely. Cendotracheal suctioning requires surgical asepsis A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all. A. Apply the oxygen source loosely if the SPO2 decreases during the procedure B. Use surgical asepsis to remove & clean the inner cannula C. Clean the outer surfaces in a circular motion from the stoma site onward D. Replace the tracheostomy ties w/new ties E. Cut a slit in gauze squares to place beneath the tube holder. A, B, C Rational: D-only replace ties if soiled or wet E-use a commercially prepared gauze w/slit not one nurse makes A provider is discharging a client with a prescription from home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all. A. Apply petroleum jelly around the inside of the nares B. Remove the nasal cannula during mealtimes C. Check the position of the cannula often D. Report any nasal stuffiness, nausea, or fatigue E. Post "no smoking" signs in a prominent location C, D, E A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated." A. "Water helps clear the tube so it doesn't get clogged Rational: this action clears the excess formula preventing any clumps/clogging A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been opened B. Verify the placement of the NG tube C. Confirm that the client doesn't have diarrhea D. Make sure the client is alert & oriented B. Verify the placement of the NG tube Rational: The greatest risk is aspiration so verifying the placement of the tube is most important A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest xray D. Initiate oxygen therapy B. Stop the feeding A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all that apply A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temp. E. Discard any residual gastric contents. A, B, C Rational: D-the formula should be room temp not body, E-unless the volume of the contents is more than 250 mL, the nurse should the residual content to the client's stomach A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain meds D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available A, B An adolescent who has diabetes mellitus is 2 days postop following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit w/assistance. He requests pain meds Q 6-8 hr while reporting pain at a 2 on a scale of 1-10 after receiving the med. His incision is approximated & free of redness, w/scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? Select all. A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care B, C A nurse is assessing a client who is 5 days post op following abd. surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all. A. Increase in incisional pain B. Fever & chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst A, B, C A nursing instructor is reviewing the wound healing process w/a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all. A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed w/adhesive E. Open burn area A, E Rational: B and D are healed w/primary intention, C is not a skin wound unless bone has pierced the skin A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera protruding. Which of the following interventions is appropriate? Select all. A. Cover the area w/saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abd. C. Use sterile gloves to apply gentle pressure to the exposed tissues D. Position the client supine w/his hips & knees bent E. Offer the client a warm beverage, such as herbal tea A, D A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all. A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences often C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least Q 3 hr while in bed A, D Rational: Not E because it should be at least every 2 hours Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? Yes. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to a assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning B, C, D An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24hr postop to use an incentive spirometer B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump D. Replacing the cartridge and tubing on a PCA pump Rationale: The RN is responsible for the PCA pump A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances B, C, E Rational: A and D are rights of medication administration A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A. Charge nurse B. RN C. LPN D. AP B. RN Rational: A client returning from surgery requires assessment and establishment of a plan of care. RNs are responsible for this, especially if the client is potentially unstable. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy A. Assault Rational: By threatening the client, the AP is committing assault. An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality B. False imprisonment Rational: The nurse gave the med as a chemical restraint to keep the client from leaving the facility against medical advice. The client did not consent. A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead w/the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." C. "I plan to write that I don't want them to keep me on a breathing machine." Rational: The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arrives A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing pre-op care regarding informed consent? Select all. A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form C. Explain the risks and benefits of the procedure D. Describe the consequences of choosing not to have the surgery E. Tell the client about alternatives to having the surgery A, B Rational: The rest of the choices are the surgeon's responsibility, not the nurse A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A. Remind the nurse that safe client care is a priority on the unit B. Ask others on the team whether they have observed the same behavior C. Report observations to the nurse manager on the unit D. Conclude that her coworker's fatigue is not her problem to solve C. Report observations to the nurse manager on the unit Rational: Any nurse who notices behavior that could possibly jeopardize client care or indicate a substance abuse problem has a duty to report the situation immediately to the nurse manager A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record C. A bone scan that is scheduled for today Rational: This is important because the nurse might have to modify the client's care to accommodate them leaving the unit A nurse enters a client's room & finds him sitting