Comprehensb20

A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

"You should depress the button on the handheld marker when you feel your baby move."

A nurse is preparing to administer metoclopramide 10 mg IM. Available is metoclopramide 5 mg/mL How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 ml

A nurse is caring for a client who has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20

A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention?

A school age child who has allergic rhinitis and is taking diphenhydramine.

A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture Of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which Of the following actions should the nurse take?

Apply the external fetal heart rate monitor.

A nurse is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer?

BMI rationale: 33 indicates obesity

A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?

C. the guy with one drooping eye and has a unibrow Rationale: This is an example of ptosis, in which there is abnormal drooping of the upper eyelid. Ptosis, along with diplopia, are early manifestations of MG.

A nurse in a long-term care facility is contributing to the plan Of care for a client who has a new ostomy. Which Of the following interventions should the nurse include?

Change the appliance two times each week Rationale: The nurse should change the appliance two times each week to maintain an effective seal around the stoma. The nurse should remove the appliance carefully and cleanse the client's stoma. **Also needs to be change at 1/3-1/2 full to prevent from bursting open

A nurse is reviewing a client's electronic medical record and finds that an assistive personnel (AP) recorded the client's temperature as 35.30 C (95.50 F) 2 hr earlier. Which of the following actions should the nurse take first?

Check the clients temperature Rationale: According to the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should retake the client's temperature.

A nurse is reinforcing teaching with a client who has fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving?

Cherry tomatoes

A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client?

Chlordiazepoxide Rationale: The nurse should expect to administer chlordiazepoxide to decrease anxiety and the risk for seizures associated with alcohol withdrawal.

A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?

Consumption of contaminated food

A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

Decreased bowel sounds

A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, "l don't think I can go through this again." Which of the following actions is the nurse's priority?

Determine if the client is experiencing psychotic thinking.

A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

Difficult concentrating Rationale: In clients who have iron deficiency anemia, body cells do not receive the required oxygen because there is less hemoglobin for binding. The nurse should recognize that impaired oxygenation of brain tissue can lead to dizziness and difficulty concentrating.

A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

Discuss this behavior with the AP while reinforcing expectations. Rationale: The charge nurse should discuss this behavior with the AP and reinforce expectations moving forward. Evaluation of the AP's performance is a part of the nurse's delegation process. Teaching and counseling the AP about behaviors and expectations is an important component of leadership.

A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?

Dosage

A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?

Establish a regular exercise routine 2 hr or more before bedtime Rationale: The nurse should include in the plan to engage the client in moderate exercise activities during the day but at least 2 hr prior to bedtime to help promote a deep, restful sleep.

A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. The nurse should report which Of the following to the provider after hearing this sound?

Fine crackles Rationale: Fine crackles are high-pitched popping sounds often caused by pulmonary edema, which can be a complication of heart failure. Wheezes are characterized as continuous, musical sounds, which are caused by narrowing of the airways. Vesicular sounds are soft, rustling sounds that occur as normal breath sounds. A pleural rub is characterized as a loud, grating sound often caused by pleurisy.

A nurse is performing postmortem care for a client prior to the arrival Of the client's family for viewing Of the body. Which Of the following actions should the nurse take?

Gently close the client's eyelids

A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The client states, "l really thought I'd be back to my usual routines by now, but I can't think of anything else except that my son is gone." Which Of the following responses should the nurse make?

Grieving for your son is hard work. it will take as much time as you need to come to terms with your loss.

A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which of the following manifestations should the nurse expect?

Hematemesis

A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?

Hydrogen peroxide Rationale: The nurse should identify that sterile hydrogen peroxide solution is used to loosen secretions from the inner cannula during cleansing. If the client's skin becomes irritated, the nurse should choose 9% sodium chloride solution.

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Hypervigilance Rationale: Common manifestations of PTSD include recurrent recollections of the precipitating trauma, hypervigilance, irritability, insomnia, and difficulty concentrating.

A nurse is assisting with the admission of a client who has a latex allergy. The nurse should identify that which of the following supplies has the potential to contain latex?

Indwelling urinary catheter

A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

Irrigate the bladder using sterile technique Rationale: The nurse should irrigate the bladder using strict sterile technique and maintain the closed catheter drainage system to minimize the risk of infection.

A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Lack of sleep. rationale: The greatest risk for this client is exhaustion or death from lack of sleep: therefore, this is the priority finding. The nurse should encourage frequent periods of rest for the client throughout the day.

A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer?

Lamb Rationale: including tuna fish reduces risk of developing cancer. including poultry reduces risk,

A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?

Lilst of potential complications to report

A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?

Moist mucus membranes. Rationale: The condition of mucous membranes is an indicator of hydration status. Moist mucous membranes indicate adequate hydration and a positive response to IV fluid therapy.

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect?

Muscle weakness.. Rationale: The nurse should expect a client who has hypokalemia to have bilateral muscle weakness. Other manifestations of hypokalemia include hyporeflexia, muscle stiffness, cramping, and paralysis.

A nurse is transferring a client from a bed to a wheelchair. The client has right-sided weakness following a recent stroke. Which of the following actions should the nurse take?

Place the wheelchair on the clients left side. Rationale: The nurse should place the wheelchair on the client's stronger side to reduce the risk of falling.

A nurse is preparing to discharge a client who is immunocompromised. Which of the following vaccines should the nurse plan to administer?

Pneumococcal polysaccharide (PPSV) The PPSV vaccine is recommended at the time of discharge for a client who is immunocompromised. MMR, Varicella, and Herpes zoster are all contraindicated for those who are immunocompromised

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the nurse recommend?

Position the head of the bed at 30 angle

A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse?

Potassium chloride 20 mEq PO every morning

A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which Of the following information should the nurse include?

Prolonged use of corticosteroids is a risk factor for infection Rationale: Prolonged use of corticosteroids places the client at risk for a health care-associated infection. Older adults are at an increased risk Blood pressure cuffs can be a source of exogenous infections

A nurse is caring for a client who has expressive aphasia following a stroke. Which of the following methods should the nurse use when communicating with the client?

Provide a picture board. Rationale: A client who has expressive aphasia has difficulty expressing needs or wants through verbalization or writing. The use of a picture board provides an alternative means of communication that might be less frustrating for the client.

A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take?

Report the observation about the AP to the Unit nurse manager Rationale: The nurse should report their observations to the unit's nurse manager because they have a duty to report any behavior that poses a risk to client safety.

A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?

Zolipedem

A nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes mellitus and inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (Select all that apply.)

[1] a pharmacist. [2] package inserts. [3] American diabetes association.

A nurse in a long-term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? (Select all that apply.)

[1] determine the facts related to the dilemma. [2] identify possible solution [3]consider the client wishes

A nurse is reinforcing teaching with a group of clients about the Heimlich maneuver during a first-aid class. The nurse should include in the teaching that which of the following manifestations indicates the need for the Heimlich maneuver to be performed? (Select all that apply.)

[1] difficulty breathing [2] coughing [3] presence of stridor Rationale: Difficulty breathing is correct. The Heimlich maneuver is performed when the airway is obstructed by a foreign body. A client who has an obstructed airway might exhibit manifestations such as coughing, choking, gagging, difficulty breathing, cyanosis, and stridor. Coughing is correct. The Heimlich maneuver is performed when the airway is obstructed by a foreign body. A client who has an obstructed airway might exhibit manifestations such as coughing, choking, gagging, difficulty breathing, cyanosis, and stridor. Presence of stridor is correct. The Heimlich maneuver is performed when the airway is obstructed by a foreign body. A client who has an obstructed airway might exhibit manifestations such as coughing, choking, gagging, difficulty breathing, cyanosis, and stridor.

A nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

[1] expose the glans of the penis [2] cleanse the penis using and antiseptic swab. [3]Begin urination [4] pass the cup into the urine stream [5] move the cup out of the urine stream. [6] replace the foreskin

A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?

a client who has pneumonia and a new onset of confusion.

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

a client whose urinary output was 100 ml for the past 12 hr Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is a urine output of less than 30 mL/hr due to the risk for fluid imbalance. Therefore, the nurse should see this client first.

A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client?

acetylcysteine

A charge nurse on a long-term care unit is preparing to delegate tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the charge nurse delegate to the LPN?

administer an initial NG tube feeding to a client who has a stroke Rationale: It is within the LPN's scope of practice to administer an initial NG tube feeding to a client who had a stroke. Because this task requires use of the nursing process, it is outside the range of function for an AP. Therefore, the LPN should expect to be assigned this task.

A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?

advanced directives are written instruction regarding end of life care

A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The nurse should instruct the client to use which of the following medications for treatment of an acute asthma attack?

albuterol Rationale: The nurse should instruct the client to use albuterol, a bronchodilator, to relieve the bronchospasms of an acute asthma attack.

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

allow the weight to hang freely

A nurse is reinforcing teaching with a client who has coronary artery disease (CAD) and is taking a low-dose aspirin daily. The nurse should include that this medication has which of the following therapeutic effects?

antiplatelet Rationale: The therapeutic benefits of low-dose aspirin for a client who has CAD include inhibiting platelet aggregation and vasoconstriction, which will decrease the incidence of thrombosis.

A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include?

apply the prosthesis immediately upon waking each day

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

applying the stocking before the client gets out of bed

A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

as soon as the client awakens in the morning

A nurse is collecting data from a client who has multiple sclerosis. Which of the following findings should the nurse expect?

ataxia Rationale: The nurse should expect a client who has multiple sclerosis to manifest ataxia, which is a lack of coordination and movement. Other manifestations include fatigue, impaired memory, diplopia, and bowel and bladder incontinence.

A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

avoid foods high in sugar content. Rationale: The nurse should instruct the client to avoid sweet foods, which often increase the manifestations of dumping syndrome. These manifestations include nausea, sweating, abdominal pain, diarrhea, and weakness.

A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?

avoid lying on the affected side

A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which Of the following actions should the nurse take?

avoid massaging the site after injecting vaccine. Rationale: The nurse should not massage the site following an intradermal injection because this can spread the vaccine into the tissue or out through the needle insertion site.

A nurse is checking a newborn's vital signs. Which Of the following methods Of temperature measurement should the nurse use?

axillary

A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the following foods should the nurse include in the plan as having the highest amount of iron?

boiled spinach

A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

cap refil of 5 seconds to the client toes

A nurse is preparing to administer digoxin to a client who has heart failure. Which Of the following findings should indicate to the nurse that the medication has been effective?

cardiac workload decreases

A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?

check for gag reflex Rationale: The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse should take is to check for a gag reflex.

A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which Of the following findings is the nurse's priority to report to the provider?

client reports burning with urination. Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that dysuria is a manifestation of a urinary tract infection. Therefore, the nurse should identify this as the priority finding to report to the provider.

A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation Of increased intracranial pressure?

confusion about knowing their own name

A nurse is reviewing laboratory reports for a client who has an Escherichia coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose?

creatinine 2.5mg/dl

A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

demonstrate assertiveness Rationale: Clients who have dependent personality disorder demonstrate fear of separation and abandonment. Therefore, reinforcing assertive behaviors will allow the client to become more independent.

A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

determine the client's mobility status

A nurse manager is preparing to complete a performance analysis for a group of assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the following actions should the staff nurse take?

discuss how each AP action measure against the job description Rationale: To provide objective information, the staff nurse should compare the behavior of each AP to the facility job description. The nurse can provide specific information about how each AP either meets the standard or demonstrates a need for improvement.

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which Of the following information should the nurse include?

eat a bedtime snack

A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

ensure the injection produces wheal on the skin Rationale: The nurse should ensure that the injection of the PPD produces a wheal, or bleb, on the skin. This indicates the medication has been injected into the dermis of the skin.

A nurse is working with an interpreter to assist the provider with explaining a diagnostic procedure to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

ensure the interpreter is culturally compatible with the client

A nurse is reinforcing teaching with a client who is bottle feeding their full-term newborn with formula. Which of the following instructions should the nurse include in the teaching?

feeding newborn at least every 3 - 4 hrs

A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects?

gastric ulcer formation

A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?

have a supply of prescribed medications Rationale: In a disaster situation, it could be difficult to obtain additional prescribed medication. Therefore, the nurse should recommend clients have a backup supply of prescribed medications to prevent a potentially harmful interruption in dosing.

A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?

heart rate 146/min

A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

i am so frustrated i cannot even open my milk carton for breakfast

A nurse is reinforcing teaching with a client about the client's recent diagnosis Of multiple sclerosis. The client states, "l am very upset and I want to be alone for a little while." Which Of the following responses should the nurse make?

i see that you are feeling overwhelmed. i will come back when you are ready.

A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

i should appply sterile saline to lubricate the suction catheter

A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent indicates an understanding of the teaching?

i should offer my child yogurt that has a probiotic as a snack

A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

i should use counter pressure for back pain during labour

A nurse is reinforcing teaching with a client who has asthma and a new prescription for an ipratropium inhaler. Which of the following statements by the client indicates an understanding of the teaching?

i should wait 1 minute before taking a second puff of the medication/

A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?

i will apply diaper cream to my baby skin during each diaper change rationale: The nurse should reinforce to the parent that applying a skin barrier, such as zinc oxide, during diaper changes will minimize skin irritation from frequent stools.

A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which Of the following statements by a parent indicates an understanding Of the instructions?

i will give our baby sponge baths until the cord falls off.

A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching?

i will imagine myself in a calm place when i cant concentrate

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions?

i will receive the nutrients i need through my IV fluid. Rationale: During initial treatment of acute diverticulitis, the client is often kept NPO and receives parenteral nutrition to promote bowel rest. As the client's condition improves, they can progress to a soft, low-fiber diet. A high-fiber diet is prescribed once the client is fully recovered from the acute inflammation.

A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

i will rinse my mouth after taking this medication Rationale: Iron preparations can stain the teeth. The nurse should instruct the client to use a straw to drink the medication and rinse the mouth immediately after taking the medication.

A nurse is reinforcing discharge teaching about car seat safety with the guardian Of a Which Of the following statements by the guardian indicates an understanding Of the teaching?

i will secure the car seat in the car by using the seatbelt.

A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following client statements indicates an understanding of the teaching?

i will undergo bowel cleansing prior to the procedure

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

if i forget to take a dose i can take it later on the same day.

A nurse is preparing to administer a medication to a client. The client states, "I'm sick Of all these medications, and I'm not taking any more today!" Which Of the following actions should the nurse take?

inform the client of the possible consequence of the medication refusal

A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?

informing a client the the nurse is going to administer an injection even through the client refuses.

A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

instruct the client not to get out of bed

A nurse is contributing to the plan of care for a client who is postoperative following a rhinoplasty. Which of the following interventions should the nurse recommend?

instruct the client to avoid the Valsalva maneuver. Rationale: The nurse should instruct the client to avoid the Valsalva maneuver and other activities that increase pressure at the operative site, resulting in an increased risk for bleeding.

A nurse is assisting in the plan Of care for a female client who is to undergo a 12-lead ECG. Which Of the following actions should the nurse include in the plan Of care?

instruct the client to remain still while the test is performed,

A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago and has a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

instruct the client to use a sitz bath at least twice a day

A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

irritability

A nurse is reinforcing teaching with a female client who requests information about how to lose weight. Which of the following statements should the nurse make?

keep fat intake to no more than 30 percent of your daily caloric intake

A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

lack of change in the pupil size when the client looks form a far to near object.

A nurse is positioning a client who is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

lateral recumbet Rationale: The nurse should assist the client into the lateral recumbent position for a lumbar puncture to ensure the proper placement of the needle.

A nurse is speaking with the partner of a client who has Alzheimer's disease. The partner states, "l love him, but caring for him is wearing me out." Which of the following responses should the nurse make?

lets discuss how caring for your partner is affecting your health

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

maintain a sequential compression device..

A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?

maintain the drainage below the level of the clients chest.

A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider?

metoprolol ER 50mg per NG tube BID Rationale: The nurse should clarify the prescription for metoprolol ER with the provider because it is an extended-release tablet. The nurse should not crush extended-release medication because parts of the medication dissolve at variable rates and the client can receive an overdose of the medication in a short period of time.

A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?

my son took my wallet so he can keep track of what i'm spending

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

obtaining clients vital signs prior to discharge

A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?

offering general leads Rationale: Offering general leads is therapeutic and will enhance positive interaction with the client because it demonstrates to the client that the nurse is listening and is interested in what the client is sharing.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

open the outer package flap of the catheterization kit away form the body

A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?

perform Kegel exercise daily Rationale: The nurse should instruct the client to perform Kegel exercises to promote the control of urine flow and reduce incontinence.

A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

perform a fundal massage for the client

A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?

place the client in a 30 lateral position

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

place the client in a lateral position

A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?

place your baby's crib away form heat vents

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider?

platelet count of 95,000 Rationale: The nurse should recognize that this platelet count is below the expected reference range for a client who is pregnant and might be indicative of HELLP syndrome. Other manifestations of HELLP syndrome include malaise and epigastric pain. The nurse should immediately notify the provider of this result.

A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

poor lighting in the learning setting Rationale: The nurse should recognize that the physical learning setting is an external factor that can affect the participants' learning ability. Environmental factors that affect learning include lighting, comfort of seating, and the temperature of the room.

A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?

prepare a new dose of insulin injection

A nurse is receiving change-of-shift report for a group Of clients. The nurse should plan to implement which Of the following time-management strategies?

prepare a priority list of client needs for the shift

A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?

purchase beef that is a loin cut

A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?

putting a glove on their dominant hand first. Rationale: The nurse is demonstrating sterile technique when they put a glove on their dominant hand first. Using the dominant hand to apply the second glove helps prevent contamination because the nurse's dominant hand is more likely to have better dexterity than their nondominant hand.

A nurse manager is providing an in-service on hand hygiene to assistive personnel. Which of the following information should the nurse manager include in the in-service?

remove rings when washing hands with soap and water

A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis (CF). Which of the following findings is the priority for the nurse to report to the provider?

report lack of appetite Rationale: The nurse should identify that the greatest risk to a child who has a decreased appetite is pulmonary infection. Anorexia, along with other manifestations, such as loss of weight and lethargy, are commonly seen in children who have CF with an infection exacerbation. Typical manifestations of pulmonary infection, such as fever and tachypnea, might not be seen in a child who has CF. Additionally, a child who is anorexic is at increased risk for diminished lung function.

A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

report the situation to the provider who obtained informed consent.

A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which Of the following actions should the nurse take?

report the suspected abuse to the appropriate agency

A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity?

scan the client facility identification band.

A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?

separate the Childs used washcloth form those of others.

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

take up to three tablets during a single angina episode. Rationale: The nurse should instruct the client to take up to three doses of the nitroglycerin, 5 min apart, if chest pain persists.

A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

the AP reports client information to the oncoming AP in the hallway. Rationale: The nurse should intervene when observing the AP reporting client information in the hallway because it is a breach of client confidentiality.

A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

the child was born at 34 weeks of gestation Rationale: The nurse should identify that children born prematurely are at an increased risk for physical maltreatment. This increased risk is due to possible impairment of bonding during infancy and an increased need for care due to medical concerns as a result of their premature delivery.

A nurse is reinforcing teaching with a client about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

the client attempts to elevate the cylinder by inhaling deeply Rationale: This is the correct action by the client. The cylinder should be elevated by the client inhaling deeply.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which Of the following findings should the nurse notify the provider?

the client has absent bowel sounds

A nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?

the facility has 12% fewer urinary tract infection over the past 6 months.

A nurse is reinforcing teaching with a client who has left-sided weakness and is learning how to ambulate with a cane. The nurse should identify that the client understands the teaching when the client places the cane in which of the following positions when advancing forward? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

the foot on your right side. B is correct. The client should hold the cane on the stronger side of the body: in this scenario. it would be in the right hand. When ambulating forward, the client should move the cane forward first (in front of right foot) and then advance the weaker leg forward next so that the client's body weight is evenly distributed between the cane and stronger leg.

A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

the nurse administered insulin lispro to a client who has diabetes mellitus and is NPO

A nurse is reinforcing teaching with a client who has tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching?

the people i live with should be tested for TB

A nurse is reinforcing teaching with a client who is scheduled for a barium enema. Which of the following statements should the nurse make?

this procedure uses diagnostic imaging to locate and obstruction Rationale: The nurse should reinforce with the client that a barium enema uses fluoroscopy, which is a type of diagnostic imaging, to locate and identify tumors or other causes of a bowel obstruction.

A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

tomatoes. Rationale: They are high in vit C apricots= vit A avocados= vit E Carrots= Vit A

A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following actions should the nurse plan to take?

use one finger to insert the suppository past the anal sphincters

A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching?

walk for 1-2 hrs each day. Rationale: The nurse should instruct the client to walk for at least 1 to 2 hr per day after surgery to promote venous return.

A school nurse is having a conversation with the parents of an adolescent. The nurse should identify which of the following situations as an ethical dilemma for the parents?

we cant decide whether to try homeschool our child or move them to a private school

A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

wear a surgical mask within 3 feet of the client.

A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?

where is your pain located

A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

wipe the drainage port with an antiseptic wipe after emptying urine form the bag

A nurse at a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?

yankeurs catheter Rationale: A Yankauer catheter is a clean suction catheter used when performing oral and oropharyngeal suctioning to remove secretions from the client's mouth to facilitate breathing or obtain a sample for diagnostic evaluation.

A nurse is reinforcing teaching with the adult children of a client who is dying. Which of the following statements should the nurse make?

you can continue talking to your prater until they are gone

A nurse is reinforcing teaching with a client who is at 20 weeks Of gestation and will undergo routine abdominal ultrasonography the following day. Which Of the following statements should the nurse include in the teaching?

you will need to have a full bladder for the procedure

A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?

you will need to schedule a bone density test. Rationale:

A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching?

you will need to take the medication for the rest of your life Rationale: Hypothyroidism is a chronic disorder that requires lifelong thyroid hormone replacement therapy. Needs to be taken 30-60 min before breakfast bc food affects the absorption level. Needs to be taken in morning bc can result in insomnia

A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not help me get better." Which of the following responses should the nurse make?

you're saying that you are doubtful that this procedure will benefit you.

A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?

your oncologist might prescribe a cold cap to war during treatment to reduce hair loss Rationale: The nurse should inform the client that cold caps cause vasoconstriction, which can help to decrease hair loss by reducing the ability of the chemotherapy medication to reach the hair follicles.

A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

your weight gain should be the same as for someone without diabetes