ATI Final Exam ~ Review Questions With Complete Solutions.

ATI Final Exam ~ Review Questions With Complete Solutions. A qnurse qis qteaching qa qclient qand qhis qfamily qhow qto qcare qfor qthe qclient's qtracheostomy qat qhome. qWhich qof qthe qfollowing qinstructions qis qappropriate qfor qthe qclient qand qfamily? 1. qRemove qthe qouter qcannula qcautiously qfor qroutine qcleaning. 2. qUse qtracheostomy qcovers qwhen qoutdoors. 3. qUse qsterile qtechnique qwhen qperforming qtracheostomy qcare qat qhome. 4. qCleanse qirritated qskin qwith qfull-strength qhydrogen qperoxide. q- q q q qcorrect qanswer.2. qUse qtracheostomy qcovers qwhen qoutdoors. A qnurse qis qgiving qan qend-of-shift qreport qabout qa qclient qadmitted qearlier qthat qday qwith qpneumonia. qWhich qof qthe qfollowing qpieces qof qinformation qis qmost qessential qto qprovide? 1. qAdmitting qdiagnosis 2. qDiagnostic qtest qresults 3. qBody qtemperature 4. qBreath qsounds q- q q q qcorrect qanswer.4. qBreath qsounds **ABCs** A qnurse qis qchecking qblood qpressures qat qa qcommunity qhealth qscreening. qWhich qof qthe qfollowing qclients qis qat qhigh qrisk qfor qprimary qhypertension? 1. qA qclient qwho qis qpregnant 2. qA qclient qwho qhas qan qelevated qLDL 3. qA qclient qwho qtakes qoral qcontraceptives 4. qA qclient qwho qhas qkidney qdisease q- q q q qcorrect qanswer.2. qA qclient qwho qhas qan qelevated qLDL A qnurse qis qplanning qcare qfor qa qclient qwho qhas qhad qa qstroke qresulting qin qaphasia qand qdysphagia. qWhich qof qthe qfollowing qtasks qshould qthe qnurse qassign qto qan qAP? q(Select qall qthat qapply.) - qAssist qthe qclient qwith qa qpartial qbed qbath. - qMeasure qthe qclient's qBP qafter qthe qnurse qadministers qan qantihypertensive qmedication. - qTest qthe qclient's qswallowing qability qby qproviding qthickened qliquids. - qUse qa qcommunication qboard qto qask qwhat qthe qclient qwants qfor qlunch. - qIrrigate qthe qclient's qindwelling qurinary qcatheter. q- q q q qcorrect qanswer.- qAssist qthe qclient qwith qa qpartial qbed qbath. - qMeasure qthe qclient's qBP qafter qthe qnurse qadministers qan qantihypertensive qmedication. - qUse qa qcommunication qboard qto qask qwhat qthe qclient qwants qfor qlunch. A qnurse qis qcaring qfor qa qclient qwho qis qcombative qin qthe qemergency qdepartment. qThe qprovider qorders qwrist qrestraints qafter qthe qclient qattempts qto qassault qthe qadmitting qnurse. qWhich qof qthe qfollowing qactions qis qappropriate qfor qthe qnurse qto qtake? 1. qTie qrestraints qto qthe qlower qedge qof qthe qside qrail. 2. qRemove qeach qrestraint qone qat qa qtime qevery q2 qhr. 3. qEnsure q3 qfinger-widths qof qspace qbetween qthe qrestraint qand qthe qclient's qwrist. 4. qUse qa qsquare qknot qto qsecurely qtie qthe qrestraints qto qthe qbed. q- q q q qcorrect qanswer.2. qRemove qeach qrestraint qone qat qa qtime qevery q2 qhr. **To qperform qROM qexercises qand qneurovascular qchecks** A qnurse qis qpreparing qto qadminister qmorphine q4 qmg qIV qbolus qto qa qclient. qAvailable qis qmorphine q5mg/mL. qWhich qof qthe qfollowing qis qan qappropriate qnursing qintervention? 1. qReturn qthe qunused qmedication qto qthe qautomatic qdispensing qsystem. 2. qKeep qthe qremaining qmedication qat qthe qclient's qbedside qfor qlater quse. 3. qHave qa qsecond qnurse qwitness qthe qdisposal qof qremaining qmedication. 4. qLock qremaining qmedication qin qsecure qcabinet. q- q q q qcorrect qanswer.3. qHave qa qsecond qnurse qwitness qthe qdisposal qof qremaining qmedication. A qnurse qis qcaring qfor qa qclient qwho qasks qabout qthe qpurpose qof qadvance qdirectives. qWhich qof qthe qfollowing qis qan qappropriate qresponse qby qthe qnurse? 1. q"It qallows qthe qcourt qto qoverrule qan qadult qclient's qrefusal qof qmedical qtreatment." 2. q"It qpermits qa qclient qto qwithhold qmedical qinformation qfrom qhealth qcare qpersonnel." 3. q"It qindicates qthe qform qof qtreatment qa qclient qis qwilling qto qaccept qin qthe qevent qof qa qserious qillness." 4. q"It qallows qhealth qcare qpersonnel qin qthe qemergency qdepartment qto qstabilize qa qclient's qcondition." q- q q q qcorrect qanswer.3. q"It qindicates qthe qform qof qtreatment qa qclient qis qwilling qto qaccept qin qthe qevent qof qa qserious qillness." A qnurse qfinds qa qclient qon qthe qfloor qupon qentering qthe qclient's qroom. qThe qroommate qreports qthat qthe qclient qwas qtrying qto qget qout qof qbed qand qfell qover qthe qbedrail qonto qthe qfloor. qWhich qof qthe qfollowing qis qcorrect qdocumentation qof qthis qincident? 1. qIncident qreport qcompleted. 2. qClient qclimbed qover qthe qbedrails. 3. qClient qfound qlying qon qfloor. 4. qClient qwas qtrying qto qget qout qof qbed. q- q q q qcorrect qanswer.3. qClient qfound qlying qon qfloor. **remember, qbe qObjective qin qdocumentation** A qclient qwho qis qpostoperative qis qverbalizing qpain qas qa q2 qon qa qpain qscale qof q0 qto q10. qThe qnurse qunderstands qthat qthe qpreoperative qteaching qregarding qpain qcontrol qhas qbeen qeffective qwhen qthe qclient qstates qwhich qof qthe qfollowing? 1. q"I qthink qI qshould qtake qmy qpain qmedication qmore qoften, qsince qit qis qnot qcontrolling qmy qpain." 2. q"Breathing qfaster qwill qhelp qme qkeep qmy qmind qoff qof qthe qpain." 3. q"It qmay qhelp qme qto qlisten qto qmusic qwhile qI'm qlying qin qbed." 4. q"I qdon't qwant qto qwalk qtoday, qbecause qI'm qexperiencing qsome qpain." q- q q q qcorrect qanswer.3. q"It qmay qhelp qme qto qlisten qto qmusic qwhile qI'm qlying qin qbed." **nonpharmacological qintervention qto qpain** A qclient qdemonstrates qanger qwhen qthe qnurse qdoes qnot qrespond qwithin q5 qmin qof qringing qfor qthe qnurse. qWhich qof qthe qfollowing qis qan qappropriate qresponse qby qthe qnurse? 1. q"I'm qsorry, qbut qanother qclient qneeded qmy qattention." 2. q"I qarrived qas qsoon qas qI qcould. qWhat qcan qI qdo qfor qyou?" 3. q"It qmust qbe qfrustrating. qI qhave qa qfew qminutes qnow." 4. q"We qhad qan qemergency qon qthe qunit, qbut qnow qI'm qhere." q- q q q qcorrect qanswer.3. q"It qmust qbe qfrustrating. qI qhave qa qfew qminutes qnow." **therapeutic qby qacknowledging qclient's qfeelings** A qnurse qis qadmitting qa qclient qwho qis qhaving qan qexacerbation qof qheart qfailure. qIn qplanning qthis qclient's qcare, qwhen qshould qthe qnurse qinitiate qdischarge qplanning? 1. qDuring qthe qadmission qprocess 2. qAs qsoon qas qthe qclient's qcondition qis qstable 3. qDuring qthe qinitial qteam qconference 4. qAfter qconsulting qwith qthe qclient's qfamily q- q q q qcorrect qanswer.1. qDuring qthe qadmission qprocess **discharge qplanning qstarts qat qadmission q(patient qneeds qfor qduring qand qafter qhospital)** A qnurse qmanager qis qoverseeing qthe qcare qof qa qunit. qWhich qof qthe qfollowing qshould qthe qnurse qmanager qidentify qas qa qviolation qof qHIPPA qguidelines? 1. qThe qassigned qnurse qreviews qthe qmedical qchart qwith qa qnursing qstudent. 2. qA qnursing qstudent qdiscusses qa qclient's qstatus qwith qthe qassigned qnurse qat qthe qbedside. 3. qThe qassigned qnurse qreturns qa qcall qto qa qclient's qPower qof qAttorney qto qdiscuss qthe qclient's qcare. 4. qA qnursing qstudent qconsults qa qformer qclassmate qto qassist qwith qher qdocumentation. q- q q q qcorrect qanswer.4. qA qnursing qstudent qconsults qa qformer qclassmate qto qassist qwith qher qdocumentation. **only qthose qin qdirect qcare** A qnurse qis qteaching qa qclient qabout qself-administering qNPH qinsulin. qWhich qof qthe qfollowing qactions qby qthe qclient qindicates qa qneed qfor qfurther qteaching? 1. qThe qclient qinserts qthe qneedle qat qa q30°-angle. 2. qThe qclient qrolls qthe qvial qbetween qboth qhands. 3. qThe qclient qholds qthe qsyringe qin qplace qfor q5 qseconds qfollowing qinjection. 4. qThe qclient quses qher qanterior qthigh qas qthe qinjection qsite. q- q q q qcorrect qanswer.1. qThe qclient qinserts qthe qneedle qat qa q30°-angle. **Insert qneedle qat q45° qto q90° q(depending qon qadipose/fat qtissue)** A qnurse qis qreviewing qa qclient's qfluid qand qelectrolyte qstatus. qWhich qof qthe qfollowing qfindings qshould qthe qnurse qreport qto qthe qprovider? 1. qBUN q15 qmg/dL 2. qCreatinine q0.8 qmg/dL 3. qSodium q143 qmEq/L 4. qPotassium q5.4 qmEq/L q- q q q qcorrect qanswer.4. qPotassium q5.4 qmEq/L **Electrolytes q(ranges):** Sodium q~ q135-145 qmEq/L Chloride q~ q95-105 qmEq/L Potassium q~ q3.5-5.0 qmEq/L Bicarbonate q~ q22-28 qmEq/L Magnesium q~ q1.5-2.0 qmEq/L A qnurse qcontacts qthe qfacility's qinterpreter qto qexplain qa qtherapeutic qprocedure qfor qa qclient qwho qdoes qnot qspeak qEnglish. qWhich qof qthe qfollowing qguidelines qshould qthe qnurse qfollow qwhen qworking qwith qthe qinterpreter? 1. qSpeak qslowly qto qallow qthe qinterpreter qto qinterpret qeach qword. 2. qExplain qthe qpurpose qof qthe qcommunication qto qthe qinterpreter. 3. qAddress qthe qinterpreter qwhen qexplaining qthe qprocedure qinformation. 4. qSupplement qwords qwith qgestures qand qnonverbal qreinforcement. q- q q q qcorrect qanswer.2. qExplain qthe qpurpose qof qthe qcommunication qto qthe qinterpreter. A qnurse qis qpreparing qto qperform qnasopharyngeal qsuctioning qfor qa qclient qwho qis qunable qto qcough qup qexcessive qsecretions. qWhich qof qthe qfollowing qactions qis qappropriate? 1. qUse qthe qclean qtechnique qthroughout qthe qprocedure. 2. qInsert qthe qcatheter qas qthe qclient qexhales. 3. qApply qsuction qfor qup qthe q20 qseconds. 4. qPerform qsuctioning qwhile qremoving qthe qcatheter. q- q q q qcorrect qanswer.4. qPerform qsuctioning qwhile qremoving qthe qcatheter. A qnurse qis qcaring qfor qa qclient qand qperforming qblood qglucose qmonitoring. qWhich qof qthe qfollowing qis qan qappropriate qnursing qintervention? 1. qWipe qaway qthe qfirst qdrop qof qblood qfrom qthe qclient's qfinger. 2. qGently qmassage qthe qclient's qfinger qin qa qdistal qto qproximal qdirection. 3. qPuncture qthe qtip qof qthe qclient's qfinger. 4. qHold qthe qclient's qfinger qin qan qelevated qposition qprior qto qtesting. q- q q q qcorrect qanswer.1. qWipe qaway qthe qfirst qdrop qof qblood qfrom qthe qclient's qfinger. **first qdrop qis qmore qserous; qcontains qfewer qRBCs** A qnurse qis qcaring qfor qa qclient qwho qcannot qbear qweight qon qhis qfractured qankle. qWhich qof qthe qfollowing qclient qstatements qindicates qa qneed qfor qfurther qteaching qregarding qthree-point qgait qcrutch qwalking? 1. q"When qI qget qout qof qa qchair, qI'll qhold qboth qcrutches qon qthe qside qnext qto qmy qweak qleg." 2. q"When qI qsit qdown, qI'll qtransfer qmy qweight qto qmy qcrutches qand qmy qstrong qleg." 3. q"When qI qgo qup qstairs, qI'll qalternate qputting qweight qon qmy qcrutches qand qmy qstrong qleg." 4. q"When qI qgo qdown qstairs, qI'll qstart qby qmoving qboth qmy qcrutches qto qthe qstep qbelow." q- q q q qcorrect qanswer.1. q"When qI qget qout qof qa qchair, qI'll qhold qboth qcrutches qon qthe qside qnext qto qmy qweak qleg." A qnurse qis qpreparing qto qadminister qoral qmedications qto qa qclient qwho qhas qdysphagia. qWhich qof qthe qfollowing qis qan qappropriate qaction qby qthe qnurse? 1. qHave qthe qclient qdrink qwater qfrom qa qstraw qafter qtaking qthe qmedication. 2. qInstruct qthe qclient qto qlift qhis qchin qupward qwhen qswallowing qmedications. 3. qOffer qeach qmedication qone qat qa qtime. 4. qPlace qthe qmedication qin qthe qclient's qmouth. q- q q q qcorrect qanswer.3. qOffer qeach qmedication qone qat qa qtime. A qnurse qis qcaring qfor qa qclient qwho qis qreceiving qmedication qintramuscularly. qThe qnurse qshould qrecognize qthat qthis qroute 1. qincreases qinfection qrates. 2. qis qthe qsafest qoption. 3. qhas qthe qslowest qabsorption qrate. 4. qdecreases qthe qclient's qrisk qfor qreactions. q- q q q qcorrect qanswer.1. qincreases qinfection qrates. **breaking qskin qintegrity qincreases qrisk qfor qinfection** A qnurse qis qworking qwith qan qOrthodox qJewish qclient qwho qhas qjust qgiven qbirth qto qa qstillborn qinfant. qWhich qof qthe qfollowing qinterventions qis qappropriate? 1. qAsk qthe qfamily qif qthere qare qany qspecial qrituals qthat qthey qwould qlike qto qfollow qat qthis qtime. 2. qInform qthe qparents qof qthe qimportance qof qconforming qto qhospital qpolicy qregarding qthe qdeath qof qa qfetus. 3. qRemain qin qthe qroom, qgiving qthe qparents qthe qopportunity qto qinitiate qa qdiscussion qabout qcultural qrituals. 4. qTake qthe qfetus qout qof qthe qroom, qand qallow qthe qparents qtime qto qgrieve qtogether. q- q q q qcorrect qanswer.1. qAsk qthe qfamily qif qthere qare qany qspecial qrituals qthat qthey qwould qlike qto qfollow qat qthis qtime. A qnurse qis qcaring qfor qfour qclients. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake qto qprevent qthe qspread qof qinfection? 1. qCarry qa qclient's qsoiled qlinens qout qof qthe qroom qin qa qmesh qlinen qbag. 2. qPlace qa qclient qwho qhas qtuberculosis qin qa qroom qwith qnegative-pressure qairflow. 3. qProvide qdisposable qplates qand qutensils qto qa qclient qwho qhas qHIV. 4. qDispose qof qa qclient's qblood-saturated qdressing qin qa qgarbage qbag qplaced qinside qa qsecond qgarbage qbag. q- q q q qcorrect qanswer.2. qPlace qa qclient qwho qhas qtuberculosis qin qa qroom qwith qnegative-pressure qairflow. **negative q= qair qin positive q= qair qout** A qnurse qis qcaring qfor qa qclient qwho qhad qa qfasting qblood qsugar qdrawn qat q0600. qThe qclient qtells qthe qnurse, q"All qI qhave qhad qsince qmidnight qis qwater qand qsome qjuice." qWhich qof qthe qfollowing qnursing qactions qis qappropriate? 1. qDocument qthe qcaloric qintake. 2. qReschedule qthis qlab qtest qfor qthe qnext qmorning. 3. qNotify qthe qlab qto qobtain qanother qspecimen. 4. qObtain qa qprescription qfor qa qglucose qtolerance qtest. q- q q q qcorrect qanswer.2. qReschedule qthis qlab qtest qfor qthe qnext qmorning. **should qfast qfor q8 qto q12 qhr qbefore qsample qis qdrawn** A qclient qis qscheduled qfor qsurgery. qThe qintraoperative qnurse qfinds qa qnecklace qon qthe qclient qafter qanesthesia qhas qbeen qadministered. qWhich qof qthe qfollowing qinterventions qshould qbe qinitiated? 1. qLeave qthe qnecklace qon qthe qclient. 2. qGive qthe qnecklace qto qa qfamily qmember. 3. qPlace qthe qnecklace qin qthe qclient's qchart. 4. qNotify qsecurity qfor qplacement qof qthe qnecklace. q- q q q qcorrect qanswer.4. qNotify qsecurity qfor qplacement qof qthe qnecklace. A qnurse qis qproviding qdischarge qinstructions qto qa qclient qwho qwill qbe qusing qa qwalker. qWhich qof qthe qfollowing qstatements qby qthe qclient qindicates qa qneed qfor qfurther qinstruction qby qthe qnurse? 1. q"I qwill qtape qelectrical qcords qto qthe qbaseboards qin qeach qroom." 2. q"I qwill qhire qsomeone qto qtrim qthe qtree qthat qoverhangs qthe qfront qporch qstairs." 3. q"I qwill qremove qthe qtable qfrom qthe qhall." 4. q"I qwill qreplace qthe qold qthrow qrug qin qthe qkitchen qwith qa qnew qone." q- q q q qcorrect qanswer.4. q"I qwill qreplace qthe qold qthrow qrug qin qthe qkitchen qwith qa qnew qone." **use qof qthrow qrugs qincrease qrisk qfor qfalls** A qnurse qhas qan qorder qto qremove qsutures qfrom qa qclient. qAfter qretrieving qthe qsuture qremover qkit qand qapplying qsterile qgloves, qwhich qof qthe qfollowing qactions qshould qthe qnurse qtake qnext? 1. qClean qsutures qalong qwith qthe qincision qsite. 2. qGrasp qthe qsutures qat qthe qknow qwith qa qpair qof qforceps. 3. qCut qthe qsutures qclose qto qthe qskin qon qone qside. 4. qPull qout qthe qsutures qwith qforceps qin qone qpiece. q- q q q qcorrect qanswer.1. qClean qsutures qalong qwith qthe qincision qsite. **greatest qrisk qto qthis qclient qis qinfection; qclean qto qminimize qrisk** A qnurse qis qplanning qcare qto qpromote qimproved qself-feeding qfor qa qclient qwho qhas qvisual qimpairment. qWhich qof qthe qfollowing qinterventions qshould qnurse qinclude qin qthe qplan qof qcare? 1. qDirect qthe qclient qin qwhat qorder qto qconsume qthe qfood. 2. qProvide qsmall-handled qutensils qfor qthe qclient. 3. qThicken qliquids qon qthe qclient's qtray. 4. qUse qa qclock qpattern qto qdescribe qfood qon qthe qplate qto qthe qclient. q- q q q qcorrect qanswer.4. qUse qa qclock qpattern qto qdescribe qfood qon qthe qplate qto qthe qclient. A qnurse qis qreviewing qlaboratory qdata qfor qa qclient qwho qhas qcontusions qto qthe qchest qwall qfollowing qa qmotor qvehicle qcrash. qWhich qof qthe qfollowing qvalues qshould qthe qnurse qreport? 1. qHct q40% 2. qSaO2 q86% 3. qWBC q9,000 qmm³ 4. qSerum qpotassium q4.1 qmEq/L q- q q q qcorrect qanswer.2. qSaO2 q86% **low qoxygen q(90%); qmay qindicate qhypoxia** A qnurse qis qcaring qfor qa qclient qwith qa qdiagnosis qof qterminal qcancer. qThe qnurse qunderstands qthat qthe qclient qis qready qto qhear qinformation qregarding qpalliative qcare qwhen qthe qclient qstates qwhich qof qthe qfollowing? 1. q"I qam qready qto qlearn qabout qchemotherapy qto qhelp qcure qmy qcancer." 2. q"I qjust qwant qyou qto qgive qme qsomething qto qget qthis qover qwith qsoon." 3. q"I qknow qthat qmany qpeople qhave qrecovered qfully qfrom qcancer, qand qso qwill qI." 4. q"I qwant qyou qto qtell qme qabout qmeasures qavailable qto qkeep qme qcomfortable." q- q q q qcorrect qanswer.4. q"I qwant qyou qto qtell qme qabout qmeasures qavailable qto qkeep qme qcomfortable." **palliative qcare q= qcomfort qand qsymptom qcontrol** A qnurse qis qcaring qfor qa qclient qwho qis qpostoperative qand qhas qsigns qof qhemorrhagic qshock. qWhen qthe qnurse qnotifies qthe qsurgeon, qhe qdirects qher qto qcontinue qto qtake qthe qclient's qvital qsigns qevery q15 qmin qand qcall qhim qback qin q1 qhr. qFrom qa qlegal qperspective, qwhich qof qthe qfollowing qactions qshould qthe qnurse qtake qnext? 1. qDocument qthe qprovider's qstatement qin qthe qmedical qrecord. 2. qComplete qan qincident qreport. 3. qConsult qthe qfacility's qrisk qmanager. 4. qNotify qthe qnursing qmanager. q- q q q qcorrect qanswer.4. qNotify qthe qnursing qmanager. **status qis qdeteriorating; quse qchain-of-command qto qensure qcare** A qnurse qis qchecking qa qclient's qblood qpressure qto qassess qfor qorthostatic qhypotension. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake? 1. qObtain qblood qpressure q30 qmin qafter qeach qmeal. 2. qObtain qblood qpressure qimmediately qafter qthe qclient qambulates. 3. qObtain qblood qpressure qin qeach qarm qand qleg. 4. qObtain qblood qpressure q2 qmin qafter qassisting qthe qclient qto qa qsitting qposition. q- q q q qcorrect qanswer.4. qObtain qblood qpressure q2 qmin qafter qassisting qthe qclient qto qa qsitting qposition. **orthostatic qhypotension q= qdrop qin qBP qwhen qget qup; qtake qBP qin qsupine, qsitting, qstanding q(1-3min qintervals)** Which qof qthe qfollowing qis qthe qresponsibility qof qa qnurse qwho qis qcaring qfor qa qclient qreceiving qPCA? 1. qInstruct qthe qfamily qto qrefrain qfrom qpushing qthe qbutton qfor qthe qclient qwhile qshe qis qasleep. 2. qInform qthe qclient qthat qbecause qshe qis qon qPCA, qvital qsigns qwill qbe qtaken qevery q8 qhr. 3. qTeach qthe qclient qto qavoid qpushing qthe qbutton qunless qpain qis qabove qa q7 qon qa qscale qof q0 qto q10. 4. qIncrease qthe qbasal qrate qand qshorten qthe qlock-out qinterval qtime qif qthe qclient's qpain qlevel qis qtoo qhigh. q- q q q qcorrect qanswer.1. qInstruct qthe qfamily qto qrefrain qfrom qpushing qthe qbutton qfor qthe qclient qwhile qshe qis qasleep. The qnurse qis qobserving qa qnewly qlicensed qnurse qwho qis qpreparing qa qsterile qfield qfor qa qdressing qchange. qWhich qof qthe qfollowing qactions qby qthe qnewly qlicensed qnurse qshould qcause qthe qnurse qto qintervene? 1. qThe qnewly qlicensed qnurse qplaces qthe qcap qof qthe qsterile qsaline qbottle qon qthe qsterile qfield. 2. qThe qnewly qlicensed qnurse qplaces qsterile qobjects q1 qinch qfrom qthe qborder qof qthe qfield. 3. qThe qnewly qlicensed qnurse qholds qthe qbottle qof qsterile qsaline qoutside qthe qedge qof qthe qfield qwhen qpouring. 4. qThe qtable qis qpositioned qat qthe qlevel qof qthe qnewly qlicensed qnurse's qwaist. q- q q q qcorrect qanswer.1. qThe qnewly qlicensed qnurse qplaces qthe qcap qof qthe qsterile qsaline qbottle qon qthe qsterile qfield. A qnurse qis qpreparing qto qadminister q750 qmL qof q0.9% qsodium qchloride qIV qto qinfuse qover q7 qhr. qThe qnurse qshould qset qthe qinfusion qpump qto qdeliver qhow qmany qmL/hr? q(Round qthe qanswer qto qthe qnearest qwhole qnumber.) _____________ qmL/hr q- q q q qcorrect qanswer.107 qmL/hr A qnurse qis qplanning qto qteach qa qpreschool qchild qhow qto qproperly quse qa qmetered qdose qinhaler. qWhich qof qthe qfollowing qmethods qis qappropriate qfor qthis qchild? 1. qHold qthe qchild qin qthe qlap qwhile qgiving qexplanations. 2. qHelp qthe qchild qidentify qher qfeelings qabout qusing qan qinhaler. 3. qEncourage qindependent qlearning. 4. qUse qrole qplay qand qimitation qwhen qexplaining. q- q q q qcorrect qanswer.4. qUse qrole qplay qand qimitation qwhen qexplaining. A qnurse qis qpreparing qto qcare qfor qa qclient qwho qhas qmethicillin-resistant qStaphylococcus qaureus q(MRSA) qin qthe qlungs. qIn qaddition qto qa qgown qand qgloves, qthe qnurse qwill qneed qwhich qof qthe qfollowing qequipment qin qorder qto qprovide qcare? 1. qFace qshield 2. qHigh-filtration qmask 3. qShoe qcovers 4. qSurgical qcap q- q q q qcorrect qanswer.1. qFace qshield **MRSA q= qblood; qmouth, qnose, qeye qprotection** A qnurse qis qcaring qfor qa qyoung qchild qwho qis qprescribed qa qblood qtransfusion. qThe qparents qhave qrefused qthe qtreatment qdue qto qreligious qbeliefs. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake? 1. qExamine qpersonal qvalues qabout qthe qissue. 2. qTell qthe qparents qthat qthis qis qa qnecessary qprocedure. 3. qInform qthe qparents qthat qtheir qconsent qis qnot qrequired. 4. qContact qthe qchaplain qto qexplain qthe qimportance qof qthe qprocedure. q- q q q qcorrect qanswer.1. qExamine qpersonal qvalues qabout qthe qissue. **provide qunbiased qcare** A qnurse qis qcaring qfor qa qclient qwho qis qpostoperative qfollowing qcolostomy qplacement. qWhich qof qthe qfollowing qfindings qshould qthe qnurse qreport qto qthe qprovider? 1. qStoma qappears qpurple qin qcolor. 2. qProtrusion qof qstoma qfrom qthe qabdomen. 3. qMucosa qof qthe qstoma qbleeds qslightly qwhen qtouched. 4. qRed qperistomal qskin qunder qthe qadhesive. q- q q q qcorrect qanswer.1. qStoma qappears qpurple qin qcolor. **notify qprovider qif qstoma qappears qdark qin qcolor q(impaired qcirculation)** A qnurse qis qplanning qteaching qfor qa qclient qwho qhas qa qnew qdiagnosis qof qtype q1 qdiabetes qmellitus qabout qinsulin qself-administration. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake qfirst? 1. qEncourage qthe qclient qto qinclude qa qfamily qmember qin qthe qteaching. 2. qDetermine qthe qclient's qlearning qstyle. 3. qProvide qwritten qdirections qfor qthe qclient qto quse. 4. qSchedule qa qseries qof qteaching qsessions. q- q q q qcorrect qanswer.2. qDetermine qthe qclient's qlearning qstyle. **1st qrule: qassess q(in qthis qcase: qclients qlearning qstyle)** Following qadministration qof qlevothyroxine q125 qmcg qat q0800, qthe qnurse qdiscovers qthe qmedication qwas qgiven qto qa qclient qfor qwhom qit qwas qnot qprescribed. qWhich qof qthe qfollowing qis qthe qcorrect qway qto qdocument qthis qerror qin qthe qmedical qrecord qof qthe qclient qwho qreceived qthe qmedication? 1. qLevothyroxine q125 qmcg qgiven qat q0800 qin qerror. qClient qis qin qno qdistress. 2. qLevothyroxine q125 qmcg qgiven qat q0800. qProvider qnotified. 3. qLevothyroxine q125 qmcg qgiven qat q0800. qIncident qreport qfiled. 4. qLevothyroxine q125 qmcg qgiven qat q0800 qin qerror. qClient qinformed qof qerror. q- q q q qcorrect qanswer.2. qLevothyroxine q125 qmcg qgiven qat q0800. qProvider qnotified. A qnurse qis qadmitting qa qnew qclient. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake qwhile qperforming qmedication qreconciliation? 1, qVerify qthe qclient's qname qon qhis qidentification qbracelet qwith qthe qMAR. 2. qCall qthe qpharmacy qto qdetermine qif qthe qclient's qmedications qare qavailable. 3. qCompare qthe qclient's qhome qmedications qwith qthe qprovider's qprescriptions. 4. qPlace qthe qclient's qhome qmedication qbottles qin qa qsecure qlocation. q- q q q qcorrect qanswer.3. qCompare qthe qclient's qhome qmedications qwith qthe qprovider's qprescriptions. **as qdefined qas qmedication qreconciliation** A qnurse qis qcaring qfor qa qclient qwho qhas qrecently qstarted qusing qa qhearing qaid qworn qbehind qthe qear. qWhich qof qthe qfollowing qclient qstatements qindicates qto qthe qnurse qthat qhe qunderstands qthe quse qof qthis qassistive qdevice? 1. q"This qtype qof qhearing qaid qdoes qnot qallow qfor qfine qtuning qof qvolume." 2. q"I qshouldn't qhave qtrouble qkeeping qthe qhearing qaid qin qplace qduring qexercise." 3. q"I qexpect qto qhear qa qwhistling qsound qwhen qI qfirst qinsert qthe qhearing qaid." 4. q"I qwill qbe qsure qto qremove qmy qhearing qaid qbefore qtaking qa qshower." q- q q q qcorrect qanswer.4. q"I qwill qbe qsure qto qremove qmy qhearing qaid qbefore qtaking qa qshower." To qprevent qfoot qdrop qin qa qclient qwho qhas qdecreased qmobility, qthe qnurse qshould 1. qplace qa qpillow qunder qthe qclient's qknees. 2. qposition qa qtrochanter qroll qunder qthe qclient's qfeet. 3. qadvise qthe qclient qto qwear qrubber-soled qslippers. 4. qplace qthe qclient's qfeet qagainst qa qfoot qboard qperpendicular qto qthe qmattress. q- q q q qcorrect qanswer.4. qplace qthe qclient's qfeet qagainst qa qfoot qboard qperpendicular qto qthe qmattress. **keep qfoot qin qdorsiflex, qkeep qfrom qfoot qdrop** A qnurse qhas qjust qinserted qan qNG qtube qfor qa qclient. qWhich qof qthe qfollowing qassessment qfindings qindicates qthat qthe qtube qis qproperly qpositioned? 1. qThe qtube qaspirate qhas qa qpH qof q7. 2. qAn qx-ray qshows qthe qend qof qthe qtube qabove qthe qpylorus. 3. qBowel qsounds qare qpresent qon qauscultation. 4. qThe qclient qreports qrelief qof qnausea. q- q q q qcorrect qanswer.2. qAn qx-ray qshows qthe qend qof qthe qtube qabove qthe qpylorus. **X-ray qto qconfirm qgastric qplacement** A qclient qis qreporting qpain qat qthe qinsertion qsite qof qhis qIV qcatheter. qThe qnurse qobserves qa qred qline qextending qoutward qfrom qthe qinsertion qsite. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake qfirst? 1. qPlace qa qwarm qcompress qover qthe qsite 2. qRestart qthe qIV qline qat qa qdifferent qsite. 3. qDiscontinue qthe qinfusion. 4. qDocument qthe qfindings. q- q q q qcorrect qanswer.3. qDiscontinue qthe qinfusion. **greatest qrisk q= qfurther qinjury qto qthe qvein; qfirst qaction qis qto qdiscontinue** A qnurse qis qcaring qfor qa qpreschooler qwho qhas qheart qdisease. qThe qprovider qprescribes qdigoxin qat qthe qmaximum qadult qdose. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake? 1. qGive qthe qmedication qas qprescribed qusing qthe qSix qRights qof qMedication qAdministration. 2. qCall qthe qprovider qto qdiscuss qconcerns qregarding qthe qdosage qfor qthe qchild. 3. qAssess qthe qclient's qheart qrate qand qrhythm qbefore qdeciding qwhether qor qnot qto qgive qthe qmedication. 4. qAdminister qthe qpediatric qdose qrecommended qin qa qmedication-reference qbook. q- q q q qcorrect qanswer.2. qCall qthe qprovider qto qdiscuss qconcerns qregarding qthe qdosage qfor qthe qchild. A qnurse qis qcaring qfor qa qclient qwho qis qat qrisk qfor qhypokalemia. qWhich qof qthe qfollowing qfoods qshould qbe qincluded qin qthe qclient's qdiet? 1. qAvocados 2. qCorn 3. qAsparagus 4. qCucumbers q- q q q qcorrect qanswer.1. qAvocados A qnurse qreceives qreport qon qa qclient qwho qis qreceiving q0.9% qsodium qchloride qat q125 qmL/hr. qWhen qthe qnurse qperforms qthe qinitial qassessment qshe qnotes qthat qthe qclient qhas qreceived q80 qmL qfor qthe qlast q2 qhr. qWhich qof qthe qfollowing qactions qshould qthe qnurse qtake qfirst? 1. qReposition qthe qclient. 2. qDocument qthe qclient's qIV qintake qin qthe qmedical qrecord. 3. qRequest qa qnew qIV qfluid qprescription. 4. qCheck qthe qIV qtubing qfor qobstruction. q- q q q qcorrect qanswer.4. qCheck qthe qIV qtubing qfor qobstruction. A qnurse qis qproviding qinstructions qfor qan qolder qadult qclient qwho qhas qa qprescription qfor qan qelectric qheating qpad qto qhis qlumbosacral qarea. qWhich qof qthe qfollowing qclient qstatements qindicates qa qcorrect qunderstanding qof qthe qteaching? 1. q"I qwill qremove qthe qheating qpad qin q30 qminutes." 2. q"I qwill qneed qto qturn qup qthe qheating qpad qafter qit qhas qbeen qin qplace qfor q10 qminutes."