Comprehensive 1

According to the principals of triage, which of the following clients requires immediate nursing intervention during a mass casualty disaster?

A middle aged adult client who has a sucking chest wound

When assessing a newborn's HR, the nurse should:

Auscultate th apical pulse and count beats for at least 1 full minute

A nurse is assessing a client every 15 minutes during the immediate postpartum period. Which of the following findings requires immediate action by the nurse?

Boggy uterus

A nurse is providing CPR for an infant. When performing a pulse check, the nurse should assess the infant's pulse at which of the following sites?

Brachial

A nurse is assessing a newborn's reflexes. Identify the area the nurse should touch the infant to elicit the Babinski sign.

Foot

A nurse educator in a medical surgical unit is conducting an orientation class for a group of newly licensed nurses. Which of the following questions by one of the newly licensed nurses requires further teaching?

How should I document on the MAR if I give a medication IV bonus that is prescribed orally?

A nurse is providing education to the parent of a child who has asthma. Which of the following statements by the parents indicates a need for further teaching?

I will keep my child from participating in sports

A nurse is admitting a child from the emergency department who has a fever and fluid filled vesicles on the trunk and extremities. Which of the following nursing interventions is the highest priority?

Implement transmission based precautions

A nurse is providing postmortem care for a client who previously consented to donate his organs. Place the following steps used during postmortem care in the correct order.

Notify organ team Collect specimens Remove tubes and vascular device Cleanse body

A nurse is caring for a client who requires an alternative communication method. Which of the following is an appropriate intervention by the nurse?

Suggest that a postoperative laryngectomy client use a pad and pencil to write out her requests

When assessing a multiparous client following a vacuum-assisted birth, the nurse should be alert for which of the following possible complications?

Cervical lac

A nurse is caring for a client who has an in dwelling urinary catheter and a closed abdominal surgical incision that requires dressing changes twice daily. Which of the following actions should the nurse take?

Change gloves between cleansing the catheter and changing the dressing

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

Clang associations

A school age child is brought to the emergency department with scald burns to both hands and wrists. The nurse suspects abuse. Which of the following actions ensures that the nurse's legal responsibility has been met?

Contacting the designated state agency about her suspicion

A nurse is caring for a client following an EGD. Which of the following findings should the nurse report to the provider?

Cool, clammy skin

A nurse is caring for a client who has a fractured ankle. The nurse has been applying ice packs to the client's ankle rotating on and off 20 minutes for 24hrs. Which of the following findings should the nurse report to the provider?

Cyanosis of nail beds

A nurse is admitting an adolescent client for treatment of depression. The client's parents report that the client has been making jokes about committing suicide. Which of the following questions is appropriate for the nurse to ask the client?

Do you have a plan to hurt yourself?

A nurse is caring for a client who is in active labor and is receiving oxytocin. The FHR pattern shows variability with accelerations. Which of the following is an appropriate nursing response?

Document and continue to monitor

A nurse is assessing a client who is 1 day post operative hip arthroplasty. Which of the following findings is the priority to report to the provider?

Dressing is saturated with sanguine out drainage

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 caring for a client who has fractured femur and is being discharged from the hospital with crutches. The nurse should teach the client and family to

Ensure that rubber tips are securely in place on the bottom of the crutches

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

Explain to the client the purpose for this legal requirement

A nurse is performing an admission assessment on a client with a recent positive pregnancy test. According to Nagele's rule, what should be this client's due date if the first day of her period was May 8?

Feb 15

A nurse is assessing an older client who has delirium. Which of the following is an expected finding?

Fluctuating level of consciousness

A nurse is caring for a client in the emergency department who is being transported to surgery when the nurse realizes the informed consent has not been signed. The client speaks Spanish and does not understand the nurse when she speaks. Which of the following actions is appropriate for the nurse to take?

Have an official interpreter provide translation

A nurse is caring for a client who requests pain medication. The nurse notes that morphine 1 mg is prescribed IV every 2 - 4 hours. The medication is available in a pre filled syringe dose of 2mg/mL. During preparation of the medication, which of the following is a correct action by the nurse?

Have another nurse observe wasting the unused portion

A client in the first trimester of pregnancy is being seen in the clinic for her monthly visit. She has been using an adjustable band with a bead that applies pressure to the P6 meridian on her wrists. Which of the following statements by the client indicates that this therapy is having the desired effect?

I have not vomited for the past two weeks

A nurse is providing discharge instructions to a client who has a new prescription for warfarin. WShich of the following client statements indictes an understanding of the teaching?

I should report a change in the color of my stools

During admission, a nurse asks a middle adult client if he has advanced directives. Which of the following responses by the client indicated an understanding of advanced directives?

I will designate my wife as my durable power of attorney

A nurse is providing discharge teaching to a client diagnosed with AIDS. Which of the following statements by the client indicates a need for further instructions?

I will work for short periods of time in the garden for relaxation

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

Jaundice

A nurse providing care to a client who has rheumatoid arthritis. Which of the following should the nurse suggest to manage the client's symptoms?

Apply cold therapy to edematous joints

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

Arrange the lunch tray for a client with a hip fracture

A nurse educator is reviewing indications for Rh 0(D) immune globulin administration with a group of newly hired nurses. Which of the following client's should receive this medication?

As O- woman following a spontaneous abortion

A newly licensed nurse is assigned a client who has a chest tube. The nurse expresses concern about her limited experience with monitoring chest tube drainage to the charge nurse. Which of the following actions should the charge nurse take first to provide teaching about chest tubes?

Ask the nurse about her knowledge of the procedure

A client who had a recent CVA is admitted to the nursing unit. Prior to transferring the client to the bedside commode, the nurse should do which of the following first?

Assess the client for functional limitations

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

Avoid venipuncture when possible

A nurse is caring for a client who has iron-deficiency anemia and elevated cholesterol. The nurse evaluates that the client is meeting nutritional needs and maintaining dietary restrictions when the client selects which of the following foods?

Black beans

A nurse is caring for a newborn whose parent asks why her baby is recieving vitamin K. The nurse should explain to the parent that the medication will prevent which of the following?

Bleeding

A nurse recognizes that a provider's prescription is inappropriate for a client. The nurse questions the provider about the prescription, but the provider insists that the nurse follow the order as written. Which of the following actions should the nurse take?

Bring the issue to the charge nurse's attention

A nurse is developing a care plan for a client who is immobile. Which of the following interventions should be included?

Maintain correct body alignment with the use of trochanter rolls

A nurse is caring for a newborn with respiratory distress syndrome. Which of the following interventions is the highest priority?

Maintain normal body temp

An older adult client with limited mobility resides in a long term care facility. The client asks the nurse why he has a hand roll in each hand. The nurse explains which of the following as being the purpose of the hand roll?

Maintains a functional position

A nurse is orienting a newly licensed nurse. Which of the following actions by a newly licensed nurse represents a breach of client safety?

Taking a blood pressure cuff used for a client with VRE and using it on another client

A s a part of the discharge instructions for the parent of a newborn, the nurse is reviewing information about measures to prevent sudden infant death syndrome (SIDS). WHich of the following statements by the parent indicates a need for further instruction?

My baby should not have the DTP vaccine because of the ricks of SIDS

A nurse is teaching a client who has a prescription for digoxin about the manifestations of toxicity. Which of the following findings should the nurse include in the teaching?

Nausea

A nurse assessing a client after administering epinephrine for an anaphylactic reaction. The nurse should monitor the client for with of the following adverse effects of this medication?

Reports of chest pain

A nurse is caring for a client who has undergone an open procedure for a ruptured appendix 48hrs ago. Which of the following assessment findings should be immediately reported to the provider?

Rigid, board-like abdomen Absent bowel sounds Temp 102.6 WBC 21,500

A nurse is developing a client education program about osteoporosis for older adults. In his instruction, the nurse should identify which of the following as a risk factor for osteoporosis?

Sedentary lifestyle

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

Serum liver enzyme levels

A nurse is providing teaching for a client who has a new prescription for chlorpromazine. Which of the following should the nurse include in the teaching?

Sip fluids frequently throughout the day

A nurse is caring for a client who is 6 days postoperative following a colon resection. The client tells the nurse " I feel like my stomach just split open" The nurse notes a protrusion of the bowel through the open wound.

Stay, call for help Place saline soaked dressing Place in supine Take vitals

A nurse is caring for a client who has a track tube following a laryngectomy. Which of the following actions should the nurse take when auctioning the client's airway?

Pass the catheter no more than 3 consecutive times

A nurse is caring for a client who is recieving an hourly infusion of 0.9% NSS IV. The client has a new prescription for cefazolin IV 1 gram to infuse over 30 min. Which of the following actions should the nurse take when infusing IV cefazolin?

Piggyback the cefazolin into the infusion

A nurse is assessing a client who is near the end of her first trimester during a routine prenatal exam. When checking to determine if the fetal HR can be detected, the nurse should:

Place the scope midline just above the symphysis pubis and apply firm pressure

A client has weakness of the left leg due to a CVA. The client has been given a quad cane to assist with walking. Which of the following actions by the client requires correction by the nurse?

Places the cane on the ineffective side of the body

A nurse is caring for a client who is at risk for developing diabetes insipidus. The nurse should plan to monitor the client for which of the following?

Polyuria

A nurse is caring for multiple clients in an antepartum clinic. For which of the following client's should the nurse plan to perform FHR monitoring?

Premature ROM Decreased fetal movement Gestational hypertension

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions is appropriate for the nurse to recommend?

Provide a diet high in protein

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 indentification?

Verify the client and blood product information with another licensed nurse

A nurse is caring for a client who is undergoing radiation therapy. The nurse notes a large area of dry, shiny red skin over the client's neck and clavicular area. Which of the following instructions regarding skin care should the nurse give the client?

Wash the area with mild soap and water

After attempting to conceive unsucessfully for more than a year, a couple presents to an infertility clinic for assessment. Which of the following is an appropriate suggestion by the nurse to help this couple cope with prolonged infertility?

Would you like some information about support groups

A nurse is assessing a client who is recently widowed. The client states " I don't know what to do without my wife. Life is just not worth living" Which of the following is an appropriate response by the nurse?

You seem to be having a difficult time right now

A nurse is caring for a client who is in labor at 39 weeks gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following is the appropriate action for the nurse to take?

continue to observe the fetal HR

A nurse is planning to teach a client who is to start a new prescription for fluoxetine. For which of the following should the nurse instruct the client to monitor and report to the provider?

Tremors

A nurse is caring for a client who is receiving oxytocin for a labor induction and notes frequent variable decelerations. Which of the following actions should the nurse take first?

Turn the client on her left side

A nurse is providing IV therapy for a group of client's. Which of the following events requires completion of an incident report?

An IV pump delivers an inadequate dose of medication.

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

An older adult client who is confused and is attempting to pull out his IV line

A nurse is assessing a client who has theophylline toxicity. Which of the following is an expected finding?

Anorexia

A nurse is assisting with the orientation of a newly licensed nurse who is caring for a client. The client is recieving enteral feedings through an NG tube. Which of the following actions by the newly licensed nurse indicates a need for further teaching?

Adds 3 mL of blue dye to each bag of tube feeding

A nurse is caring for a client who has a hip fracture and is in Buck's traction. Which of the following actions by an assistive personnel requires intervention by the nurse?

Adjusting the client's hanging weights

A nurse is caring for a client who is scheduled for an IV pyelogram the next day.Which of the following actions is appropriate for the nurse to take?

Administer a laxative

A nurse is caring for a toddler following a tonsillectomy. Which of the following nursing interventions is appropriate?

Administer pain medication on a regular schedule for the first postoperative day.

A nurse is evaluating an client who is taking chlorpromazine. Which of the following findings indicates that the medication is effective?

Decreased hallucinations

A nurse is planning care for a toddler who has failure to thrive. Which of the following strategies should the nurse include in the plan of care?

Develope a structured routine

A client who has impaired vision is discharged home. Which of the following actions indicates that the client's family understands safety measures to prevent injury?

Marks step edges with colored tape

A nurse is caring for a client who has fluid volume overload. Which of the following tasks can be delegated to an AP?

Measure the client's vital signs

A nurse is caring for a group of client's in a community mental health clinic. Which of the following therapy groups is appropriate for the nurse to lead?

Medication education group