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

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?

Ask the partner to list specific concerns.

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?

"I would like to talk to you about the unit policies regarding break time."

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?

Dyspnea

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

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

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?

A client whose caregiver requests adult day care services

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?

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

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?

"We can expect the hospice nurse to provide support for us after our mother's death."

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?

Time the mediation was given

A nurse administers an incorrect dose of a 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?

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

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?

Floating dark spots

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?

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

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 receiving an MAOI and is requesting a cheeseburger for dinner.

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?

Abdominal bloating

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?

Borderline

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 forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

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

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?

Recommend rescreening in 1 year.

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?

Contact Child Protective Services.

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?

Proceed with provision of medical care.

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?

A client who channels their energy into a new hobby following the loss of their job

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?

Strict adherence to routines

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?

The child exhibits discomfort while walking.

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?

Initiate transmission-based precautions.

A nurse in the 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?

Urine specific gravity 1.052

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

"How does this make you feel?"

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?

Droplet

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

Report of chest pain

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?

Rapid decrease in blood pressure

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

Oxytocin

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

Edema

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

pH 7.31

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

Occlusive dressing on the insertion site

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

Flight of ideas

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

Increased opacity of the lens

A nurse is assessing a client who has 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?

Blurred vision

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?

Pink, frothy sputum

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

The client reports a decrease in episodes of nausea.

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?

Wheezing

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?

Hemoglobin 14.9 g/dL

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?

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

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?

Nasal flaring

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

Auscultate the apical pulse at least 1 min.

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

Nuchal rigidity

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

Irritability when being held

A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following the placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report tot he provider?

Acute confusion

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

Aspirate contents from the tube and verify the pH level.

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?

Noting the progress of the group toward assigned goals

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?

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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?

Cervical laceration

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?

Place the client in a quiet environment.

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 (ICP)?

Assist with deep breathing and coughing.

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

Change the position of the client.

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?

Instruct the client to elevate the affected extremity when sitting.

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

Insert a lubricated gloved finger and advance along the rectal wall.

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?

Initiate continuous cardiac monitoring.

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?

Dry mouth

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?

Turn off the CPM machine during mealtime.

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

Decreased hallucinations

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?

Withhold the heparin infusion.

A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin 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?

Assign the client to a private room with negative air pressure.

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

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

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

Explore the client's reasons for refusing the treatment.

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?

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

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?

Measure the client's daily weight.

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)?

Tremors

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

Monitor the client's mouth every 8 hr.

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

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

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?

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

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

Amount of vaginal bleeding

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?

Hyponatremia

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?

Check the client's oxygen saturation level.

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?

aPTT

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

Irrigate the catheter with 0.9% sodium chloride irrigation.

A nurse is caring for a client who is receiving continuous bladder irrigation following a 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?

Tension pneumothorax

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?

Jaundice

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?

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

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?

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

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

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

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.

Serum sodium 138 mEq/L

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

Serum liver enzyme levels

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?

Albumin 2.8 g/dL

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?

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

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

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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?

"I told my doctor that I would like to start a support group for other women who are sick in my community."

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client is an example of altruism.

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

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?

Administer high-dose antibiotic therapy.

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

Sedentary lifestyle

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

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

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

February 15 1. Subtract 3 calendar months from LMP date 2. Add 1 year 3. Add 7 days to LMP date

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 (LMP) 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 (EDB)?

Allow for frequent rest periods throughout the day.

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?

Increase the client's dietary iron intake.

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

Avoid including raw fruits in the client's diet.

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?

Perform gastrostomy feedings through a client's established gastrostomy tube.

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

Instruct the client to void.

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

Maintain sterile objects within the line of vision.

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 aseptic technique?

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

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?

Use the ventrogluteal site.

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?

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

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

13 gtt/min

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?

18 g

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

Instruct the client to avoid coughing during the procedure.

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?

Radial vein of the inner arm

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?

Ask another nurse to witness the disposal of the new patch.

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 patch, the client declines to accept it. Which of the following actions should the nurse take?

Fiber

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?

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

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?

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

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation 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?

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

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?

Broccoli Yogurt Cream cheese

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?

"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 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?

Ensure that the client understands the medication regimen.

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?

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

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?

Wear clothing made with cotton fabrics while oxygen is in use.

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?

"I will make sure my child receives a yearly influenza immunization."

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

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

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

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

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

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?

"Notify your provider if you experience increased thirst."

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?

Use a three-point gait.

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?

Irritability

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 hypoglycemia?

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

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

Short-term memory loss

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?

Take the medication 15 min before playing sports.

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?

"I will not allow anyone to smoke near my baby."

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

Respiratory acidosis

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

Sodium 148 mEq/L

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

45 seconds

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

"I will need to measure your weight daily."

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

"I will wear a supportive bra overnight."

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

Cough

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

Determine the client's reading skills.

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?

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

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?

Seeks input from the other nurses

A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?

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

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?

Delegate non-nursing tasks to ancillary staff.

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

Making a list of activities to complete

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?

Autonomy

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?

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

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?

Difficulty performing ADLs

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?

Make a referral for social services.

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?

Ideas of self-harm

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

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

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?

The client is pacing around the chair in which their partner is sitting.

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?

***Implement fall precautions for the client.

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?

Starts a task then determines what supplies are needed

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

A middle adult client who has unstable vital signs

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

Agency for Healthcare Research and Quality

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

Survey the scene for potential hazards to staff and children.

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?

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

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

A client who is at 33 weeks of gestation and has sever gestational hypertension

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

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

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?