Comprehensive Review for the NCLEX-RN Examination, 7th Edition

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ATI NC

12 terms kop When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?

• Securely grasp the client's arm and leg.
• Put bed rails up on the side of bed opposite from the

nurse.

• Correctly position and use a turn sheet.
• Lower the head of the client's bed slowly.
• Put bed rails up on the side of bed opposite from the nurse.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. Which action has the highest priority in decreasing the client's risk of infection?

• Administration of plasma expanders
• Use of careful hand washing technique
• Application of a topical antibacterial cream
• Limiting visitors to the client with burns
• Use of careful hand washing technique

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homelessness. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

• Low serum albumin level
• Low serum transferrin level
• High hemoglobin level
• High cholesterol level
• Low serum albumin level

In completing a client's pre operative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

• Witness the client's signature to the permit.
• Answer the client's questions about the surgery.
• Inform the surgeon the client has questions about the

surgery.

• Reassure the client that the surgeon will answer any

questions before the anesthesia is administered.

• Inform the surgeon the client has questions about the surgery.

The nurse is assessing several clients prior to surgery.Which factor in a client's history poses the greatest threat for complications to occur during surgery?

• Taking birth control pills for the past 2 years
• Taking anticoagulants for the past year
• Recently completing antibiotic therapy
• Having taken laxatives PRN for the last 6 months
• Taking anticoagulants for the past year

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

• Place the chair parallel to the bed, with its back toward

the head of the bed and assist the client in moving to the chair.

• With the nurse's feet spread apart and knees aligned

with the client's knees, stand and pivot the client into the chair.

• Assist the client to a standing position by gently lifting

upward, underneath the axillae.

• Stand beside the client, place the client's arms around

the nurse's neck, and gently move the client to the chair.

• With the nurse's feet spread apart and knees aligned with the client's knees,

stand and pivot the client into the chair.The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?

• "Fill your lungs with air through your mouth and then

compress the inhaler."

• "Compress the inhaler while slowly breathing in

through your mouth."

• "Compress the inhaler while inhaling quickly through

your nose."

• "Exhale completely after compressing the inhaler and

then inhale."

• "Compress the inhaler while slowly breathing in through your mouth."

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first?

• Accept and document the client's wish to refrain from

bathing.

• Offer to give the client a bed bath, avoiding the

perineal area.

• Obtain written brochures about menstruation to give

to the client.

• Teach the importance of personal hygiene during

menstruation with the client.

• Teach the importance of personal hygiene during menstruation with the client.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

• "How will this affect your present sexual activity?"
• "How active is your current sex life?"
• "How has your sex life changed as you have become

older?"

• "Tell me about your sexual needs as an older adult."
• "How will this affect your present sexual activity?"

The nurse is using the Glasgow Coma Scale to perform a neurological assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?

• Document that the client responds to painful stimulus.
• Observe the client's response to verbal stimulation.
• Place the client on seizure precautions for 24 hours.
• Report decorticate posturing to the healthcare

provider.

• Document that the client responds to painful stimulus.

The nurse teaches the use of a gait belt to a caregiver whose spouse has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to use the belt?*

• Standing on the spouse's strong side, the caregiver is

ready to hold the gait belt if any evidence of weakness is observed.

• Standing on the spouse's weak side, the caregiver

provides security by holding the gait belt from the back.

• Standing behind the spouse, the caregiver provides

balance by holding both sides of the gait belt.

• Standing slightly in front and to the right of the spouse,

the caregiver guides the client forward by gently pulling on the gait belt.

• Standing on the spouse's weak side, the caregiver provides security by holding

the gait belt from the back.

The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the highest priority?

• Assist the client with daily cleansing.
• Tell the client that incontinence happens with aging.
• Offer 200 mL of fluid every 2 hours while awake.
• Take the client's temperature every 4 hours.
• Assist the client with daily cleansing.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

• Use the normal saline solution once more and then

discard.

• Obtain a new sterile syringe to draw up the labeled

saline solution.

• Use the saline solution and then relabel the bottle with

the current date.

• Discard the saline solution and obtain a new

unopened bottle.

• Discard the saline solution and obtain a new unopened bottle.

The nurse is concerned the client will develop a nosocomial infection. Which nursing action is best for the nurse to take when providing care for an incontinent client?

• Maintain standard precautions.
• Initiate contact isolation measures.
• Insert an indwelling urinary catheter.
• Instruct client in the use of adult diapers.
• Maintain standard precautions.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard.Which is the best action for the nurse to take?

• Deflate the cuff completely and immediately reattempt

the reading.

• Reinflate the cuff completely and leave it inflated for

90 to 110 seconds before taking the second reading.

• Deflate the cuff to zero and wait 30 to 60 seconds

before reattempting the reading.

• Document the exact level visualized on the

sphygmomanometer where the first fluctuation was seen.

• Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the

reading.A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• Tell the client that the blood pressure is high and that

the reading needs to be verified by another nurse.

• Contact the healthcare provider to report the reading

and obtain a prescription for an antihypertensive medication.

• Replace the cuff with a larger one to ensure an ample

fit for the client to increase arm comfort.

• Compare the current reading with the client's

previously documented blood pressure readings.

• Compare the current reading with the client's previously documented blood

pressure readings.