Q&A Hero

Q: A client is newly diagnosed with heart failure. Which interventions should the nurse prepare to provide this client? Select all that apply. 1. Bed rest 2. Elevate legs 3. Oxygen therapy 4. Fluid restriction 5. Low sodium diet

Q: The nurse places lead aVR on a client. What tracing will this lead produce? 1. Activity between the center of the heart and left arm 2. Activity between the center of the heart and right arm 3. Activity between the center of the heart and the fourth ICS 4. Activity between the center of the heart and the left leg or foot

Q: The nurse is preparing to document care provided to a client who received rescue breathing while being transported to radiology. What should the nurse include in the documentation for this client? Standard Text: Select all that apply. 1. Date and time of event 2. Factors that precipitated the event 3. Length of time with no breathing 4. Response to rescue breathing 5. Tasks assigned to the unlicensed assistive personnel

Q: The nurse is attending a football game when another spectator reports chest pain and collapses. The nurse assesses the client and finds he is pulseless and not breathing. After the nurse calls for help, someone brings an AED. Which action by the nurse is the most appropriate? 1. Not using the device, because it needs to be plugged in and there is no electricity 2. Turning the machine on, placing the patches, and then plugging in the cable 3. Connecting the cables, placing the patches, and then turning on the machine 4. Placing the patches, turning on the machine, and then plugging in the cable

Q: When performing rescue breathing in a hospital, which is the preferred method for the nurse to use until the health care provider arrives to intubate the client? 1. Mouth-to-mouth 2. Mouth-to-mask 3. Bag-valve-mask method 4. The jaw-thrust maneuver

Q: The nurse is caring for a conscious adult client with an obstructed airway. When performing abdominal thrusts, which action by the nurse is appropriate? 1. Making a fist with one hand, with the thumb on top, and placing the thumb just below the xiphoid process 2. Using the side of the hand and placing it just above the xiphoid process 3. Grasping the fist with the other hand and placing the flat of the hand into the client's abdomen 4. Making a fist with one hand, tucking the thumb inside the fist, grasping the hand with the other fist, and pushing the fist above the victim's navel and below the xiphoid process

Q: While working on the orthopedic unit, the nurse finds an assigned client pulseless and not breathing. When the code team responds, which action by the nurse is appropriate? 1. Leaving the room and calling the family members to notify them of the sudden change in the client's condition 2. Getting the crash cart and emergency supplies that will be needed by the code team 3. Participating in the code in whatever role is necessary 4. Standing at the bedside and answering questions as they arise

Q: The nurse finds a client pulseless and not breathing. What tasks could the nurse safely assign to the unlicensed assistive personnel (UAP) in this situation? Standard Text: Select all that apply. 1. Perform chest compressions. 2. Get the crash cart. 3. Call a code blue. 4. Administer emergency medications. 5. Bag the client using a bag-valve mask until the doctor arrives to intubate the client.

Q: For which client would the rapid response team be least indicated? 1. Asthmatic client with a respiratory rate greater than 30 breaths per minute, oxygen saturation of 84%, and a heart rate of 142 beats per minute 2. A client with no history of seizures who has a sudden change in mentation and has a seizure 3. A client who suddenly begins to talk with difficulty and is not able to move the left arm and leg 4. The client with a history of angina who has a PRN order for nitroglycerin who reports crushing chest pain

Q: The nurse on a medical"surgical unit is caring for a client who complains of chest pain. Assessment findings include a blood pressure of 72/40, pulse rate of 40, and respiratory rate of 32. Which action by the nurse is the priority in this situation? 1. Calling a code 2. Calling the rapid response team 3. Calling the client's primary health care provider 4. Calling the emergency department (ED) and requesting they send a health care provider

Q: Which finding should the nurse report to the health care provider as soon as possible? 1. After beginning sequential compression device application, the client's toes are found to be cool to the touch and mottled, with absent pedal pulses. 2. After applying antiemboli stockings, the client says the stockings feel snug. 3. When applying antiemboli stockings, the nurse finds they are too small for this client. 4. The client asks the nurse to wait to apply the antiembolism stockings until after breakfast.

Q: After fitting the sleeve of the sequential compression device onto the client's legs, which action should the nurse take next? 1. Documenting the procedure 2. Turning the machine on 3. Connecting the sleeve to the control unit 4. Adjusting the alarms

Q: Which action by the nurse is least appropriate when applying antiemboli stockings? 1. Assisting the client to a lying position in bed 2. Turning the stocking right-side-out 3. Washing and drying the legs 4. Having the client point the toes

Q: The nurse could safely delegate which task to the unlicensed assistive personnel (UAP)? 1. Removal of antiemboli stockings to wash the feet and legs, then reapply the stockings 2. Assessing the client's circulation to the feet every 4 hours while wearing antiembolism stockings 3. Evaluating for presence of Homans' sign 4. Measuring and fitting the client for antiembolism stockings

Q: A client scheduled for surgery has a history of venous stasis problems. Which strategies should the nurse consider to reduce the risk of postoperative venous stasis? Standard Text: Select all that apply. 1. Pneumatic compression device 2. Sequential compression device 3. Antiembolism stockings 4. Getting the client out of bed as soon as possible 5. Keeping the legs lower than the level of the heart

Q: Which health problems are classified as venous thromboembolisms? Standard Text: Select all that apply. 1. Deep vein thrombosis 2. Pulmonary embolism 3. Coronary artery thrombosis 4. Myocardial infarction 5. Aortic aneurysm

Q: Which action by the nurse is appropriate when testing for Homans' sign? 1. Pointing the client's toes down 2. Having the client point the toes up toward the calf 3. Flexing the client's toes as wide apart as possible 4. Rotating the client's foot

Q: The nurse is assisting a client with postural drainage. What should be included when explaining the process to the client? Select all that apply. 1. Expectorate secretions 2. Return to a sitting position slowly 3. Remain in each position for 3 to 15 minutes 4. Take a deep breath between position changes 5. The head of the bed will be in the flat position

Q: The nurse is instructing a client on the use of a peak flow meter. In which order should the nurse provide these instructions? 1. Inhale deeply 2. Clean the unit 3. Slide the indicator to zero 4. Blow out through the mouth 5. Attach mouthpiece to the meter

Q: When assisting the health care provider with removal of the chest tube, which instruction should the nurse provide to the client during this procedure? 1. Breathe normally 2. Hold still 3. Hold breath 4. Cough

Q: When caring for a client with a chest tube in place, the nurse maintains safety by keeping which items at the client's bedside at all times? 1. Bag and mask with oxygen supply 2. Two rubber-tipped clamps, gauze, and petroleum gauze 3. Emergency phone numbers 4. An extra chest tube of the same size inserted into the client

Q: The nurse is caring for a client who has a small pneumothorax and is capable of being ambulatory. Which prescription should the nurse anticipate when caring for this client? 1. Chest tube placed in the upper chest on the side of the pneumothorax 2. Chest tube placed in the lower chest on the side of the pneumothorax 3. Heimlich chest drain valve in the upper chest on the side of the pneumothorax 4. Heimlich chest drain valve in the lower chest on the side of the pneumothorax

Q: The nurse is caring for a client with a longstanding permanent tracheostomy that has been in place for several years in order to provide mechanical ventilation. Which type of tracheostomy should the nurse anticipate this client may have based on the health history? 1. Uncuffed tracheostomy 2. Cuffed tracheostomy 3. Fenestrated tracheostomy 4. Uncuffed or fenestrated tracheostomy

Q: The nurse is performing tracheostomy care. Which portion of the trach should the nurse use when tying the new trach ties? 1. Inner cannula 2. Outer cannula 3. Obturator 4. Flange

Q: The nurse is caring for a client being weaned from the ventilator, and wants to improve the client's ability to communicate. Which item should the nurse request an order for from the health care provider? 1. Cuffed tracheostomy tube 2. Uncuffed tracheostomy tube 3. Fenestrated tracheostomy tube 4. Obturator

Q: Which client would be in particular need of a closed airway suctioning system? 1. The client post-bone marrow transplant 2. The postoperative client 3. The client with a long-term tracheostomy on 25% oxygen via mask 4. The client with excessive oral secretions

Q: The nurse is caring for a client who had oromaxillary surgery a few hours ago. The client is arousable, but is still sedated following anesthesia, and sleeps deeply when not disturbed. The client's respiratory effort is adequate, but the nurse notes the client is having issues maintaining an open airway when asleep. Which airway should the nurse choose for this client? 1. Oropharyngeal airway 2. Nasopharyngeal airway 3. Endotracheal tube 4. Tracheostomy

Q: The nurse is using a curved hard plastic tube to suction the client's oral cavity. Which term should the nurse use when referring to this piece of equipment? 1. Whistle-tipped catheter 2. Yankauer suction tube 3. Open-tipped catheter 4. Closed suctioning system

Q: The client is started on 90% oxygen by nonrebreather mask at 0800. The nurse working the night shift assesses the client, who complains of substernal pain and dyspnea and has rales audible in the lower lung field bilaterally. Based on these assessment findings, what should the nurse suspect? 1. Myocardial hypoxia 2. Pulmonary emboli 3. Oxygen toxicity 4. Congestive heart failure

Q: The nurse is caring for a 31-week premature infant requiring oxygen therapy after delivery. Which would be the most effective means of delivering oxygen? 1. Partial rebreather mask 2. Nonrebreather mask 3. Face mask 4. Oxygen hood

Q: The nurse needs to deliver the highest concentration of oxygen (95% to 100%). Which type of oxygen delivery device should the nurse choose? 1. Face mask 2. Nasal cannula 3. Partial rebreather mask 4. Nonrebreather mask

Q: Which teaching point is least likely to be included when instructing a client to perform breathing exercises? 1. Breathing in deeply through the nose with the mouth closed 2. Avoiding arching the back 3. Holding the breath for 30"40 seconds 4. Breathing out slowly

Q: The nurse is caring for a client who had major abdominal surgery yesterday. Which assessment finding would indicate inadequate airway clearance that might be cleared with coughing and deep breathing? 1. Tachypnea with rales heard in the upper lobes and over the trachea 2. Bradypnea with wheezing heard throughout all lung fields 3. Tachypnea with wheezing heard throughout all lung fields 4. Tachypnea with rhonchi heard in the lower lobes

Q: The nurse observes a client while using the prescribed incentive spirometer. Which items will the nurse include when documenting this observation in the nursing notes? Standard Text: Select all that apply. 1. Type of spirometer 2. Number of breaths taken 3. Education provided 4. Medications administered 5. Code status

Q: A client asks why a central line is being placed in the right arm. What should the nurse respond to this client? 1. "It is more stable." 2. "It costs less than another site for a central line." 3. "It doesn"t get infected as often as other central lines. 4. "It is the best approach for the medicine that you need to receive."

Q: The nurse is caring for a client with a central line. What criteria should be used to determine if the access cap needs to be changed? 1. Fluid being administered 2. Cap was changed 3 days ago 3. The line is used for blood samples 4. Length of time the catheter will be in place

Q: A client asks why a BIOPATCH is being used as part of a central line dressing. What should the nurse respond to this client? 1. "It ensures no air gets into the line." 2. "It reduces the risk of an infection." 3. "It keeps the catheter from moving." 4. "It stops germs for a minimum of 3 days."

Q: An implanted subcutaneous port is occluded. What should the nurse do first? 1. Aspirate the clot 2. Change the needle 3. Instill a fibrinolytic agent 4. Forcefully flush the catheter

Q: The nurse is preparing to administer a liter of fluid through a client's central line. What should the nurse do after attaching the syringe to the designated port? 1. Ask the client to cough 2. Aspirate for a blood return 3. Withdraw 20 mL of blood 4. Inject 10 mL of saline flush

Q: The healthcare provider is preparing to insert a percutaneous central vascular device. What should the nurse instruct the client to do while the catheter is being inserted? 1. Hum 2. Cough 3. Count to 10 4. Take a deep breath

Q: A client is having a central venous catheter inserted. After positioning and preparing the client what should the nurse do? 1. Perform hand hygiene 2. Apply a mask and gloves 3. Open antimicrobial prep pads 4. Open glove packet and sterile drape pack

Q: The charge nurse is observing a new graduate care for a client with a Groshong catheter. For which observation should the charge nurse interrupt this client's care? 1. Preparing fluids for infusion 2. Clamp applied to the catheter 3. Catheter not flushed with heparin 4. Client response to medication assessed

Q: When deciding if parenteral nutrition should be given peripherally or centrally, the nurse recognizes which statement is true? 1. Lipids must be given centrally. 2. The maximum percentage of dextrose that can be given peripherally is up to 10%. 3. Clients requiring long-term parenteral nutrition generally receive it peripherally. 4. Providing parenteral nutrition peripherally cannot meet calorie needs.

Q: The nurse receives a bag of total parenteral nutrition (TPN) for the client. Prior to hanging the solution, which nursing actions are priorities? Standard Text: Select all that apply. 1. Checking the expiration date 2. Creating a sterile field 3. Checking the nutrients in the bag against the order written by the primary care provider with another licensed nurse 4. Adding additional medications to the fluid 5. Check rate of infusion on physician's orders

Q: After changing the client's central line dressing, what should the nurse include when documenting this procedure? Standard Text: Select all that apply. 1. Fluid infusing into the catheter 2. Assessment of the central line insertion site 3. Type of dressing applied 4. Aseptic technique under which the dressing was changed 5. Client complaints or concerns

Q: The nurse caring for a client with a central line accidentally infuses an air embolism. Which is the highest-priority action of the nurse? 1. Notifying the health care provider 2. Notifying the charge nurse 3. Assessing the client 4. Positioning the client in left Trendelenburg and applying oxygen

Q: The nurse caring for a client receiving parenteral nutrition via a central venous catheter determines that the client's temperature is elevated, white blood cell count is elevated, and the client is lethargic. The nurse suspects the client is septic. Which actions by the nurse are appropriate in this situation? Standard Text: Select all that apply. 1. Replacing the parenteral nutrition with a normal saline solution 2. Changing the IV tubing 3. Saving the remaining TPN 4. Recording the lot number of the TPN 5. Notifying the health care provider.

Q: The nurse is caring for a client who is to have a peripherally inserted central catheter (PICC) line inserted tomorrow afternoon. The client's peripheral access line is infiltrated, and needs to be restarted. Which site would the nurse avoid using? 1. Median cubital vein 2. Cephalic vein 3. Radial vein 4. Dorsal metacarpal veins

Q: When removing an old central line dressing, which action by the nurse is the priority? 1. Pulling the tape off in the direction of the catheter 2. Inspecting the insertion site for signs of infection 3. Pressing the catheter into the client's skin while removing the tape 4. Applying sterile gloves

Q: The nurse is caring for a client with a central venous catheter used for intermittent medication administration. When flushing the catheter prior to administering the next dose of medication, which initial action by the nurse is the most appropriate? 1. Aspirating the catheter for blood 2. Obtaining a 3 mL syringe and filling it with normal saline for flushing the line 3. Flushing the catheter, using as much force as required in order to clear the line 4. Positioning the client in reverse Trendelenburg position

Q: Which clients may benefit from central venous IV access? Standard Text: Select all that apply. 1. The client requiring long-term IV therapy 2. The client receiving caustic IV therapy 3. The client requiring numerous IV infusions that are not compatible and cannot be infused together 4. The unstable client requiring reliable IV access for administration of medications required immediately 5. The client who is afraid of needles and does not want a catheter in the peripheral extremity

Q: A client is prescribed to receive a unit of packed red blood cells. What should be checked prior to administering the blood to this client? Select all that apply. 1. Client name 2. Unit number 3. Blood group 4. Client birthday 5. Expiration date

Q: A client is prescribed intravenous fluids to treat dehydration. Which solution should the nurse use to disinfect the skin prior to catheter placement for these fluids? 1. Betadine 2. Soap and water 3. Chlorhexidine gluconate 4. Alcohol-based hand sanitizer

Q: A client is prescribed a medication to be administered IV push that is incompatible with the primary intravenous solution. What should the nurse do to safely administer this medication? 1. Insert a new angiocatheter 2. Change the route to an oral dose 3. Flush the angiocatheter with normal saline 4. Discontinue the primary infusion for several hours

Q: The nurse is hanging a secondary bag with an antibiotic for a client. Which action should the nurse take when performing this skill? 1. Lower the secondary bag 2. Clamp the primary bag tubing 3. Regulate the flow with the primary bag 4. Regulate the flow with the secondary bag

Q: A client is admitted with severe vomiting and diarrhea. On what should the nurse focus when planning this client's care? 1. Fluid deficit 2. Infection risk 3. Skin integrity 4. Altered tissue perfusion

Q: A client has a urine output of 350 mL of urine over the last 24 hours. Which health problem should the nurse consider as causing this low output? Select all that apply. 1. Pain 2. Trauma 3. Surgery 4. Hemorrhage 5. Elevated sodium

Q: The nurse receives an order to administer 3 liters of IV fluid over the next 24 hours. The infusion device would be set to administer how many mL per hour? ____ mL/hour Standard Text: Record the answer rounding to the nearest whole number.

Q: A client receiving a blood transfusion for 15 minutes complains of suddenly feeling cold and is shivering. Blood pressure has decreased since the last assessment. Which is the nurse's priority action? 1. Notify the health care provider. 2. Monitor the client's blood pressure every 5 minutes. 3. Stop the blood infusion, and run the normal saline on the other side of the Y tubing. 4. Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with normal saline.

Q: The nurse discontinues the client's IV prior to discharge. After removing the catheter, which actions by the nurse are appropriate? Standard Text: Select all that apply. 1. Applying pressure to the insertion site until bleeding stops 2. Examining the removed catheter to ensure that it is intact 3. Teaching the client to inform the nurse if the site begins to bleed at any time 4. Holding the client's extremity below the level of the heart if bleeding persists 5. Covering the venipuncture site with a sterile dressing

Q: The nurse is setting up an IV infusion on an electronic infusion pump. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse? 1. Resetting the pump to resume infusion 2. Discontinuing the client's IV access and restarting in a different area 3. Assessing the client's IV site and the tubing for kinks or closed roller clamps 4. Asking the client if the pump has been tampered with in any way

Q: The nurse initiating IV therapy is preparing a solution to which potassium chloride has been added. After adding the medication, which action by the nurse regarding the IV label is appropriate? 1. Writing the time the IV solution needs to be changed 2. Placing it upside-down on the container 3. Putting it around the IV tubing 4. Documenting the size of the angiocatheter inserted to obtain IV access

Q: The nurse is performing venipuncture to initiate IV therapy. The venipuncture site is chosen based on which indicators? Standard Text: Select all that apply. 1. Using the client's dominant arm, whenever possible 2. Choosing a relatively straight vein 3. Avoiding sclerotic veins 4. Looking for a site sufficiently distal to joints 5. Choosing a vein that is visible in addition to palpable

Q: Which aspect of intravenous therapy could the nurse safely delegate to the unlicensed assistive personnel (UAP)? 1. Watching the IV insertion site of the client who complained of pain at the site 2. Changing the IV site dressing on the client's left hand 3. Reporting client's complaints of pain or leakage from the IV site when bathing the client 4. Replacing client's IV solution when bag runs dry if it is only D5W, without medications added

Q: The nurse working in the emergency department is caring for a client who experienced deep-thickness burns over 40% of the body and is in shock. Which order should the nurse anticipate for this client? 1. Electrolyte solutions 2. Volume expanders 3. Nutrient solutions 4. Total parenteral nutrition

Q: The nurse is caring for a client with a medical diagnosis of increased intracranial pressure. Which IV fluid order should the nurse accept without questioning? 1. Normal saline at 125 mL/hour. 2. Dextrose 5% and water at 80 mL/hour. 3. Dextrose 5% and 0.45% NaCl at 75 mL/hour. 4. Normal saline 0.45% at 200 mL/hour.

Q: A client receiving an infusion of Dextrose 5% and water complains of a burning pain along the course of the vein. The site is red, warm, and is mildly edematous. Which term should the nurse use when documenting these findings? 1. Phlebitis at the IV insertion site 2. IV infiltrate 3. Extravasated vesicant drug 4. Extravasation

Q: The nurse is initiating IV therapy for an adult client who requires IV fluid infusion for 2"3 days and might require blood administration. What should the nurse choose as the best option for IV catheterization? 1. Butterfly 2. Huber needle 3. Angiocatheter 4. Implantable venous access device

Q: A client is recovering from hip arthroplasty using the anterolateral approach. What should the nurse ensure to maintain the integrity of the joint? 1. Place needed items on operative side 2. Keep needed items on the non-operative side 3. Instruct to avoid bending at the waist to put on shoes 4. Instruct to avoid crossing the operative leg past the body's midline

Q: The nurse is assisting a client recovering from spinal fusion surgery with the application of a back brace. What action should be done prior to placing the brace on the client? 1. Apply lotion to the skin 2. Assist the client to put on a T-shirt 3. Measure the client's abdominal girth 4. Dust the skin with baby or corn powder

Q: A client's x-ray report shows a fractured leg where one part of fractured bone is driven into another. How should the nurse document this client's fracture? 1. Impacted 2. Greenstick 3. Comminuted 4. Compression

Q: A client comes into the emergency department with a soft tissue ankle sprain. In which order should the nurse instruct the client to treat this injury at home? 1. Apply ice 2. Rest the ankle 3. Elevate the foot 4. Apply an ace bandage

Q: The nurse is caring for a client who is in skin traction. Which nursing actions are appropriate for this client? Standard Text: Select all that apply. 1. Assess neurovascular status every 4 hours, once stable. 2. Place sheep skin under pressure areas. 3. Massage the skin with lotion or alcohol every 4 hours if redness is noted. 4. Remove the weight first when removing nonadhesive traction. 5. Use a fracture bedpan to minimize movement during elimination.

Q: The nurse is providing care to a client who has a short arm cast. Which nerve areas should the nurse assess to determine if irritation is occurring? Standard Text: Select all that apply. 1. Radial 2. Ulnar 3. Median 4. Peroneal 5. Tibial

Q: The nurse caring for a client in traction inspects the apparatus and determines all is well when noting which finding? 1. The weight is sitting on the floor. 2. The rope is on the side of the pulley. 3. The knots are positioned 5 inches from the pulley. 4. All ropes are intact and connected with slipknots, and short ends are taped.

Q: The nurse caring for a client with a plaster cast applied several days ago notes crumbs of plaster on the skin just under the edge of the cast. Which action by the nurse is the most appropriate? 1. Leaving the crumbs there to avoid injuring the skin 2. Using a surgical scrub brush to remove the crumbs 3. Using a dry cloth to remove the crumbs to avoid wetting the cast 4. Pull inner stockinette out and over the edge and secure with tape

Q: The nurse working in the emergency department (ED) is assisting the health care provider with cast application. Which nursing action is the most appropriate after the health care provider completes application of the cast? 1. Holding the casted arm from the top of the cast to place it in a splint 2. Holding the casted arm from the top of the cast to place it on pillows 3. Using the palm of the hand to place the casted arm into a splint 4. Using the palm of the hand to place the casted arm on pillows

Q: The nurse admits a client from the emergency department (ED) with a newly placed leg cast. Which actions should the nurse perform to prevent neurovascular impairment? Standard Text: Select all that apply. 1. Assess the toes for nerve and circulatory impairment every hour for 8 hours. 2. Place the leg on pillows. 3. Apply ice to the site. 4. Elevate the foot of the bed. 5. Report excessive swelling or indications of neurovascular impairment.

Q: Which task could be safely delegated by the nurse to the unlicensed assistive personnel (UAP)? 1. Caring of the client with the newly placed cast 2. Explaining to the client how to respond to itching under the cast 3. Caring of the insertion site for Crutchfield tongs 4. Caring of the client with a stable cast

Q: An adolescent client newly placed in traction says, "Lying in this bed all the time is going to turn my body into mush. Is there any way I could exercise while I'm in traction?" Which response by the nurse is the most appropriate? 1. "Many people worry about muscle weakness when they are confined to bed. You could perform range of motion, isometric, and specific exercises." 2. "Don't worry about your muscles, because you can get them back after you get out of traction." 3. "You're young and in great shape. Your muscles won't weaken with a few weeks in bed." 4. "I'll put a referral in for physical therapy to come and work with you."