ATI comprehensive predictor STUDY THIS ONE, exit exam

What can be delegated to Assistive personnel (AP)? (Topic 4)

- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients

A nurse on a med surge unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? (Topic 4)

A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia

B. Reinforcing teaching with a client who is learning to walk with 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

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? (Topic 4)

Select all:

A. the roommate is up independently

B. The client ambulates with his slippers on over his antiembolic stockings

C. The client uses a front wheeled walker when ambulating

D. The client had pain meds 30 minutes 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 an LPN at the beginning of the shift. Which of the following assignments should the LPN question?

A. Assisting a client who is 24 hr 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

A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: (Topic 26)

A. Right client

B. Right supervision/evaluation

C. Right direction/communication

D. Right time

E. Right circumstances

B

C

E

A nurse manager of a med surge unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client?

A. Charge nurse

B. RN

C. LVN

D. AP

B

What is the study of conduct and character?

Ethics

What are the values and beliefs that guide behavior and decision making?

Morals

What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest

Autonomy

What are positive actions to help others

Beneficience

What is an agreement to keep promises

Fidelity

What is fairness in care delivery and use of resources

Justice

What is avoidance of harm or injury

Non-maleficence

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles?

A. Fidelity

B. Autonomy

C. Justice

D. Nonmalificience

A

A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

A. Fidelity

B. Autonomy

C. Justice

D. Beneficience

D

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle

A. Fidelity

B. Autonomy

C. Justice

D. Nonmaleficence

C

A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle

A. Fidelity

B. Autonomy

C. Justice

D. Nonmalificence

D

Which of the following situations can be identified as an ethical dilemma?

A. A nurse on a med surge unit demonstrates signs of chemical impairment

B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him

C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill

D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form

C

Most managers can be categorized as

authoritative, democratic, and laissez faire

makes decisions of the group

motivates by coercion

communication occurs down the chain of command

Work output by the staff is usually high-good for crisis situations and bureaucratic settings

Authoritative

includes the group when decisions are made

Motivates by supporting star achievements

Communication occurs up and down the chain of command

Work output by staff is usually of good quality-good when cooperation and collaboration is necessary

Democratic

makes very few decisions and does little planning

motivation is largely the responsibility of individuals staff members

Communication occurs up and down the chain of command and between group members

Work output is low unless an informal leader evolves from the group

*the use of any of these styles may be appropriate depending on the situation

Laissez faire

The nurse should consider the hierarchy of human needs when prioritizing interventions, which are?

- Physiological needs first (oxygen, shelter, food)

- Safety & security needs (physical safety)

- Love and belonging

- Self esteem

- Self actualization

The ABC framework identifies, in order, the three basic needs for sustaining life

Airway

Breathing

Circulation

Nurses must follow what code of standards in delegating and assigning tasks

ANA codes of standards

What values would a nurse possess to be a client advocate?

- caring

- autonomy

- respect

- empowerment

What do the nurse need to keep in mind about the client when being their advocate?

Client's religion & culture

When should planning discharge process begin?

a. at time of admission

b. 2 days after client is admitted

c. whenever the nurse has the time to do planning

d. when the physician has the discharge order

A

What is an interdisciplinary team?

A group of health care professionals from different disciplines

Fill in the blank:

1. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone.

1 & 2 = collaboration

What is the nurse's contribution to an interdisciplinary team?

- knowledge of nursing care & its management

- a holistic understanding of the client, her/his healthcare needs & healthcare systems.

A four-month-old infant is admitted to the pediatric intensive care unit

with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse

observes nuchal rigidity. Which assessment finding would indicate an

increase in intracranial pressure?

1. Positive Babinski.

2. High-pitched cry.

3. Bulging posterior fontanelle.

4. Pinpoint pupils.

2

A client is receiving total parenteral nutrition (TPN). To determine the

client's tolerance of this treatment, the nurse should assess for which of the

following?

1. A significant increase in pulse rate.

2. A decrease in diastolic blood pressure.

3. Temperature in excess of 98.6°F (37°C).

4. Urine output of at least 30 cc per hour.

4

The client is exhibiting symptoms of myxedema. The nursing

assessment should reveal

1. increased pulse rate.

2. decreased temperature.

3. fine tremors.

4. increased radioactive iodine uptake level.

2

A nonstress test is scheduled for a client at 34-weeks gestation who

developed hypertension, periorbital edema, and proteinuria. Which of the

following nursing actions should be included in the care plan in order to

BEST prepare the client for the diagnostic test?

1. Start an intravenous line for an oxytocin infusion.

2. Obtain a signed consent prior to the procedure.

3. Instruct client to push a button when she feels fetal movement.

4. Attach a spiral electrode to the fetal head.

3

Which of the following nursing interventions is MOST important for a

45-year-old woman with rheumatoid arthritis?

1. Provide support to flexed joints with pillows and pads.

2. Position her on her abdomen several times a day.

3. Massage the inflamed joints with creams and oils.

4. Assist her with heat application and ROM exercises.

4

The nurse is caring for a young adult admitted to the hospital with a

severe head injury. The nurse should position the patient

1. with his neck in a midline position and the head of the bed elevated 30°.

2. side-lying with his head extended and the bed flat.

3. in high Fowler's position with his head maintained in a neutral position.

4. in semi-Fowler's position with his head turned to the side.

1

The nurse is teaching a 40-year-old man diagnosed with a lower motor

neuron disorder to perform intermittent self-catheterization at home. The

nurse should instruct the client to

1. use a new sterile catheter each time he performs a catheterization.

2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization.

3. perform the catheterization procedure every 8 hours.

4. limit his fluid intake to reduce the number of times a catheterization is needed.

2

A client is being discharged with sublingual nitroglycerin (Nitrostat).

The client should be cautioned by the nurse to

1. take the medication five minutes after the pain has started.

2. stop taking the medication if a stinging sensation is absent.

3. take the medication on an empty stomach.

4. avoid abrupt changes in posture.

4

A 38-year-old woman is returned to her room after a subtotal

thyroidectomy for treatment of hyperthyroidism. Which of the following, if

found by the nurse at the patient's bedside, is nonessential?

1. Potassium chloride for IV administration.

2. Calcium gluconate for IV administration.

3. Tracheostomy set-up.

4. Suction equipment.

1

A nurse recognizes that an initial positive outcome of treatment for a

victim of sexual abuse by one parent would be that the client

1. acknowledges willing participation in an incestuous relationship.

2. reestablishes a trusting relationship with his/her other parent.

3. verbalizes that s/he is not responsible for the sexual abuse.

4. describes feelings of anxiety when speaking about sexual abuse.

3

An adolescent client is ordered to take tetracycline HCL (Achromycin)

250 mg PO bid. Which of the following instructions should be given to this

client by the nurse?

1. "Take the medication on a full stomach, or with a glass of milk."

2. "Wear sunscreen and a hat when outdoors."

3. "Continue taking the medication until you feel better."

4. "Avoid the use of soaps or detergents for two weeks."

2

After a client develops left-sided hemiparesis from a cerebral vascular

accident (CVA), there is a decrease in muscle tone. Which of the following

nursing diagnoses would be a priority to include in his care plan?

1. Alteration in mobility related to paralysis.

2. Alteration in skin integrity related to decrease in tissue oxygenation.

3. Alteration in skin integrity related to immobility.

4. Alteration in communication related to decrease in thought processes

2

A client has a history of oliguria, hypertension, and peripheral edema.

Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be

restricted in the client's diet?

1. Protein.

2. Fats.

3. Carbohydrates.

4. Magnesium.

1

An extremely agitated client is receiving haloperidol (Haldol) IM every

30 minutes while in the psychiatric emergency room. The MOST important

nursing intervention is to

1. monitor vital signs, especially blood pressure, every 30 minutes.

2. remain at the client's side to provide reassurance.

3. tell the client the name of the medication and its effects.

4. monitor the anticholinergic effects of the medication.

1

The nurse is caring for clients in the skilled nursing facility. Which of the

following clients require the nurse's IMMEDIATE attention?

1. A client admitted for a cerebral vascular accident (CVA) whose prescription for

warfarin (Coumadin) expired two days ago.

2. A client in pain who was receiving morphine in an acute care institution and was

transferred with a prescription for acetaminophen with codeine.

3. A client who has dysuria and foul-smelling, cloudy, dark amber urine.

4. An immunosuppressed client who has not received an influenza immunization.

1

The nurse is observing care given to a client experiencing severe to

panic levels of anxiety. The nurse would intervene in which of the following

situations?

1. The staff maintains a calm manner when interacting with the client.

2. The staff attends to client's physical needs as necessary.

3. The staff helps the client identify thoughts or feelings that occurred prior to the

onset of the anxiety.

4. The staff assesses the client's need for medication or seclusion if other

interventions have failed to reduce anxiety.

3

A 69-year-old client is undergoing his second exchange of intermittent

peritoneal dialysis (IPD). Which of the following would require an

intervention by the nurse?

1. The client complains of pain during the inflow of the dialysate.

2. The client complains of constipation.

3. The dialysate outflow is cloudy.

4. There is blood-tinged fluid around the intra-abdominal catheter.

3

The clinic nurse is performing diet teaching with a 67-year-old client

with acute gout. The nurse should teach the client to limit his intake of

1. red meat and shellfish.

2. cottage cheese and ice cream.

3. fruit juices and milk.

4. fresh fruits and uncooked vegetables.

1

A client is scheduled for a left lower lobectomy. The physician has

ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine

that the medication is appropriate if the client displays which of the

following symptoms?

1. Agitation and decreased level of consciousness.

2. Lethargy and decreased respiratory rate.

3. Restlessness and increased heart rate.

4. Hostility and increased blood pressure.

3

A 59-year-old woman with bipolar disorder is receiving haloperidol

(Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my

breasts." Which of the following responses by the nurse is BEST?

1. "You are seeing things that aren't real."

2. "Why don't we go make some fudge."

3. "You are experiencing a side effect of Haldol."

4. "I'll contact your physician to change your medication."

3

The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for

a client. The nurse should advise the client the BEST time to take this

medication is

1. before breakfast.

2. with dinner.

3. with food.

4. at hs.

4

. If a client develops cor pulmonale (right-sided heart failure), the nurse

would expect to observe

1. increasing respiratory difficulty seen with exertion.

2. cough productive of a large amount of thick, yellow mucus.

3. peripheral edema and anorexia.

4. twitching of extremities.

3

The nurse is performing triage on a group of clients in the emergency

department. Which of the following clients should the nurse see FIRST?

1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a

rusty metal can.

2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister

but not the place

and time.

3. A 49-year-old with a compound fracture of the right leg who is complaining of

severe pain.

4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of

470 mg/dL.

2

The nurse in the outpatient clinic teaches a client with a sprained right

ankle to walk with a cane. What behavior, if demonstrated by the client,

would indicate that teaching was effective?

1. The client advances the cane 18 inches in front of her foot with each step.

2. The client holds the cane in her left hand.

3. The client advances her right leg, then her left leg, and then the cane.

4. The client holds the cane with her elbow flexed 60°.

2

A client returns to his room following a myelogram. The nursing care

plan should include which of the following?

1. Encourage oral fluid intake.

2. Maintain the prone position for 12 hours.

3. Encourage the client to ambulate after the procedure.

4. Evaluate the client's distal pulses on the affected side.

1

The nurse is caring for a patient following an appendectomy. The patient

takes a deep breath, coughs, and then winces in pain. Which of the

following statements, if made by the nurse to the patient, is BEST?

1. "Take three deep breaths, hold your incision, and then cough."

2. "That was good. Do that again and soon it won't hurt as much."

3. "It won't hurt as much if you hold your incision when you cough."

4. "Take another deep breath, hold it, and then cough deeply

1

A young woman is transferred to a psychiatric crisis unit with a

diagnosis of a dissociative disorder. The nurse knows which of the following

comments by the client is MOST indicative of this disorder?

1. "I keep having recurring nightmares."

2. "I have a headache and my stomach has bothered me for a week."

3. "I always check the door locks three times before I leave home."

4. "I don't know who I am and I don't know where I live."

4

A 23-year-old man is admitted with a subdural hematoma and cerebral

edema after a motorcycle accident. Which of the following symptoms should

the nurse expect to see INITIALLY?

1. Unequal and dilated pupils.

2. Decerebrate posturing.

3. Grand mal seizures.

4. Decreased level of consciousness.

4

. The nursing team includes two RNs, one LPN/LVN, and one nursing

assistant. The nurse should consider the assignments appropriate if the

nursing assistant is assigned to care for

1. a client with Alzheimer's requiring assistance with feeding.

2. a client with osteoporosis complaining of burning on urination.

3. a client with scleroderma receiving a tube feeding.

4. a client with cancer who has Cheyne-Stokes respirations.

1

An elderly client is returned to her room after an open reduction and

internal fixation of the left femoral head after a fracture. It is MOST

important for the nursing care plan to include that the client

1. eat a high-protein, low-residue diet.

2. lie on her unoperated side.

3. exercise her arms and legs.

4. cough and deep breathe.

4

Which of the following is a correctly stated nursing diagnosis for a client

with abruptio placentae?

1. Infection related to obstetrical trauma.

2. Potential for fetal injury related to abruptio placentae.

3. Potential alteration in tissue perfusion related to depletion of fibrinogen.

4. Fluid volume deficit related to bleeding.

4

An 8-year-old client is returned to the recovery room after a

bronchoscopy. The nurse should position the client

1. in semi-Fowler's position.

2. prone, with the head turned to the side.

3. with the head of the bed elevated 45° and the neck extended.

4. supine, with the head in the midline position.

1

Which of the following assessment findings would indicate to the nurse

the need for more sedation in a client who is withdrawing from alcohol

dependence?

1. Steadily increasing vital signs.

2. Mild tremors and irritability.

3. Decreased respirations and disorientation.

4. Stomach distress and inability to sleep.

1

The home care nurse is instructing a client recently diagnosed with

tuberculosis. It is MOST important for the nurse to include which of the

following as a part of the teaching plan?

1. During the first two weeks of treatment, the client should cover his mouth and

nose when he coughs or sneezes.

2. It is necessary for the client to wear a mask at all times to prevent transmission of

the disease.

3. The family should support the client to help reduce feeling of low self-esteem and

isolation.

4. The client will be required to take prescribed medication for a duration of 6-9

months.

4

The nurse's INITIAL priority when managing a physically assaultive

client is to

1. restrict the client to the room.

2. place the client under one-to-one supervision.

3. restore the client's self-control and prevent further loss of control.

4. clear the immediate area of other clients to prevent harm.

3

A client with newly diagnosed type I diabetes mellitus is being seen by

the home health nurse. The physician orders include: 1,200-calorie ADA

diet, 15 units of NPH insulin before breakfast, and check blood sugar qid.

When the nurse visits the client at 5 PM, the nurse observes the man

performing a blood sugar analysis. The result is 50 mg/dL. The nurse would

expect the client to be

1. confused with cold, clammy skin and a pulse of 110.

2. lethargic with hot, dry skin and rapid, deep respirations.

3. alert and cooperative with a BP of 130/80 and respirations of 12.

4. short of breath, with distended neck veins and a bounding pulse of 96.

1

The nurse is supervising the staff providing care for an 18-month-old

hospitalized with hepatitis A. The nurse determines that the staff's care is

appropriate if which of the following is observed?

1. The child is placed in a private room.

2. The staff removes a toy from the child's bed and takes it to the nurse's station.

3. The staff offers the child french fries and a vanilla milkshake for a midafternoon

snack.

4. The staff uses standard precautions.

1

When using restraints for an agitated/aggressive patient, which of the

following statements should NOT influence the nurse's actions during this

intervention?

1. The restraints/seclusion policies set forth by the institution.

2. The patient's competence.

3. The patient's voluntary/involuntary status.

4. The patient's nursing care plan.

3

The nurse is caring for an 80-year-old client with Parkinson's disease.

Which of the following nursing goals is MOST realistic and appropriate in

planning care for this client?

1. Return the client to usual activities of daily living.

2. Maintain optimal function within the client's limitations.

3. Prepare the client for a peaceful and dignified death.

4. Arrest progression of the disease process in the client.

2

A client with a peptic ulcer had a partial gastrectomy and vagotomy

(Billroth I). In planning the discharge teaching, the client should be

cautioned by the nurse about which of the following?

1. Sit up for at least 30 minutes after eating.

2. Avoid fluids between meals.

3. Increase the intake of high-carbohydrate foods.

4. Avoid eating large meals that are high in simple sugars and liquids.

4

A nurse is caring for a 37-year-old woman with metastatic ovarian

cancer admitted for nausea and vomiting. The physician orders total

parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of

the following is the BEST indication that the patient's nutritional status has

improved after 4 days?

1. The patient eats most of the food served to her.

2. The patient has gained 1 pound since admission.

3. The patient's albumin level is 4.0mg/dL.

4. The patient's hemoglobin is 8.5g/dL.

3

A 23-year-old woman at 32-weeks gestation is seen in the outpatient

clinic. Which of the following findings, if assessed by the nurse, would

indicate a possible complication?

1. The client's urine test is positive for glucose and acetone.

2. The client has 1+ pedal edema in both feet at the end of the day.

3. The client complains of an increase in vaginal discharge.

4. The client says she feels pressure against her diaphragm when the baby moves.

1

After abdominal surgery, a client has a nasogastric tube attached to low

suctioning. The client becomes nauseated, and the nurse observes a

decrease in the flow of gastric secretions. Which of the following nursing

interventions would be MOST appropriate?

1. Irrigate the nasogastric tube with distilled water.

2. Aspirate the gastric contents with a syringe.

3. Administer an antiemetic medicine.

4. Insert a new nasogastric tube.

2

After sustaining a closed head injury and numerous lacerations and

abrasions to the face and neck, a five-year-old child is admitted to the

emergency room. The client is unconscious and has minimal response to

noxious stimuli. Which of the following assessments, if observed by the

nurse three hours after admission, should be reported to the physician?

1. The client has slight edema of the eyelids.

2. There is clear fluid draining from the client's right ear.

3. There is some bleeding from the child's lacerations.

4. The client withdraws in response to painful stimuli.

2

The nurse is caring for a manic client in the seclusion room, and it is

time for lunch. It is MOST appropriate for the nurse to take which of the

following actions?

1. Take the client to the dining room with 1:1 supervision.

2. Inform the client he may go to the dining room when he controls his behavior.

3. Hold the meal until the client is able to come out of seclusion.

4. Serve the meal to the client in the seclusion room.

4

A client is given morphine 6 mg IV push for postoperative pain.

Following administration of this drug, the nurse observes the following:

pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the

following nursing actions is MOST appropriate?

1. Allow the client to sleep undisturbed.

2. Administer oxygen via facemask or nasal prongs.

3. Administer naloxone (Narcan).

4. Place epinephrine 1:1,000 at the bedside.

3

What type of infectious diseases are required to be reported to the health department?

- severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA)

What is the process of taking a telephone order from a provider?

Patient name, drug, dose, route, frequency

read back for accuracy

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA

a) Place the client in a negative pressure room

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 care

e) Use antimicrobial sanitizer for hand hygiene

A

B

E

A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching?

a) Assign the client to a room with a negative air-flow system

b) Use alcohol-based hand sanitizer when leaving the clients room

c) clean contaminated surfaces in the clients room with a phenol solution

d) have family members wear a gown and gloves when visiting

D

A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?

a) place a warm compress over the IV site

b) record the findings in the client's chart

c) notify the client's primary care provider

d) prepare to insert a new IV catheter

A

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client?

a) use a bed exit alarm system

b) raise 4 side rails while client is in bed

c) apply one soft wrist restraint

d) dim the lights in the client's room

A

A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

a) implement a regular toileting schedule

b) encourage the client to wear athletic socks when ambulating

c) place all 4 bed rails in the upright position

c) require a family member to remain at the bedside

A

Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?

a) insert the suction catheter while the client is swallowing

b) apply intermittent suction when withdrawing the catheter

c) place the catheter in a location that is clean and dry for later use

d) hold the suction catheter with the clean, non-dominant hand

B

A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

a) request an occupational therapy consult to determine the need for assistive devices

b) assign assistive personnel to perform self-care tasks for client

c) instruct the client to focus on gradually resuming self-care tasks

d) ask the client if a family member is available to assist with his care

C

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding?

a) serum albumin level of 3 g/dL

b) HDL level of 90 mg/dL

c) Norton scale score of 18

d) Braden scale score of 20

A

A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

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 the rest since"

d) "I drink a lot, so I will fill up the bottle and complete the test quickly"

C

A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?

a) tap water

b) sterile water

c) 0.9% sodium chloride

d) 0.45% sodium chloride

C

A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching?

a) use the cane on the weak side of the body

b) advance the cane and the atrong leg simultaneously

c) maintain two points of support on the floor

d) advance the cane 30 to 45 cm (12-18 in) with each step

C

Which of the following should indicate to a nurse the need to suction a client's tracheostomy?

a) irritability

b) hypotension

c) flushing

d) bradycardia

A

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 40.5C (105F)

c) cleanse the wound from the center outwards

d) use a 20 mL syringe to irrigate the wound

C

A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid?

a) lemon-lime sports drinks

b) ginger ale

c) black coffee

d) orange sherbet

D

A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take?

a) assess for bladder distention after 6 hr

b) encourage the client to use a bed pan in the supine position

c) restrict the clients intake of oral fluids

d) pour warm water over the clients perineum

D

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

1. Cancer of any kind.

2. Impaired hearing.

3. Prescription drug intoxication.

4. Heart failure.

3

Which of the following is essential when caring for a client who is experiencing delirium?

1. Controlling behavioral symptoms with low-dose psychotropics.

2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation.

4. Decreasing or discontinuing all previously prescribed medications.

2

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

1. Explain the experience of having delirium.

2. Resume a normal sleep-wake cycle.

3. Regain orientation to time and place.

4. Establish normal bowel and bladder function.

3

A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?

1. Administer PRN haloperidol (Haldol) to decrease the need to walk.

2. Assess the client's gait for steadiness.

3. Restrain the client in a geriatric chair.

4. Administer PRN lorazepam (Ativan) to provide sedation.

2

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply.

1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.

3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.

4. Promote relaxation before bedtime with a warm bath or relaxing music.

5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.

2

3

4

The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?

1. Sleep disturbances.

2. Concomitant depression.

3. Agitation and assaultiveness.

4. Confusion and withdrawal.

3