comp b 2023

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 mental health unit after an attempted 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. Which of the following statements by the client indicates that this therapy is having the desired effect?

"I have not vomited as much recently."

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching?

"I should watch for common reactions like dry mouth and constipation."

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

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

A nurse is providing information to a client immediately before their 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 teaching a pt who has opioid use disorder about methadone. which of the following information should the nurse include in the teaching?

"Sedation is a common adverse effect of this medication."

A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. remove the inner cannula. 2. remove the soiled dressing. 3. clean the stoma with 0.9% sodium chloride irrigation. 4. change the tracheostomy collar.

Urine specific gravity reference range

1.005 to 1.03

Serum sodium level expected reference range

136 mEq/L to 145 mEq/L

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

A client who is confused and has been attempting to get out of bed

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

Acute confusion

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 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 the client needs additional nutrients added to the feeding?

Albumin 2.8 g/dL (3.5 to 5 g/dL)

A nurse is caring for a client who has become aggressive and potentially violent. Which of the following actions should the nurse take?

Allow the client time for reflection and decision making.

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 min.

A nurse is providing teaching to a client who Take the medication on an empty stomach 30 min before breakfast. has a prescription for levothyroxine 25 mcg PO daily. Which of the following instructions should the nurse include in the teaching?

Autonomy

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.

when caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain meds. which of the following strategies incorporates visualization techniques to help dec the child's discomfort?

Blowing bubbles with liquid soap to "blow the hurt away"

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

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?

Borderline

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

Establish the termination date of therapy.

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?

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

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

Flush the client's gastrostomy tube with 30 mL of water before administering the medication.

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect?

Grandiose delusions

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?

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

A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider?

Hemoptysis 275 mL/24 hr

Risk from fecal-oral transmission (recent travel to an underdeveloped country & occupational risk)

Hep A

Bloodborne transmission

Hep B & Hep C

Antiviral medication

Hep B, & C

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor?

Hypertension

the nurse is providing edu to the parent of a school age child with 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

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?

Ideas of self-harm

A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take?

Initiate fall precautions for the client.

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 assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect?

Lack of remorse

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

Maintain regular notes about the nurse's time management skills.

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?

Place the skin barrier over the stoma and hold it for 30 seconds.

A nurse is administering 1 unit of packed RBCs to a client. The client becomes anxious and reports shortness of breath and urticaria 15 min after initiation of the transfusion. Which of the following actions should the nurse take?

Prepare to administer epinephrine to the client.

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 manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first?

Provide information about scheduling issues to the staff.

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

Recent weight loss

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

When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to

apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled.

Antidote for magnesium sulfate

calcium gluconate

The client has hypokalemia, which increases the risk for

cardiac arrhythmias. Once the client's medical concerns are addressed, the nurse should then focus on the underlying psychological issues behind the eating disorder, such as the client's fear of weight gain.

a home health nurse is caring for a group of older adults. the nurse should initiate a referral to a program of all-inclusive care for the elderly (PACE) for which client?

client whose caregiver requests adults day care services

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?

confusion

Actions for a client with malignant hyperthermia

dantrolene and oxygen

Hypernatremia places the client at risk for a

decreased level of consciousness, falls, and seizure activity. Therefore, the nurse should monitor the client's level of consciousness and place the client on fall and seizure precautions.

Signs of neuroleptic malignant syndrome

decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges

Actions for a client with epiglottitis

droplet precautions and IV antibiotics

Characteristics of thyroid storm

fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness

Encephalitis is characterized by

fever, nuchal rigidity, and altered mental status.

Manifestations of bacterial meningitis can include

fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness.

UTI prevention education

gently cleanse the perineum before intercourse

Actions for a client with neuroleptic malignant syndrome

hold the client's antipsychotic medications and cooling blanket

Parameters to monitor for a client with malignant hyperthermia

hypercapnia and muscle rigidity

Hypothermia can lead to the occurrence of

hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.

A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. which of the following actions should they take first?

inform the nurse manager of the issue

Manifestations of Hep A, Hep B, & Hep C

jaundice, yellow sclera, RUQ pain on palpation, dark yellow urine, inc AST & ALT levels

Hypocalcemia findings

muscle spasms, numbness around lips, and decreased calcium level

A nurse working on an inpatient mental health unit is caring for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?

observe the client every 15 minutes

A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching?

oranges

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

oxytocin

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

Set the catheter tray on the overbed table at waist height.

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

The client's heel is reddened and tender.

A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss

Reye syndrome is characterized primarily by

altered mental status and impaired hepatic function.

A nurse is teaching a client who has a new prescription for 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."

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

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

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."

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 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 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."

Parameters to monitor with abruptio placentae

-BP -Platelet count

A nurse is caring for multiple clients in an antepartum clinic. For which of the following clients should the nurse plan to perform fetal heart monitoring? (Select all that apply.)

-a client who has premature rupture of membranes -client who reports decreased fetal movement -client who has gestational hypertension

Actions for abruptio placentae

-avoid cervical exam -insert large bore IV catheter

Discharge teaching for a client who has hyperemesis gravidarum

-eat every 2-3 hrs -separate liquids from solids every 2 to 3 hrs -eat foods high in protein that are low in fat -warm ginger ale or ginger tea

Manifestations of UTI

-frequency -dysuria -urgency

Prescriptions for a client with ICP

-oxygen therapy -monitoring blood glucose -keeping lights dim

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

Normal newborn temperature range

97.7 to 98.9F

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

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 diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?

A client who has significant head trauma and agonal respirations

A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's guardian. Which of the following actions should the nurse take?

Ask the caller for verification of their identity.

A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?

Ask the client to point to items on a picture menu.

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.

A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?

Audible stridor

A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care?

Auscultate the affected extremity for a bruit.

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 Child Protective Services

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

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?

Delegate non-nursing tasks to ancillary staff.

A nurse is interviewing a pt who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?

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.

A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first?

Develop a safety plan with the client.

A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect?

Diaphoresis

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

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 caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care?

Encourage the parents to bring toys from home.

A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take?

Inject 20 units of air into the NPH insulin vial.

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

Install a raised toilet seat at home.

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 a 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 providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include?

Introduce new foods one at a time over 3 to 5 days

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take?

Involve the client in selection of a physical therapy provider.

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?

Irritability

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 charge nurse is observing a new nurse adminstering enteral feedings via NG tube. which of the following actions by the new nurse indicates an understanding of the procedure?

Keeps the head of the bed elevated to 45° for 1 hr after feedings

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 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 caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit?

Orthostatic hypotension

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?

Performing a rapid needs assessment

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

Persistent uterine contractions

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 vomits on a reusable BP cuff. Which of the following actions should the nurse take?

Place the BP cuff in a labeled bag to send it for decontamination.

A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms?

Sublimation

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

Supervise the client during and after eating.

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 client who has a prescription for levothyroxine 25 mcg PO daily. Which of the following instructions should the nurse include in the teaching?

Take the medication on an empty stomach 30 min before breakfast.

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

The client is able to accurately describe the upcoming procedure.

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?

Turn off the CPM machine during mealtime

A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35 to 7.45), PaO2 56 mm Hg (80 to 100 mm Hg), PaCO2 54 mm Hg (35 to 45 mm Hg), HCO3- 26 mEq/L (21 to 28 mEq/L), and SaO2 87%. Which of the following is the correct interpretation of these values?

Uncompensated respiratory acidosis

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 creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3 (2500 to 8000/mm3). Which of the following interventions should the nurse include in the plan?

Withhold administering the varicella vaccine to the child.Withhold administering the varicella vaccine to the child.

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

a sedentary lifestyle

Unexpected findings for a client who is postoperative following an appendectomy

pain, nausea, heart rate, and oxygen saturation

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

perform gastrostomy feedings through a clients gastrostomy tube.

A client who has a cervical SCI is at risk for

pneumonia and autonomic dysreflexia

A UTI left untreated leads to

pyelonephritis

Findings indicative of psychosis

restlessness, auditory hallucinations, and pressured speech

Medications for UTI

sulfamethoxazole/trimethoprim and phenazopyridine

Signs of malignant hyperthermia

tachycardia, tachypnea, hypotension, and irregular heart rhythm

Parameters to monitor for a client with epiglottitis

temperature and breath sounds

Parameters to monitor for neuroleptic malignant syndrome

temperature, hydration status

An enlarged uterus compresses

the intestines and causes constipation

a charge nurse is observing a newly licensed nurse performing a physical assessment on a client. which of the following actions by the nurse indicates that the charge should intervene?

the new nurse writes detailed notes while performing the HTTA

Contraindication for hyperemesis gravidarum patient

to increase intake of high fat foods

HF

tobacco use, BNP level, dec O2 sat

COPD

tobacco use, dec O2 sat

Pneumonia

tobacco use, elevated WBC, productive cough w/ sputum, inc temp, dec O2, resp acidosis

C. difficile and Stevens-Johnson syndrome are potential side effects of

trimethoprim/sulfamethoxazole.

a nurse is assessing a client who has a skeletal traction for a femur fracture. which of the following findings should the nurse identify as the priority?

upper chest petechiae which is a manifestation of fat embolism syndrome

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 protective cover on the scale when weighing