A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment. the nurse should record which of the fallowing client statements?

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the fallowing tasks should the nurse delegate?

Ambulating a client who is postoperative.

A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus.

a nurse is planning care for a client who has vision loss. which of the fallowing interventions should the nurse include in the plan of care to assist the client with feeding

Arrange food in consistent pattern on the clients plate.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Auscultate lung sounds.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward.

a nurse is caring for a client who requires a 24-hour urine collection. which of the following statement by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of the incident?

Client found lying on the floor.

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

1. Check the cord routinely for frays or tearing2. consider purchasing a generator for power backup3. observe for signs of hypoxia

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpated the popliteal pulse after 92 mm Hg. Which of the following images displays the appropriate mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

122

A nurse is assessing a client who received a IV fluid bolus for dehydration. which of the fallowing findings should the nurse identify as indication of fluid volume excess?

Distended neck veins

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8oz of ice chips.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPPA?

A nurse asks a nurse from another unit to assist with documentation for a client.

A nurse is admitting a client who has rubella. which of the fallowing types of transmission based precautions should the nurse initiate?

Droplet.

a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requires further intervention?

Erythema on pressure points

a client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the fallowing actions should the nurse take next?

Evacuate the client.

a nurse is performing a Romberg's test during the physical assessment of a client. which of the following techniques should the nurse use?

Have the client stand with her arms at her side and her feet together.

A nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statement indicates an understanding of herbal supplement use?

I can take echinacea to improve my immune system.

A nurse is caring for a patient with behind the ear hearing aid.

I will be sure to remove my hearing aid before taking a shower.

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia (PCA) pump. which of the fallowing actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day. "Which of the following components of the prescription should the nurse question?

Medication dose.

a nurse is performing a peripheral vascular assessment for a client. when placing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent blood flow. this sound indicates which of the following?

Narrowed arterial lumen

a middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?

People in middle adulthood often find satisfaction in nurturing and guiding young people.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

Rapid heart rate

a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the fallowing findings should the curse identify as potential indication of elder abuse?

The caregiver insists on remaining in the room.

A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

The newly licensed nurse places the cap of the bottle of the sterile saline solution on the sterile field.

A nurse is caring for a client who is refusing a scheduled blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion.

a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed.

A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

breath sounds

nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

compare prescriptions with medications the client received while at the facility.

a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to long term care facility. which of the fallowing documentations should the nurse include?

current medications.

a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure

inject 10 units of air into the bottle of NPH insulin1. inject 5 units of air into the bottle of regular insulin withdraw the correct dose of regular insulin from the bottle withdraw the correct dose of NPH insulin from the bottle

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the fallowing pieces of personal protective equipment when providing care for the client?

n95 respirator

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

practice sessions

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

select a suction catheter that is half the size of the lumen.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3mg

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy the nurse should include the teaching that therapy might be contraindicated for which of the fallowing clients?

A client who has asthma

a nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? (Select all that apply)

A. place the client in a rom with negative pressure airflowB. wear gloves the assisting the client with oral careE. use antimicrobial sanitizer for hand hygiene

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine.

a nurse is caring for a client who decreased mobility. which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures?

apply an ankle foot orthotic device to the clients foot

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take?

flush the tube wit 15 ml of sterile water.

A nurse is preparing to administer 0.5mL of oral single dose liquid med to a client. What action should the nurse take?

gently shake the container of medication prior to administration.

a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficlile infection. which of the fallowing information should the nurse include in the teaching?

have family members wear gown and gloves when visiting.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

have the client use a trapeze bar when changing position.

a nurse is planning an educational program for a group of older adults at a senior living center. which of the fallowing recommendations should the nurse include?

you should receive a pneumococcal immunization every 10 years

A nurse is caring for a client who requires an informed consent for a surgical procedure. which of the fallowing actions it the nurses responsibility?

witness the clients signature on the consent form.

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

wrap monitoring cord with stockinette and tape them in place.

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

initiate an enteral feeding through a gastrostomy tube

a nurse is caring for a client who is reporting difficulty falling asleep. which of the following measures should the nurse recommend?

maintain a consistent time to wake up each day.

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

skin blanching

a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend?

walking briskly

a community health nurse is checking blood pressures for group of clients at a community health screening. which of the fallowing clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

what could i have done to deserve this illness?

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending stairs, i will first shift my weight to my right leg.

a nurse in a clinical is caring for a middle age adult who states, "the doctor says that since I am at an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responses should the nurse make?

you should have a fecal occult blood test every year.