ATI RN FUNDAMENTALS

ATI RN FUNDAMENTALS PROCTORED EXAM QBANK 2023 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-administermedications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medicationsthe client received during hospitalization. 2- A nurse isreviewing 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 isteaching a group ofstaff nurses about the use of essential oilsfor 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 hasrubella. 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 isrefusing 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'sfamily to intervene. 8- A nurse in an acute care facility is preparing a discharge summary for a client who istransferring 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 requiresfurther 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 isreviewing 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 histrash 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 clientstatements 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'sroom and finds her on the floor. The client'sroommate 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) "incidentreport 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'sforehead C) have the client stand with their arms at theirsides and their feet together D) perform direct percussion over the area of the kidneys 17- A nurse isteaching a client whose left leg isin a cast about using crutches. Which of the following statementsshould 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) "Ishould place my crutches 12 inches in front and to the side of each foot." C) "As Isit 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 ofsterile water B) draw up medicationstogether 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) Monitorserum 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'sfeet 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) Wrapmonitoring cords with stockinette and tape them in place. C) Cleanse latex ports on IV tubing with chlorhexidine before injectingmedication. D) Wear hypoallergenic latex glovesthat contain powder. B) Wrapmonitoring 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 findingsshould 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 haslimited mobility in hislower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A) Place the client in high-Fowler's position. B) Increase the client'sintake 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 isreceiving 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 istoo high 30- A nurse hasjust 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. bowelsounds are present on auscultation d. the client reportsrelief of nausea 31- A home health nurse is completing an admission assessment of an older adult client who hastheir caregiver present. Which of the following should the nurse identify as a potential indication of elder abuse? a. the caregiver is the client'sfinancial 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. Aftersecuring a safe environment, which of the following actionsshould 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. assessthe 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 ofthe following instructions should the nurse provide to the client and his family? select all that apply. a. check the cord routinely forfrays and tearing b. keep the unit at least 1.2 m (4 feet) away from a gas stove c. consider purchasing a generatorfor power backup d. observe forsigns of hypoxia t synthetic clothing and bedding 35- A nurse is caring for a client who has an NG tube and isreceiving 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'llsave 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. wearsterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degreesfarenheit) 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 ofthe 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'sroom c. clean contaminated surfaces in the client'sroom with a phenolsolution 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 administersubcutaneously. 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 tasksto 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 hastuberculosis. 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 antimicrobialsanitizer 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 ofthe following actions by the newly licensed nurse requiresintervention by the charge nurse? a. the newly licensed nurse placesthe cap of a bottle ofsterile 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 ofsterile 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 ifshe 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. witnessthe client'ssignature on the consent form c. inform the client of alternativesto 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'sstatus 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 isreceiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify asindicating 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 saysthat, 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 isto have a sigmoidoscopy every 10 years' 54- A nurse is caring for a client who hasterminal 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 isreviewing protocol in preparation forsuctioning 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 wallsuction 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. "thistype of hearing aid does not allow for fine tuning of volume" b. "Ishouldn'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 isteaching an older adult client who is atrisk 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 ofshift 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 findingsindicates 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 A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing? a. Serum albumin 3 g/dL b. Total lymphocyte count 2400 mm3 c. HCT 42% d. HGB 16g/dL ◗ Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk forpoor wound healing. The other lab values are within normal limits. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? Chapter 27 Vitals signs page 244 a. Apply the cuff above the client’s antecubital fossa. b. Use a cuff with a width that is about 60% of the client's arm circumference. - width of the cuff should be 40 % of arm circumference c. How the clients sit with his arm resting above the level of his heart. - MUST BE AT HEART LEVEL d. Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should not be more than 2 to 3 mm hg per second ◗ Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? Chapter 53 Airway management page 563 a. Hold the suction catheter with the clean non-dominant hand. b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum. c. Place the catheter in a location that is clean and dry for later use new line.- NEVER EVER REUSE THE SUCTION CATHETER . you throw it away after being used. d. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing . ◗ Rationale: sterile technique for trachea ◗ Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No longer than 10- 15 seconds to avoid hypoxemia A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. “SS”for sliding scale b. “BRP” for bathroom privileges c. “OJ” for orange juice- do not d. “SQ” for subcutaneous- do not A nurse is collecting A blood pressure reading from a client who is sitting in a chair period the nurse determines that the clients BP is 158/96 mmhg. which of the following actions should the nurse take? a. Ensure that the width of the BP cuff is 50% of the client’s upper arm circumference. It says 40% b. Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC HYPOTENSION c. Recheck the clients BP and her other arm for comparison. d. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? Chapter 53 Airway Management page 562 a. Supine and low-Fowler's position b. Right lateral in Trendelenburg position c. Side lying with the right side of the chest elevated d. Prone with pillows under the extremities A nurse’s neighbor is scheduled for elective surgery. The neighbor’s provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest? At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location? of the sternum 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 1 A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A. Planning & evaluating control & prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks A, B, C, E Rational: Not D because endemic disease is already prevalent within a population, so reporting is not necessary A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: A. Put all four side rails up on the bed B. Ask the unlicensed assistive personnel to place restraints on the client’s upper extremities C. Request that the client’s roommate put the call light on when the client is attempting to get out of bed D. Check on the client at regular intervals to ascertain the need to use the bathrooms The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis? A. Hand hygiene B. Contact precautions C. Droplet precautions D. Airborne precautions The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate? A. Drink hot tea at frequent intervals B. Gargle with antiseptic mouthwash C. Use an electric toothbrush D. Eat a soft, bland diet A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates the client is ready to try a liquid diet? The client: A. Is hungry B. Has not requested pain medication for 8 hours C. Has frequent bowel sounds D. Has had a bowel movement A client has returned from surgery during which the jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse in instructing the unlicensed assistive personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give to the UAP? A. Keep the client in a side-lying position with the head slightly elevated B. Do not reposition the client without the assistance of a registered nurse C. The client can assume any position that is comfortable D. Keep the client’s head elevated on two pillows at all times The nurse’s best explanation for why the severely neutropenic clientis placed in reverse isolation is that reverse isolation helps prevent the spread of organisms: A. To the clientfrom sources outside the client’s environment B. From the client to healthcare personnel, visitors and other clients C. By using special techniques to handle the client’s linens and personal items D. By using special techniques to dispose of contaminated materials 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 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