Dynamic quiz week 3 & 4

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

A. Set the suction machine at 120 mmHg

B. Provide oral hygiene frequently (correct)

C. Measure the amount of drainage from the NG tube every shift (correct)

D. Secure the NG tube to the client’s gown (correct)

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

A. Serve foods at warm or hot temperatures

B. Offer the client low-density foods

C. Make sure the client lies supine after meals

D. Limit drinking liquids with food (correct)

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information?

A. Areas with no public access (correct)

B. Outside the door of a client’s room

C. In the cafeteria during break

D. In the hallway near the nurses’ station

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

A. Loss Signup and view all the answers

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.)

A. Coat the tip of the tube with a water-soluble lubricant Signup and view all the answers

A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?

A. The client holds the hand with the palm up. Signup and view all the answers

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure?

C. Use the index finger to insert the suppository Signup and view all the answers

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client’s dentures be removed prior to surgery. Which of the following responses should the nurse provide?

D. "What worries you about being without your teeth?" Signup and view all the answers

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

C. Confirm unresponsiveness. Signup and view all the answers

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client’s wound has eviscerated?

A. Cover the incision with a moist sterile dressing Signup and view all the answers

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

A. Place the client in the Trendelenburg position Signup and view all the answers

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

D. Place the stool specimen collection container in a biohazard bag Signup and view all the answers

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

D. Supports self-determination Signup and view all the answers

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

C. Carefully remove the gloves and proceed with hand hygiene. Signup and view all the answers

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

770 Signup and view all the answers

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

D. Halo of erythema on the surrounding skin Signup and view all the answers

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?

D. Instruct the client to apply pressure to the inside corner of the eye after instillation Signup and view all the answers

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make?

D. "Can you explain the concerns you're having right now?" Signup and view all the answers

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

C. Insert the tip of the tubing 8 cm (3.1 in) Signup and view all the answers

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?

D. Infection acquired from a diagnostic procedure Signup and view all the answers

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?

C. Decreased cardiac output Signup and view all the answers

A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include?

C. "Include 2.5 cups of vegetables in your daily diet." Signup and view all the answers

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?

C. Intraoperative Signup and view all the answers

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

29 Signup and view all the answers

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?

D. Advise the client to perform range-of-motion exercises while in bed Signup and view all the answers

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs Signup and view all the answers

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Fill in the blank

2 Signup and view all the answers

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

B. Ask the client to identify the specific food allergies Signup and view all the answers

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines Signup and view all the answers

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?

"Would you like to talk about how you feel?" Signup and view all the answers

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

Starch Signup and view all the answers

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?

Clean the drain site from the center outward Signup and view all the answers

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

Provide more water with feedings Signup and view all the answers

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?

"If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." Signup and view all the answers

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session Signup and view all the answers

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?

Lentils Signup and view all the answers

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?

Sodium 123 mEq/L Signup and view all the answers

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day Signup and view all the answers

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select?

Choose a vein that is soft on palpation Signup and view all the answers

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

Depressed deep-tendon reflexes Signup and view all the answers

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients’ commitment to a long-term goal of weight loss?

Attempt to increase the clients’ self-motivation Signup and view all the answers

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions Signup and view all the answers

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

The client keeps 2 points of support on the ground Signup and view all the answers

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches. Signup and view all the answers

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking Signup and view all the answers

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound." Signup and view all the answers

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based rub to clean my hands." Signup and view all the answers

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client Signup and view all the answers

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial nerve XII Signup and view all the answers