A nurse is bathing a client who cannot get out of bed. During the bath, the nurse encourages the client to assist with what cares he or she can perform. What is the rationale for this request?

The nurse is caring for a client with watery diarrhea following a course of clindamycin. The nurse suspects clostridium dificile. Which of the following isolation precautions are necessary for this client? Select all that apply.

A 50-year-old client with measles has been admitted to the hospital and is in isolation. The client’s daughter asks the nurse, “How can I keep from catching this myself if I have been vaccinated?” Which answer from the nurse is most appropriate?

A client is receiving TPN, and the charge nurse observes another nurse attempting to change the central line dressing with clean gloves and sterile dressings. The charge nurse should do which of the following? Select all that apply.

A nurse is preparing to put on sterile gloves. The nurse has opened the package and pulled the paper wrapping away to expose the gloves. The wrist end of the gloves is facing the nurse. Which best describes the process of putting on the first glove?

The client has been ordered to have tier 1 standard precautions. What are the nursing interventions for this? Select all that apply.

A child was injured in an accident and has become a paraplegic. The child must use crutches on a permanent basis. Which type of crutches would most commonly be used in this situation?

Which of the following is a benefit of using a four-wheel walker for client ambulation? Select all that apply.

The nurse is educating a client on the proper use of crutches. The client asks why he can’t rest his body weight on the pads under his armpits. What is the best explanation by the nurse?

A nurse is assisting a client using a rollator walker to ambulate across the unit. Which indicates that the client is using this device correctly? Select all that apply.

The nurse is discharging a client who will be using crutches for the first time. The nurse is utilizing the teach-back method to confirm the client’s understanding of using crutches. Which of the following indicates that more teaching is necessary?

A 28-year-old client has been diagnosed with Charcot-Marie-Tooth disease. The nurse is explaining the types of assistive devices available to the client. Which of the following would most likely be used by a client with this condition?

A nurse is ambulating a client who is using a cane. What is the proper side for the nurse to stand on while ambulating this client?

A 20-year-old client is admitted to a rehab unit following a motorcycle accident. Which would be the most appropriate method for measuring the client for crutches?

A client admitted last night with bilateral femur fractures wants to go to the bathroom. What should the nurse do first?

A nurse is assisting a client with dementia to take a shower. Which interventions would be most appropriate to maximize safety? Select all that apply.

Despite trying multiple interventions to manage a client’s behavior, the nurse has decided to use restraints through an order from the provider. In which situation would the client most likely need mitt restraints?

A client is continuing to attempt to get out of bed after being informed to stay in bed while recovering from surgery. Which situation best describes the concept of least restrictive device use regarding restraints?

A 10-month-old child is recovering from a cleft lip repair, and the provider has determined the child would benefit from restraints post-operatively. Which kind of restraints would the nurse most likely apply to this child?

A nurse has just restarted a client’s peripheral IV after the last one infiltrated. The nurse has determined that the IV is working and is in the correct position. Which principles should the nurse use when securing the IV site? Select all that apply.

A nurse is preparing to assist with placement of a central venous catheter for a client who is in the hospital. Which of the following considerations would the insertion team utilize when selecting a site for catheter placement? Select all that apply.

A patient with a peripheral IV has developed infiltration at the insertion site. Which of the following signs or symptoms would the nurse look for with IV infiltration? Select all that apply.

A nurse is preparing to take a blood sample from a client’s arterial line. During the process of drawing blood, the client complains of severe pain in the extremity and the nurse stops the process. What other situations would require that the nurse stop blood sampling from an arterial line? Select all that apply.

A nurse in the ICU is caring for a client who has a radial arterial line. The provider has ordered an ABG to be drawn from the line. Which of the following is part of the process of drawing from this line? Select all that apply.

A nurse is preparing to start an IV in a client but is having a difficult time establishing venous access. Which condition would most likely contribute to difficulties for the nurse starting an IV?

A client is receiving TPN, and the charge nurse observes another nurse attempting to change the central line dressing with clean gloves and sterile dressings. The charge nurse should do which of the following? Select all that apply.

A nurse is preparing to change the dressing site on a client’s central line. Which factors must the nurse consider when performing a central line dressing change? Select all that apply.

A nurse is inserting an indwelling catheter in a male client. Select the following steps that the nurse performed that indicate that aseptic technique was followed when inserting the catheter. Select all that apply.

The nurse is caring for a client with urinary retention due to an enlarged prostate. The nurse is inserting a Foley catheter, and has advanced the catheter through the urethra but meets resistance and cannot advance further. What is the next step for the nurse to take?

A student nurse is observing the preceptor insert a urinary catheter into a male. Which of the following actions is the first action the preceptor will perform after placing the waterproof drape and fenestrated drape on the client?

Which of the following steps should the nurse include as part of tracheostomy suctioning?

A nurse is caring for a client after having a tracheostomy placed. Which of the following are appropriate nursing interventions for the client with a tracheostomy?

A 9-month-old child has been made NPO and the nurse must insert a nasogastric tube to connect to low-intermittent suction. The nurse has measured the proper length for the tube insertion and is preparing to insert the tube. Which intervention would most likely make the process easier?

A nurse is inserting a nasogastric tube into a client to remove excess secretions and decompress the stomach. Which action of the nurse would best help to ease the clients discomfort with the insertion?

A client is hooked up to low intermittent suction through a nasogastric tube, and the nurse is preparing to irrigate the tube. After assessing the client’s abdomen and determining that the tip of the tube is located in the stomach, the nurse draws up 30 mL of normal saline into a syringe. Which best describes the next step in this process?

A nurse is inserting a nasogastric tube into a client to remove excess secretions and decompress the stomach. Which action of the nurse would best help to ease the clients discomfort with the insertion?

A nurse is caring for a client with a nasogastric tube and is preparing to administer an enteral feeding. The nurse wants to check that the tube is in the proper place. Which of the following actions is appropriate for checking placement?

A client is post op day 2 after a gastrectomy due to stomach cancer. The client had a nasogastric tube placed during surgery. After walking with physical therapy, the nasogastric tube has become dislodged. What is the priority nursing intervention at this time?

A 9-month-old child has been made NPO and the nurse must insert a nasogastric tube to connect to low-intermittent suction. The nurse has measured the proper length for the tube insertion and is preparing to insert the tube. Which intervention would most likely make the process easier?

A nurse is observing a student nurse who is preparing to administer medications through a nasogastric tube. Which action by the student nurse requires immediate intervention?

The nurse is assessing a client after having a colostomy placed the day before. On assessment, which of the following findings would be the MOST concerning?

The nurse is caring for a client who had an ileostomy placed yesterday. The client calls the nurse and frantically states, “My stoma looks really weird and I’m worried something is wrong with it.” The nurse notes the stoma to be beefy red. Which response is most appropriate?

A nurse is helping a client who will be going home with an ostomy after surgery. Which of the following demonstrates how the nurse would prepare the client for ostomy care at home? Select all that apply.

A client with a gastric ileus is on bed rest with a nasogastric tube in place for nutrition. Which actions should the nurse perform that would best prevent aspiration of stomach contents in this client? Select all that apply.

The nurse is caring for a client with an ileostomy. During assessment of the client, the nurse notes that the pouch opening is 1/2 inch larger than the stoma site. Which of the following poses a risk for this client?

Your patient had an ileostomy placed 2 weeks ago. Which bowel pattern would be expected for this patient?

A nurse is caring for a post-op client who has developed wound dehiscence at their surgical site. The nurse notes with assessment that the client’s abdominal organs have eviscerated through the wound opening, so the nurse places a saline-soaked gauze over the wound site. Which of the following are appropriate actions for the nurse to take? Select all that apply.

The nurse is charting a skin assessment on the newly admitted client. The client has a multiple cracks in a wound on the left leg. The nurse should chart this using what terminology?

A nurse is preparing to perform a dressing change on a client with a chronic wound due to poor blood flow from diabetes. The nurse has an alginate dressing to apply to the wound. This type of dressing is most appropriate for which type of wound?

A client with a wound on his lower leg needs the nurse to change the dressing. The nurse has Hydrogel dressing material to apply to the wound. What information is true regarding this type of dressing? Select all that apply.

A nurse is changing the dressing on a diabetic wound for a client with an alginate dressing in place. The nurse removes the dressing and irrigates the wound bed before applying another dressing. Which best describes the rationale for the nurse’s action?

A nurse is caring for a post-op client who has developed wound dehiscence at their surgical site. The nurse notes with assessment that the client’s abdominal organs have eviscerated through the wound opening, so the nurse places a saline-soaked gauze over the wound site. Which of the following are appropriate actions for the nurse to take? Select all that apply.

After surgery, a client has a Jackson-Pratt (JP) drain inserted to the surgical site. The nurse is checking the drainage within the first 24 hours post-op. Which of the following colors would be concerning to the nurse? Select all that apply.

After surgery, a client has a Jackson-Pratt drain inserted to the surgical site. The nurse knows that the drain is ready to be discontinued when which of the following is observed?

A nurse is caring for a post-op client who has developed wound dehiscence at their surgical site. The nurse notes with assessment that the client’s abdominal organs have eviscerated through the wound opening, so the nurse places a saline-soaked gauze over the wound site. Which of the following are appropriate actions for the nurse to take? Select all that apply.

A nurse is preparing medications for a client with swallowing difficulties. The nurse must crush the pills before administration. Which of the following suffixes would the nurse question for crushing? Select all that apply.

The nurse is administering timolol maleate ophthalmic solution in each of the client’s eyes. Which statement by the client indicates the need for more teaching?

A client comes into the clinic with an eye that is red and irritated. Discharge is present. The nurse can expect to give which of the following eye medications to this client? Select all that apply.

The nurse is teaching a client how to administer eye drops. The client tilts their head back and gently pulls the lower lid down to form a pocket. What next action by the client indicates correct understanding of this procedure?

The nurse is taking a medication history from a client with herpes simplex of the eye. The nurse should ask if the client is taking which of the following drugs?

The nurse recognizes that which of the following substance is considered a topical anti-infective? Select all that apply.

A nurse is caring for a pregnant client who needs treatment for rosacea. The client asks the nurse about using topical corticosteroids for treatment. Which of the following information should the nurse provide this client?

An 87-year-old client has a prescription for nitroglycerin that must be applied topically. Which factor must the nurse consider when administering this type of medicine to an older adult?

A nurse must reconstitute a medication to give to a client as an intravenous dose. The nurse obtains the vial of powder and draws up the appropriate amount of diluent into a syringe. Which step would the nurse take next?

Which of the following must the nurse consider when preparing medication from an ampule? Select all that apply.

The nurse recognizes that which of the following substance is considered a topical anti-infective? Select all that apply.

Which of the following must the nurse consider when preparing medication from an ampule? Select all that apply.

A client who uses injectable insulin must mix a dose of NPH with a rapid-acting insulin. After the client has vented both of the insulin vials, what order should he follow to appropriately mix the two types of insulin?

A client who is trying to become pregnant must start taking fertility drugs through daily subcutaneous injections. The nurse is teaching the client about how to self-administer the injections at home. Which information would the nurse include as part of this teaching? Select all that apply.

The nurse is giving a client an insulin injection. Which of the following sites is appropriate for this type of injection? Select all that apply.

The nurse is caring for a client and notes an order for 5,000 units of heparin q12 hours for deep vein thrombosis (DVT) prophylaxis. The route is missing, so the nurse contacts the provider. The nurse correctly anticipates administering this medication as which type of injection?

The nurse is administering a subcutaneous insulin injection after noting a glucose result of 175. The nurse follows which of the following guidelines for insulin administration? Select all that apply.

The nurse is giving insulin to a client and notices fibrous, fatty masses around the injection site. Which of the following is an appropriate action by the nurse?

A nurse is preparing to administer insulin to a four-year-old girl who has high blood glucose levels after being admitted to the hospital. The nurse prepares 4 units of regular insulin to be administered subcutaneously. Which of the following interventions will most likely uphold the safety of this client when administering the insulin?

A nurse is teaching a diabetic client about how to give insulin injections to himself on a daily basis. The nurse teaches the client that the area where insulin is absorbed most rapidly after injection is which of the following?

A nurse is preparing to give a dose of insulin subcutaneously to a client. Which of the following needle sizes is most appropriate for this injection?

A nurse is administering a dose of 5 units of insulin to a client, using the subcutaneous tissue in the abdomen as the site of administration. The nurse has prepared the skin and inserted the needle into the tissue. Which action should the nurse perform next?

A nurse is preparing to administer an intramuscular injection to a client using the dorsalgluteal site. In which position should the nurse place this client?

A nurse is giving an intramuscular injection to a client. Before giving the dose, the nurse notes that the client has a large amount of subcutaneous tissue over the muscle. Select all of the following appropriate responses to this situation.

A nurse chooses the dorsogluteal site on a client in which to administer an intramuscular injection. Which of the following should the nurse consider when giving an injection in this location?

A client who is to receive an intramuscular injection starts crying before the shot and tells the nurse that she is afraid that it will hurt a lot. Which strategies could the nurse employ that would help this client when administering the injection? Select all that apply.

A nurse has been ordered to give a patient an intravenous (IV) dose of an opioid pain medication following surgery. Which of the following should alert the nurse to question administering the IV opiate medication? Select all that apply.

A patient has a non-tunneled central catheter placed for intravenous administration of antibiotics. Which of the following is true regarding this type of catheter? Select all that apply.

A client has an order for an IV dose of intravenous potassium due to hypokalemia. The nurse is setting up the infusion to administer. Which information would the nurse include when explaining the infusion to the client? Select all that apply.

A nurse must reconstitute a medication to give to a client as an intravenous dose. The nurse obtains the vial of powder and draws up the appropriate amount of diluent into a syringe. Which step would the nurse take next?

A nurse has an order to administer an intravenous drug to a patient who is in the hospital. Which of the following is an example of an indication of when an intravenous medication would be required for a patient, as opposed to other routes? Select all that apply.

A 56-year-old client is preparing to have an intravenous pyelogram. Select all of the following measures the nurse would take to prepare the client for this test.

A nurse is hanging a new IV bag for a client to replace the last one that is empty. Which of the following principles should the nurse consider when using an IV pump? Select all that apply.

The nurse is setting up an IV norepinephrine drip for a hypotensive client. The nurse has primed the tubing and turned on the pump. The pump is alarming and the nurse cannot stop the alarm without turning off the entire pump. Which of the following actions is appropriate?

The nurse notes that a client’s IV site is wet after the last IV tubing change and determines that the dressing needs to be changed. The nurse has performed hand hygiene, stopped the current infusion, and has removed the old dressing. Which best describes the next step in this process?

A nurse is caring for a client who requires intravenous fluids to prevent fluid and electrolyte imbalance. The nurse has developed a clinical pathway to direct care of this client. What best describes the purpose of a clinical pathway?

A student nurse is watching the nurse preceptor set up a secondary infusion. The student notes that after pushing the “start” button on the pump, the nurse takes a moment to look at the drip chamber. Which of the following is the reason for this?

The nursing student is preparing to prime a secondary IV infusion in order to administer the infusion to a client. The student’s preceptor notes that the student correctly sets up the infusion when the student performs which of the following ordered steps?

The nurse enters a client’s room at the beginning of the shift and finds two secondary IV tubing sets hanging, each with a different, empty IV medication bag attached. Neither tubing set is labeled with a date. Which of the following actions is most appropriate for the nurse to take?

A nurse is starting a day shift in the intensive care unit. The client has a maintenance infusion, as well as 5 IV piggyback medications. How should the nurse verify that the correct medications are infusing appropriately with this client?

A client is to receive a dose of an antibiotic to be administered using a volumetric pump. Which of the following describes this type of pump? Select all that apply.

A nurse is giving an IV antibiotic to a client that will be administered every eight hours via IV piggyback while maintenance fluid is running on an IV smart pump. Which step would the nurse perform after the piggyback infusion is completed?

A nurse is administering an IV medication as a piggyback to a standard IV infusion using a smart IV pump. Which of the following is a true statement regarding smart IV pumps? Select all that apply.

The nurse is caring for a client with acute hypotension. The nurse receives an order to initiate IV norepinephrine titrated to keep systolic blood pressure >90. The client has maintenance fluid running and an initial blood pressure of 78/55. The nurse sets up the secondary infusion of IV norepinephrine by following the 6 rights of medication administration. The nurse spikes the bag, primes the tubing, programs the pump at an initial dose of norepinephrine 8 mcg/min, scans the client and the pump, and starts the infusion. 15 minutes later the client’s blood pressure drops to 65/38. Which of the following is a potential reason for this?

A client in DKA has an order for an insulin infusion at 5 units per hour. The nurse is setting up IV insulin, 100 units/100 mL as a secondary line, with D10W as the primary infusion. The nurse follows the 6 rights of medication administration, clamps the secondary tubing, spikes the insulin bag, squeezes the chamber until it is ⅔ full, and slowly opens the roller clamp to prime the tubing. The nurse then cleanses the Y-port closest to the client and connects the secondary tubing, ensuring the bag is hanging above the primary infusion. The pump is programmed to run the secondary infusion at 5 mL per hour, so the nurse starts the pump. Which statement correctly describes what is wrong with this situation?

The nurse is caring for a client with an order for the following secondary infusions: heparin at 30 cc/hr, and nitroglycerin at 1.5 mL/hr. The client calls the nurse and complains of a headache. The nurse enters the room to find that the secondary rates have been mixed up, and the heparin is running at 1.5 mL/hr, while the nitroglycerin is running at 30 cc/hr. The nurse immediately stops both infusions. What is the next priority action for the nurse?

A nurse is preparing to assist the healthcare provider with insertion of an arterial line into a client’s radial artery. Prior to insertion of this line, which intervention should the nurse perform?