Adult III ACB, Adult III ACA

A home health nurse is assessing a 2 week old newborn who had a birth weight of 3.64kg (8lbs) and is being breastfed. Effective breastfeeding?

6-8 wet diapers per day

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Strict adherence to routines

A nurse is administering enoxaparin. Where?

SubQ

A nurse in a mental health facility is planning care for a client who has anorexia nervosa. Which intervention should the nurse include in the plan of care?

Supervise the client during and after eating

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Support the client's left arm on a pillow while sitting.

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Survey the scene for potential hazards to staff and children.

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

Take the medication 15 min before playing sports.

A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?

A middle adult client who has unstable vital signs

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

Avoid including raw fruits in the client's diet.

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?

"A client who requires airborne precautions should be placed in a negative-pressure airflow room."

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

"Have you had any stomach pain or bloody stools?"

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

"How does this make you feel?"

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

"I can designate my partner as my health care surrogate."

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Client statement indicates this therapy is giving the desired effect?

"I haven't vomited as much recently"

A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which client statement indicates the client understands the teaching?

"I should report a change in the color of my stools"

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. Which client statements shows understanding of teaching?

"I should watch for dry mouth and constipation"

A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism?

"I told my doctor that I would like to start a support group for other women who are sick in my community." -- This statement indicates that the client is using the constructive defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept.

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

"I will be checking you once with your eyes open and once with them closed."

A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching?

"I will cover my baby's body when I wash her hair." "I will use the bulb syringe first in her mouth and then in her nose."

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

"I will make sure my child receives a yearly influenza immunization." -- Children who have asthma should be immunized and protected from infections.

A nurse is teaching a client who has a new prescription for a total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

"I will need to measure your weight daily." -- The nurse should instruct the client that daily weight measurement is a necessary part of administering nutrition through a central line to avoid fluid overload and monitor for adequate weight gain.

A nurse is providing teaching to the guardians of a newborn about measures to prevent SIDS. Which of the following guardian statements indicates an understanding of the teaching?

"I will not allow anyone to smoke near my baby." -- This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarettes smoke and the occurrence of SIDS.

A nurse is caring for a client who has a terminal illness and requests no life saving measures if a cardiac arrest occurs. Nurse should make what statement?

"I will provide you with information about medical treatment to include in your living will"

A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will wear a supportive bra overnight."

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

"I would like to talk to you about the unit policies regarding break time." -- The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront.

A home health nurse is teaching about infection prevention to a cancer pt on chemo. Which statement indicates understanding?

"I'll walk short distances throughout the day"

A nurse is caring for a client who has end stage Alzheimer's Disease. The adult child of the client says 'I don't know why I bother to visit my mother anymore". Nurse response?

"It seems like you feel your visits are a waste of time"

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?

"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments"

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?

"My child has only a small amount of mucus after percussion therapy."

A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner is priority?

"My husband doesn't know I;ve already moved out and filed for divorce"

A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience increased thirst."

A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching?

"Shake the medication bottle feel before each dose is given." "Store the medication in the refrigerator." "Report diarrhea to the provider immediately."

A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?

"Tell me more about your understanding of the options."

A nurse receives a request from a client to review the information in his medical record. Which response should the nurse give?

"There's a protocol for reviewing your medical record, and I can initiate the process"

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

"We can expect the hospice nurse to provide support for us after our mother's death." -- Hospice care includes bereavement services after a family member's death.

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?

"You have the right to change your mind about this procedure at any time."

A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?

"You seem to be having a difficult time right now."

A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?

"You will need to fast the night before the test."

A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include?

"You will receive fingersticks for blood glucose testing"

A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make?

"You're afraid that your other kidney will fail at some point after the organ donation."

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?

"Your body temperature might decrease slightly just prior to ovulation."

A nurse is providing discharge teaching to a client following a cataract extraction. Client statement understands teaching?

"bend at my knees when picking up objects from the floor"

A nurse is teaching a newly admitted client who has heart failure about advance directives. Nurse statement?

"complete advance directives in the case you can't express your own wishes"

A nurse is providing discharge teaching to a new parent about car seat safety. Which statement should the nurse include in the teaching?

"secure the retainer clip at the level of baby's armpits"

A nurse is teaching the parents of a preschooler about sleep promotion. Parents report child reluctance in going to bed "I'm not tired". Statement shows parental understanding?

"we should read a story together before bed every night"

A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eye glasses. Which of the following instructions should the nurse give to the child?

"you should keep both eyes open during the test"

A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter. Which of the following information should the nurse include in the teaching?

"you should keep the catheter clamped when not in use"

Intermittent Urinary Catheterization

'straight cath'

A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?

(image with patient facing you with her right leg lifted)

A nurse is reviewing the lab results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect?

45 seconds

A nurse is providing teaching about improving nutrition for a client who has MS. Which instructions should the nurse include?

-a speech pathologist -rest before eating -thicken beverages before eating

A nurse is assessing a client who is experiencing autonomic dysreflexia. Expected nursing findings?

-facial flushing -nasal congestion -headache

A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. "I'm worried about being discharged because I live alone. My insurance doesn't cover ostomy supplies." Nursing action?

-refer to community based social worker -initiate home health consult -give info about local support groups

5,000U SubQ heparin, available 10,000U/mL. How much to administer?

0.5mL

A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a 22lb toddler who is experiencing a grand mal seizure. Available is 5mg/mL. How many mls should the nurse administer?

0.6mL

A nurse is providing teaching to the parent of a child who has a permanent trach. Steps of trach care:

1. remove inner cannula 2. remove soiled dressing 3. clean w/ saline 4. change the trach collar

A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

12.5 gtt/min

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lbs. What is the amount in grams the nurse should administer?

18 g

A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain.

A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism?

A client who channels their energy into a new hobby following the loss of their job -- The nurse should identify that this client is using the defense mechanism of sublimation by channeling negative feelings over the loss of their job into a new hobby.

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

A client who has cellulitis and is receiving oral antibiotics every 8 hr

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

A client who is at 33 weeks of gestation and has severe gestational hypertension -- The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment, place suction equipment and oxygen at the bedside, and position the call light within the client's reach.

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

Droplet

A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first?

A client who is postoperative with abdominal distention and no bowel sounds.

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A client who is receiving an MAOI and is requesting a cheeseburger for dinner.

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

A client who was abused as a child describes the abuse as if it happened to someone else.

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A client whose caregiver requests adult day care services

A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?

Abdominal bloating

A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?

Acute confusion

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include the plan?

Administer high-dose antibiotic therapy

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?

Advocacy is a leadership role that helps others to self-actualize

A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?

Agency for Healthcare Research and Quality

A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding?

Albumin 2.8 g/dL

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

Allow for frequent rest periods throughout the day -- The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion.

A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

Amount of vaginal bleeding

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

An older adult client who is anxious and attempting to pull out an IV line

A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?

Apply a cold pack to the client's ankle for 30 min every hour.

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?

Aspirate contents from the tube and verify the pH level

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Arrange the lunch tray for a client who has a hip fracture.

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

Ask another nurse to witness the disposal of the new patch

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

Ask the partner to list specific concerns.

A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?

Assign the client to a private room with negative air pressure

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assist with deep breathing and coughing -- The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia.

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Auscultate the apical pulse at least 1 minute.

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

Autonomy

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

Blurred vision -- The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider. Other adverse effects include constipation, urinary retention, and dry mouth.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearm The nurse should identify these behaviors as characteristics of which of the following personality disorders?

Borderline

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)

Broccoli, Yogurt, Cream Cheese

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD?

C

A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?

Check the client's oxygen saturation level -- Restlessness and lightheadedness are indications of hypoxia.

A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first?

Change the position of the client.

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth?

Cervical laceration

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

Contact CPS

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

Cough -- The client can develop a cough due to a buildup of bradykinin in the lungs.

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

Decreased hallucinations -- The nurse should recognize that chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia.

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following method should the nurse include in the teaching?

Delegate non-nursing tasks to ancillary staff.

A nurse is interviewing a client who is now without a home d/t natural disaster. After ensuring the clients safety, what's the nurses first action?

Determine the client's perception of the personal impact of the crisis

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

Determine the client's reading skills -- The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost.

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

Difficulty performing ADLs -- The nurse should initiate a referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, and eating.

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

Dry mouth

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

Dyspnea

A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?

Edema

A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include?

Empty the appliance when it is one-third to one-half full.

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

Ensure that the client understands the medication regimen

A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?

Explore the client's reasons for refusing the treatment.

A nurse is preparing to transfer a client who has had a stroke to a rehab facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?

Facilitate an interdisciplinary conference at the new facility for the family.

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period was May 8. According to Nagele's rule, which of the following dates should the nurse document as the client's estimated date of birth?

Feb 15

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

Fiber -- The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation.

A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using?

Flight of ideas

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?

Floating dark spots

A client is receiving lorazepam IV for panic attacks and develops a RR of 6/min and a BP of 90/44mm Hg. What med should the nurse anticipate administering?

Flumazenil

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?

Form a committee of staff members to investigate current staffing issues.

A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Have the client wear a surgical mask while being transported outside the room.

A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Hgb 14.9 g/dL

A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?

Hold the insulin pen device perpendicular to the client's skin to inject the medication.

A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect?

Hyponatremia

A nurse on a mental health unit is conducting a mental status examination (MSE) on a new admitted client. Which of the following components of the MSE is the priority for the nurse to assess?

Ideas of self-harm.

A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse take first?

Identify health-related issues within the community

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

Implement fall precautions for the client.

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Increase the client's dietary iron intake

A nurse is assessing a client who has a decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?

Increased opacity of the lens

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?

Initiate continuous cardiac monitoring -- The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

Initiate transmission-based precautions

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

Insert a lubricated gloved finger and advance along the rectal wall

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Inspection, Auscultation, Percussion, Palpation

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?

Instruct the client to avoid coughing during the procedure.

A nurse is caring for a client who has deep-vein thrombosis. Which of the following actions should the nurse take?

Instruct the client to elevate the affected extremity when sitting.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Instruct the client to void.

A nurse is caring for a client who is receiving continuous bladder irrigation following transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?

Irrigate the catheter with 0.9% sodium chloride irrigation.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypolglycemia?

Irritability

A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placenta of a VP shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held.

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?

Jaundice

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical ascetic technique?

Maintain sterile objects within the line of vision.

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

Make a referral for social services

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?

Making a list of activities to complete.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measure the client's daily weight.

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

Monitor the client's mouth every 8 hr.

During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Move the client to a room near the nurses' station.

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

Nasal flaring

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

Noting the progress of the group toward assigned goals.

A nurse is assessing a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect?

Nuchal rigidity

A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?

Occlusive dressing on the insertion site

A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer?

Oxytocin

A nurse is planning to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP?

Perform gastrostomy feedings through a client's established gastrostomy tube

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

Pink, frothy sputum

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure?

Place the client in a quiet environment

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Proceed with provision of medical care.

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Radial vein of the inner arm

A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging?

Rapid decrease in blood pressure

A nurse in a provider's office is caring for an 18-month-old toddler who has a blood lead level of 3 mcg/dL. Which of the following actions should the nurse take?

Recommend rescreening in 1 year.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Report of chest pain

A nurse is initiating discharge planning for a client who has a stroke and is experiencing R side weakness. Nurses first action?

Request PT referral

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mmHg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Respiratory acidosis

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should indicate which of the following variables as a risk factor for osteoporosis?

Sedentary lifestyle -- The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels.

A nurse manager is planning to use a democratic leadership style?

Seeks input from the other nurses

A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?

Serum liver enzyme levels

A nurse is caring for a client who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?

Serum sodium 136 mEq/L

A nurse is providing teaching to a client who is scheduled for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?

Short-term memory loss

A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following lab values should the nurse report to the provider?

Sodium 148 mEq/L

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licenses nurse requires intervention by the preceptor?

Starts a task then determines what supplies are needed

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

Tension pneumothorax

An RN is observing a licensed practical nurse and an assistive personnel move a client up in bed. For which of the following situations should the nurse intervene?

The LPN and the AP grasp the client under his arms to lift him up in bed

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

The child exhibits discomfort while walking.

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

The client is pacing around the chair in which their partner is sitting -- Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences.

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?

The client reports a decrease in episodes of nausea.

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?

The time of the client's last dose of pain medication

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

Time the medication was given

A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?

Tremors -- Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia.

A nurse is reviewing lab findings of a client experiencing chest pain. The nurse should identify that an elevation in which lab indicates myocardial cell tissue injury?

Troponin T

A nurse is caring for a client who has a prescription for a continuous passive motion machine following a total knee arthroplasty. Which of the following actions should the nurse take?

Turn off the CPM machine during mealtime -- The nurse should turn off the CPM machine during meals to promote client comfort and dietary intake.

A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?

Urine specific gravity 1.052 -- The nurse should recognize this urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates dehydration from vomiting.

A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?

Use a protective cover on the scale when weighing the infant.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?

Use a reward system to modify the child's behavior.

A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?

Use a three-point gait.

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Use the ventrogluteal site.

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

Verify the client and blood product information with another licensed nurse.

A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which finding is a contraindication for the client to receive clozapine?

WBC count 2800/mm3

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?

Wear clothing made with cotton fabrics while oxygen is in use

A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

Wheezing

A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take?

Withhold the heparin infusion

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference?

a client who has DM and repeat admissions for DKA

A nurse is assessing a client who has Raynaud's disease. Which finding should the nurse expect?

blanching of the fingers and toes

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the client's heparin?

aPTT

A nurse has 4 patients. What should the nurse delegate to the AP for meals?

alzheimers w/ aphasia

A nurse is caring for a 12 hour post op on a PCA for pain control and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information.

an Ap who is assisting a client to bed

A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition?

an adolescent with foodborne botulism

A nurse is performing trach care for a client post op following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

apply suction for 10 seconds

A nurse working on a med-surg unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's parents. Nursing action?

ask the caller for verification of their identity

A client who is 24 hours post op following abdominal surgery refuses to ambulate. First nursing action?

ask the client to rate their pain level

A charge nurse assigns a new nurse to a client with a chest tube. The new nurse expresses concern d/t limited experience with monitoring drainage. What should the charge do to teach about chest tubes?

ask the nurse about their knowledge of the procedure

A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which action should the nurse take first?

assess for functional limitations

A nurse is caring for an older adult client in the PACU following general anesthesia. What finding should the nurse report to the provider

audible stridor

A nurse is planning care for a client receiving HD from an AV fistula in the R arm. Which intervention should the nurse include in the plan of care?

auscultate for bruit

A nurse is teaching about child safety measures. What statement indicates understanding?

avoid sun exposure 10am-2pm

A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care?

avoid venipunctures when possible

A nurse is assessing a 2hr old newborn. Report to MD?

axillary temp 36.2C (97.2F)

A nurse is caring for a newborn whose parents ask why their baby is receiving vitamin K. The nurse explains vitamin K prevents:

bleeding

When caring for a child a nurse plans to use nonpharm interventions to enhance pain med effectiveness. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort?

blowing bubbles to "blow the hurt away"

A nurse is assessing a client during the immediate postpartum period. Which finding requires immediate intervention?

boggy uterus

A nurse is preparing to administer a long-acting insulin to a client who has DM. Which of the following actions should the nurse plan to take first?

check the dose with another nurse

A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following?

clang association

A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take?

clear objects from the client walking area

A nurse is caring for a group of clients. Which event requires an incident report?

client's IV pump administers inadequate dose of medication

A nurse is caring for four clients at the beginning of a shift. After report, which client should the nurse attend to first?

confused client getting out of bed

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Assessment finding priority?

confusion

A nurse is caring for a client with MRSA. Implement which precautions?

contact

A nurse is caring for a newborn with herpes simplex virus (HSV). Which isolation precautions?

contact

A nurse is caring for a client that is in labor at 39 weeks gestation. During the second stage of labor, the nurse observes early decelerations on the monitor. What action should the nurse take?

continue observing the fetal heart rate

A nurse is caring for a client with a potassium level of 3. What manifestation should the nurse monitor for?

decreased DTR

A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?

decreased central vision

A nurse is caring for an older adult client. Physiological change associated with aging?

decreased lung expansion

A nurse in an ER is planning discharge for a client who has experienced intimate partner violence. Which action should the nurse take first?

develop a safety plan

A nurse is caring for a client receiving TPN by IV at 60mL/hr. The nurse discovers the infusion pump isn't working. Which action should the nurse take while waiting for a new pump?

dextrose 10% in water using manual drip tubing at 60mL/hr

A nurse in an ER is assessing a client that took MDMA. What should the nurse expect?

diaphoresis

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend?

diced steamed carrots

A nurse on a mental health unit has a patient refusing IM lorazepam. What is the nursing action?

document the refusal

A nurse is teaching home wound care to the family of a child who has a large wound. Which intervention should the nurse recommend?

double bag soiled dressings in plastic bags for disposal

A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first?

dry the newborn

A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing intervention?

elevate the leg

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. What should the nurse include in the plan of care?

encourage the parents to bring toys from home

A nurse is caring for a client at 28 weeks gestation. The client asks what's causing her constipation. Which response should the nurse make?

enlarged uterus compresses the intestines

A nurse is preparing to administer 2U FFP to a client. Which action should the nurse plan to take?

enter the plasma product number into the client's medical record

A mental health nurse is conducting the first of many meetings with a client whose partner recently died. The nurse should perform which action to establish trust in the orientation phase of the nurse-client relationship?

establish the termination date

A nurse is caring for a client who has a STI that must be reported to the state health department. Which of the following actions should the nurse take?

explain to the client why this information will be shared

A nurse is performing an admission assessment on a preschooler who is in the acute phase of Kawasaki disease. Which finding should the nurse expect?

fever unresponsive to antipyretics

A nurse is administering meds to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent the tube from clogging?

flush the tube before meds

A charge nurse observes a staff nurse document a dressing change in a client's chart that wasn't performed. First charge nurse action?

gather more information about the staff nurse's actions

A nurse is caring for a client in the manic phase of bipolar. Expected manifestations?

grandiose delusions

A nurse in an outpatient clinic is working with a client that has PTSD and asks for recommended nonpharm therapy. What should the nurse recommend to help alleviate distress?

guided imagery

A nurse is teaching a client about a new prescription for estradiol. For which of the following adverse effects should the nurse tell the client to monitor and contact the provider?

headaches

A nurse is assessing a client w/ sickle cell anemia. Manifestation of vaso-occlusive crisis?

hematuria

A nurse is assessing a child with CF. Which finding is priority to report to the provider?

hemoptysis 275mL in 24 hours

A nurse is providing teaching for a client about newborn safety. Which statement should the nurse include in the teaching?

hot water heater temp 120F or less

A nurse is assessing a client who has obstructive sleep apnea. Which complication should the nurse monitor?

hypertension

A nurse is providing client education to a postpartum client who has decided to bottle feed their newborn. Instructions to prevent the discomfort of engorgement?

ice packs on the breasts for 15 minutes several times per day

A charge nurse is preparing to administer 0900 meds and is told by pharmacy the meds are not available. First charge nurse action?

inform the nurse manager

A nurse is caring for a client who has generalized anxiety disorder and is going to start alprazolam. Which action should the nurse take?

initiate fall precautions

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?

initiate oral rehydration therapy for the toddler

A nurse is preparing to administer 15U regular insulin along with 20U NPH. Which action plan should the nurse take?

inject 20U air into NPH insulin vial

An RN is planning care for a group of clients and is working with an LPN and an AP. What tasks should the RN delegate to the LPN?

insert a NG tube

A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which instruction should the nurse include?

install a raised toilet seat at home

A nurse is providing dietary teaching to the parents of a 6 month old. What instructions should the nurse give?

introduce new foods over 5-7 days

A nurse manager reviews falls occur most often between 0530 and 0730. Which action should the nurse take in root cause analysis?

investigate environmental factors

A nurse is caring for a client that requires PT after discharge. First nursing action?

involve the client in selecting their PT provider

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates understanding of the procedure?

keeps the HOB elevated to 45 degrees for 1hr after feedings

A nurse is assessing a client who has antisocial personality disorder. Expected manifestations?

lack of remorse

A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which condition prior to starting the procedure?

latex allergy

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?

low back pain

A nurse is administering cyclophosphamide to a school age child with neuroblastoma. Nursing action to administer medication?

maintain hydration with liberal fluid intake

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which method should the manager use to evaluate time management skills?

maintain regular notes about the nurses time management skills

A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which med to reduce intracranial pressure?

mannitol

A home health nurse is planning care for an older adult client who has impaired vision. Which intervention in the plan of care to prevent injury at home?

mark the edges of stairs for contrast

a nurse is caring for a client who is 4hrs postpartum with a boggy uterus and heavy lochia. First nursing action?

massage the uterus to expel clots

A nurse is teaching a client who is to start taking misoprostol and is currently on long-term NSAIDs for arthritis. The nurse should provide what information?

serum pregnancy test

A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanity and sexual references. Which of the following actions should the nurse take first?

move the client to a private place away from others

A nurse is teaching a client that has a new prescription for digoxin about manifestations of toxicity. Which finding should the nurse include in the teaching?

nausea

A nurse is assessing a client who is 2hrs post op following a cardiac cath. Report to MD?

neuro status

A nurse manager is on a planning committee to develop an emergency preparedness plan. Which action takes place first when implementing an emergency preparedness plan?

notify the incident commander

A nurse is assessing a client who has MS. Which manifestation should the nurse expect?

nystagmus

A nurse is caring for a client who has hypertension and is taking captopril. Delegatetask to AP?

obtain vital signs

A nurse is planning teaching about allowable foods for a client with uric acid-based urinary calculi formation. What foods should the nurse recommend?

oranges

A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The nurse should identify which of the following findings as fluid volume deficit?

orthostatic hypotension

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

pH 7.31

A nurse is assessing a client who has a stage II pressure injury. Expected would characteristics?

partial thickness skin loss

A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage?

perform a rapid needs assessment

A nurse is caring for a client at 37 weeks gestation and is experiencing abruptio placentae. Which finding should the nurse expect?

persistent uterine contractions

An AP and a nurse are turning a patient on their R side. Which AP action requires the nurse to intervene?

place a pillow

A nurse is caring for a client that vomits on a reusable BP cuff. Nurses action?

place the BP cuff in a labeled bag for decontamination

A nurse is caring for a child who is experiencing a tonic-clonic seizure. What action should the nurse take?

place the child in a side-lying position

A nurse is providing colostomy care for a client using a two-piece pouch system. Which action should the nurse take?

place the skin barrier over the stoma and hold it for 30 seconds

A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Expected finding?

protein

A charge nurse is planning care for a client in mechanical restraints. What interventions?

provide a staff member to stay with the client continuously

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate staff acceptance, what should the nurse manager do first?

provide information about scheduling issues to staff

A nurse is teaching the parent of a school-age child about administering ear drops. Parent response indicating understanding?

pull the top of the ear up and back

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which assessment finding should the nurse expect?

pulsus paradoxus

A nurse is assessing a client who has delirium. Which manifestation should the nurse expect?

rapid speech

Foods high in vitamin A

raw carrots

A nurse working in a long term care facility is assessing an adult client. Which of the following findings places the client at risk for developing a pressure injury?

recent weight loss

A nurse is teaching a client who has opioid use disorder about methadone. Information to include in teaching?

sedation is a common adverse effect of this medication

A nurse is preparing a sterile field in order to insert an indwelling urinary catheter on a male client. Which technique should the nurse use to maintain aseptic technique?

set the tray on the table at waist height

A community health nurse is performing triage tagging following a mass casualty incident. Black tag?

significant head trauma w/ agonal respirations

A nurse is assessing a 2 month old infant during a well-baby exam. Which of the following actions should the nurse take to assess the infant's rooting reflex?

stroke the cheek

"My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out". The client demonstrates which defense mechanism?

sublimation

A nurse is assessing a preschooler who has CF and has been receiving oxygen therapy for the past 36 hours. Which finding shows oxygen toxicity?

substernal pain

A charge nurse overhears 2 staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which action should the charge nurse take?

tell the nurses to stop the discussion

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following requires manager intervention?

tells the hospital chaplain a client's diagnosis

A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which finding is the priority for the nurse to provide to the provider?

temp 102.9f

A charge nurse is teaching a newly licensed nurse how to identify true labor. What should the nurse include in the teaching?

the cervix transitions to an anterior position

A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client can sign the informed consent?

the client an accurately describe the procedure

A night shift nurse is giving change-of-shift-report to the day shift nurse on a client ready for discharge. Priority information to oncoming nurse?

the client needs assistance transferring from bed to w/c

A nurse is caring for a client with a closed femur fracture and has had a fiberglass leg cylinder cast for 24 hours. Which of the following assessment findings should the nurse identify as the priority?

the client's heel is red and tender

A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for organ donation. Which information should the nurse plan to include?

the family can have the child in an open casket

A nurse is reviewing the ABG results of a client with COPD. The results include pH 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCOs 26 mEq/L, SaO2 87%. Correct interpretation?

uncompensated respiratory acidosis

A nurse is assessing a client who has skeletal traction for a femur fracture. Which should the nurse identify as the priority?

upper chest petechiae

A nurse is performing gastric lavage for a client who has GI bleeding and a NG in place. Nursing action?

use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube

A home health nurse is providing teaching to a client that has hep A.Which of the following instructions should the nurse include?

use hydrogen peroxide to clean kitchen surfaces

A nurse is caring for an immediately post op total vaginal hysterectomy. Which action should the nurse take first?

vital signs

A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child returns to school. Which of the following responses should the nurse make?

when crusts have formed on every lesion

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. What intervention should the nurse include in the plan?

withhold the varicella vaccine

A charge nurse is watching a newly licensed nurse perform a physical assessment. Which action should the charge nurse intervene?

writes detailed notes