Definitely not ATI - RN Comprehensive Online Practice 2019 A

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? Initiate the referral at the time of discharge. Have the client contact a physical therapist when feeling ready to begin therapy. Verify that insurance will pay for outpatient physical therapy. Involve the client in selection of a physical therapy provider.

Involve the client in selection of a physical therapy provider. The nurse should involve the client in the referral process, including selection of the physical therapist and the location. --- The nurse should initiate the referral as soon as possible after identifying the need. Waiting until the time of discharge can delay the client's recovery. Instructing the client to contact a physical therapist when feeling ready can significantly delay recovery. The nurse should initiate the referral as soon as possible after receiving a prescription from the provider. The nurse should notify the case manager or social worker of the prescription for physical therapy. They will search for providers that are willing to take the client's insurance and report to the nurse which facilities the client can consider. The client can then choose from that selection of providers.

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? Bradycardia Low back pain Hypertension Distended jugular veins

Low back pain The nurse should expect low back pain in a client who is having a hemolytic transfusion reaction. --- The nurse should expect tachycardia, rather than bradycardia, in a client who is having a hemolytic transfusion reaction. The nurse should expect hypotension, rather than hypertension, in a client who is having a hemolytic transfusion reaction. The nurse should expect distended jugular veins in a client who has circulatory overload, rather than in a client who is having a hemolytic transfusion reaction.

A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? Give an antiemetic 30 min after medication administration. Monitor blood glucose levels. Maintain hydration with liberal fluid intake. Monitor for tumor lysis syndrome.

Maintain hydration with liberal fluid intake. The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication. --- The nurse should administer an antiemetic 30 min before administration of the medication to decrease gastrointestinal effects. Cyclophosphamide does not affect blood glucose levels. Tumor lysis syndrome can occur in clients who are diagnosed with acute lymphoblastic leukemia, not neuroblastoma.

A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? Propranolol Phenytoin Lorazepam Mannitol

Mannitol The client should receive mannitol, an osmotic diuretic, to reduce intracranial pressure caused by cerebral edema. --- A client should receive propranolol, a beta blocker, to decrease blood pressure. A client should receive phenytoin, an antiepileptic, to prevent seizures. A client should receive lorazepam, a short-acting sedative, to manage discomfort and agitation.

A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? Mark the edges of stairs for contrast. Cover exposed extension cords with throw rugs. Use 40-watt bulbs in lighting fixtures. Instruct the client to obtain vison testing once every other year.

Mark the edges of stairs for contrast. Marking the edges of stairs with paint or colored tape for contrast can help older adult clients who have impaired vision prevent injury by decreasing the risk of falls. --- Extension cords should be removed from high-traffic areas in the home and placed along the edges of walls. Placing cords under throw rugs can increase an older adult client's risk for falls. The nurse should ensure that an older adult client's home has adequate lighting. This includes the use of light fixtures that use at least 75-watt bulbs to optimize the client's visibility. The nurse should instruct older adult clients to receive vision testing at least once each year. For a client who has impaired vision, it might be necessary for the nurse to recommend vision testing more often.

A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? Administer oxygen. Initiate an infusion of oxytocin. Massage the uterus to expel clots. Obtain a CBC.

Massage the uterus to expel clots. Using the evidence-based practice approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding. --- The nurse should administer oxygen to improve gas exchange. However, there is another action the nurse should take first. The nurse should initiate an infusion of oxytocin to promote uterine contractions. However, there is another action the nurse should take first. The nurse should obtain a CBC to monitor the status of the client. However, there is another action the nurse should take first.

A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? Measure the client's vital signs. Reposition the client. Encourage the client to use an incentive spirometer. Administer pain medication.

Measure the client's vital signs. The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4 hr for the next 48 hr. --- The nurse should reposition the client every 2 hr to prevent postoperative complications such as atelectasis. However, there is another action the nurse should take first. The nurse should encourage the client to turn, cough, deep breathe, and use an incentive spirometer every 2 hr for 24 hr to increase lung expansion and prevent pneumonia. However, there is another action the nurse should take first. The nurse should administer pain medication on a regular schedule for the first 48 hr for a client who is postoperative and has vital signs within the expected reference range following a total vaginal hysterectomy. However, there is another action the nurse should take first.

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

Nausea The nurse should instruct the client to monitor for and report manifestations of digoxin toxicity, such as nausea, anorexia, abdominal pain, bradycardia, and visual changes. --- The nurse should inform the client that diarrhea, rather than constipation, is a manifestation of digoxin toxicity. The nurse should inform the client that wheezing is a manifestation of anaphylaxis, not digoxin toxicity. The nurse should inform the client that muscle weakness, rather than rigidity, is a manifestation of digoxin toxicity.

A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? Contact the triage officer. Implement the client tracking system. Ask the communications officer to release a press statement. Notify the incident commander.

Notify the incident commander. The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order. --- Contacting the triage officer is important to ensure personnel are available to evaluate incoming clients. However, this is not the first action to take when implementing an emergency preparedness plan. Implementing the client tracking system is important for making client room assignments and informing family members. However, this is not the first action to take when implementing an emergency preparedness plan. Asking the communications officer to release a press statement is important to inform the public. However, this is not the first action to take when implementing an emergency preparedness plan.

A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? Abdominal striae Masklike face Nystagmus Ptosis

Nystagmus Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis. --- Abdominal striae are a manifestation of Cushing's syndrome. Masklike face is caused by rigidity of the facial muscles and is a manifestation of Parkinson's disease. Ptosis is the drooping of the upper eyelids due to a decreased level of acetylcholine and is a manifestation of myasthenia gravis.

A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Obtain the client's blood pressure before the nurse administers medication. Initiate a referral with a dietitian for the client. Inform the client about the adverse effects of the medication. Recommend a salt substitute to the client.

Obtain the client's blood pressure before the nurse administers medication. The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of function for an AP. --- Initiating a referral with a dietitian requires assessment skills and is the role of the nurse. This is outside the range of function for an AP. Informing the client about the adverse effects of a medication is the role of the nurse and is outside the range of function for an AP. Recommending a salt substitute to the client is the role of the nurse and is outside the range of function for an AP.

A nurse is preparing to perform an intermittent urinary catheterization for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use? https://nextgen.atitesting.com/student/images/rn_ca_2013_formb_4a-70a.jpg https://nextgen.atitesting.com/student/images/rn_ca_2013_formb_4a-70b.jpg https://nextgen.atitesting.com/student/images/rn_ca_2013_formb_4a-70c.jpg https://nextgen.atitesting.com/student/images/rn_ca_2013_formb_4a-70d.jpg

Option 4: This is a straight urinary catheter, which should be used to perform an intermittent catheterization for a client who has urinary retention. --- This is an indwelling urinary catheter, which should be used for continuous urinary drainage. This is a three-way urinary catheter, which should be used for continuous bladder irrigation. This is a specimen catheter, which should be used to obtain a sterile urine specimen.

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? Liver Oranges Chicken Red wine

Oranges A client who is prone to uric acid calculi formation can eat citrus fruits. --- A client who is prone to uric acid calculi should avoid eating organ meats, which contain purine. A client who is prone to uric acid calculi should avoid eating chicken, which contains purine. A client who is prone to uric acid calculi should avoid consuming red wines, which contain purine.

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 Organizing an immunization campaign Identifying the specific roles of disaster workers Conducting home visits to identify health hazards

Performing a rapid needs assessment Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage. --- The nurse should assist in the organization and implementation of an immunization campaign during the prevention stage of a disaster management plan. Other tasks include preventing, treating, or containing disease. The nurse should identify the specific roles of disaster workers during the preparedness stage of a disaster management plan. This assists nurses to be aware of the expectations and responsibilities of ancillary team members. The nurse should conduct home visits to identify health hazards during the recovery stage of a disaster management plan. Other tasks include identifying a lack of safe shelter or clean water and any other potential hazards that result from the disaster.

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 Bright red vaginal bleeding Hyperactive deep-tendon reflexes Fundal height of 40 cm

Persistent uterine contractions The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding. --- The nurse should expect a client who has placenta previa to experience a relaxed uterus and bright red vaginal bleeding. With abruptio placentae the nurse should expect to find dark red vaginal bleeding. The nurse should expect a client who has preeclampsia to have hyperactive deep-tendon reflexes. The nurse should expect a client who has placenta previa to have a fundal height that is greater than expected gestational age.

A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? Allow the newborn to breastfeed temporarily. Relieve pressure by expressing milk daily. Place ice packs on the breasts for 15 min several times per day. Sleep with a loose-fitting bra to prevent nipple stimulation.

Place ice packs on the breasts for 15 min several times per day. The client should place ice packs on the breasts to reduce swelling and relieve the pain caused by engorgement. --- The nurse should instruct the client to avoid nipple stimulation, because it increases milk production, leading to engorgement. The nurse should instruct the client to avoid expressing milk to prevent further milk production, because this can lead to engorgement. The client should wear a tight-fitting, supportive bra or breast binder to decrease the discomfort caused by engorgement.

A nurse is caring for a child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into child's mouth. Place the child in a side-lying position. Administer rescue breaths until the seizure subsides. Obtain an ECG during the seizure.

Place the child in a side-lying position. The nurse should place the child in a side-lying position during a seizure to maintain a patent airway, decrease the risk of aspiration, and facilitate drainage of oral secretions. --- The nurse should not insert any objects into the child's mouth while the child is experiencing a seizure. The nurse should administer rescue breaths following a seizure if the child does not begin to have spontaneous respirations. The nurse should obtain the child's vital signs following a seizure. The child might need to have an ECG or an electroencephalogram (EEG) following the seizure for further evaluation.

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. Dampen the skin before applying the skin barrier and ostomy pouch. Place the skin barrier over the stoma and hold it for 30 seconds. Cut the skin barrier opening 0.6 cm (0.25 in) larger than the stoma.

Place the skin barrier over the stoma and hold it for 30 seconds. The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. --- The nurse should cleanse the skin at the stoma site using a washcloth and warm water to reduce the risk of skin irritation. The nurse should thoroughly dry the skin around the stoma using a patting motion before applying the skin barrier to ensure the pouch adheres to the client's skin. The nurse should cut the skin barrier opening no more than 0.3 cm (0.13 in) larger than the stoma to reduce the risk of skin irritation.

An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? Uses a draw sheet to move the client to the left side of the bed Raises the total height of the bed to waist level Places a pillow under the client's right arm Lowers the side rails on the left side of the bed

Places a pillow under the client's right arm. The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder. --- Using a draw sheet to move the client reduces friction, which protects the client's skin, reduces workload, and prevents injury to the nurse and the AP. Raising the height of the bed to waist level prevents injury by positioning the bed at the nurse's and the AP's center of gravity. Lowering the side rails on one side of the bed prevents the nurse and the AP from straining their bodies. The opposite side rail should remain up to promote client safety.

A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? Uric acid crystals Protein WBCs Nitrites

Protein A client who has glomerulonephritis has increased glomerular permeability, which allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the urinalysis report. --- The presence of uric acid crystals in the urine is an expected finding for a client who has urolithiasis. The presence of WBCs in the urine is an expected finding for a client who has a lower urinary tract infection, cystitis, or pyelonephritis. The presence of nitrites in the urine is an expected finding for a client who has a urinary tract infection.

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. Ask staff members to participate in a trial of the new scheduling system. Encourage staff to offer alternate scheduling solutions. Develop goals to implement the new scheduling system.

Provide information about scheduling issues to the staff. The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary. --- Participating in a trial implementation of the new schedule is a component of the moving stage of change. Encouraging staff to offer alternate scheduling solutions is a component of the moving stage of change. Involving staff members in the change will make them feel included and less resistant to the new schedule. Developing goals and objectives to implement the new schedule is a component of the moving stage of change.

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? Carotid bruit Tracheal deviation Pulsus paradoxus Heart murmur

Pulsus paradoxus The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension. --- The nurse should expect to hear a carotid bruit when assessing a client who has atherosclerosis. The nurse should expect to assess tracheal deviation in a client who has a pneumothorax. The nurse should expect to auscultate muffled heart sounds, which are an expected finding of cardiac tamponade, along with fatigue and dyspnea.

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? Projecting blame Excessive clinging Rapid speech Social awkwardness

Rapid speech Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns. --- Clients who have paranoid personality disorder project blame Clients who have dependent personality disorder demonstrate excessively clinging behavior. Clients who have schizotypal personality disorder exhibit social awkwardness.

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. (Placing the steps in the selected order of performance. Use all the steps.) Clean the stoma with 0.9% sodium chloride irrigation. Remove the inner cannula. Change the tracheostomy collar. Remove the soiled dressing.

Remove the inner cannula. Remove the soiled dressing. Clean the stoma with 0.9% sodium chloride irrigation. Change the tracheostomy collar. When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the soiled dressing and then clean the stoma with 0.9% sodium chloride irrigation. Finally, the nurse should instruct the parent to change the tracheostomy collar.

A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first? Ask a social worker to identify the client's insurance eligibility for rehabilitation services. Request a referral for the client to receive physical therapy. Arrange for the delivery of prescribed medications to the client's home. Provide the client with a list of community resources.

Request a referral for the client to receive physical therapy. The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for physical therapy. --- The nurse should ask a social worker to determine the client's insurance eligibility for rehabilitation services to enable continuity of care closer to the time of discharge. However, there is another action the nurse should take first. The nurse should arrange for the delivery of prescribed medications to the client's home to ensure the client has the medications available. However, there is another action the nurse should take first. The nurse should provide the client with a list of community resources once the health care team establishes which services will be used for rehabilitation. However, there is another action the nurse should take first.

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? Open the top outer flap of the package toward the body. Clean the penis with the nondominant hand. Don sterile gloves after opening the lubricant packet. Set the catheter tray on the overbed table at waist height.

Set the catheter tray on the overbed table at waist height. To maintain sterility, the nurse should place the catheter tray on a work surface at or above waist level. --- The nurse should open the top outer flap away from the body to prevent contamination of the sterile field by reaching over it when opening the remaining flaps. The nurse should clean the penis with the dominant hand. The nurse should don sterile gloves before touching any of the items in the sterile field.

A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? Stroke the infant's cheek. Depress the infant's tongue. Turn the infant's head to one side. Tap on the bridge of the infant's nose.

Stroking the infant's cheek. The nurse should stroke the infant's cheek to assess the rooting reflex, which should cause the infant to turn towards that side and suck. --- The nurse should depress the infant's tongue to assess the extrusion reflex, which should cause the infant to stick out the tongue. The nurse should turn the infant's head to one side to assess the asymmetric tonic neck reflex, which should cause the infant to extend her arm and leg on that side and flex her arm and leg on the other side. The nurse should tap on the bridge of the infant's nose to assess the glabellar reflex, which should cause the infant to close her eyes tightly.

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? Displacement Regression Suppression Sublimation

Sublimation The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior. --- Displacement occurs when a client transfers emotions of a particular situation to another nonthreatening situation. Regression occurs when a client reverts to a childlike pattern of behavior that might have been exhibited previously. Suppression is the denial of a disturbing feeling or situation.

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? Wheezes Tachycardia Restlessness Substernal pain

Substernal pain The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased work of breathing, such as in a preschooler who has cystic fibrosis. --- Clients who develop oxygen toxicity are more likely to have crackles and substernal chest pain than wheezes. Tachycardia indicates the client has hypoxemia, is working hard to obtain oxygen, and requires oxygen therapy. Restlessness indicates the client has hypoxemia, is working hard to obtain oxygen, and requires oxygen therapy.

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? Give the client a choice of foods and beverages. Supervise the client during and after eating. Encourage casual conversation about food during meal times. Provide opportunities for the client to choose their own meal times.

Supervise the client during and after eating. The nurse should monitor the client during and for 1 hr after meals to prevent the client from hiding food or purging. --- The nurse should offer the client a structured meal plan to ensure appropriate caloric intake and adequate nutrition. The nurse should encourage conversation that does not focus on the theme of food during meal times. The nurse should emphasize eating as a social activity. The nurse should establish specific meal times as part of a structured meal plan.

A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? Apologize to the client for the nurses' actions. Advise the nurses that they are being insubordinate. Tell the nurses to stop the discussion. Document the incident in the client's medical record.

Tell the nurses to stop the discussion. The nurses are violating client confidentiality by having the discussion in a public hallway. The charge nurse should tell the nurses to stop the discussion to prevent any further breach of confidentiality. --- The charge nurse should not discuss the nurses' actions with the client. The nurse should report the situation to the nursing supervisor to investigate and take further action. The nurses are not committing insubordination, because insubordination occurs when an employee disobeys a person in authority such as a manager or supervisor. If the nurse needs to report the incident, the nurse should do so on an incident report, which is not included in the client's medical record.

A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? Temperature 39.4° C (102.9° F) Headache Constipation Dry mouth

Temperature 39.4° C (102.9° F) The greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temperature, dysrhythmia, decreased level of consciousness, and a labile blood pressure. Therefore, the priority finding for the nurse report to the provider is a fever. --- Headache is a common adverse effect of chlorpromazine. The nurse should report the client's headache to the provider and request analgesia. However, another finding is the priority for the nurse to report. Constipation is a common adverse effect of chlorpromazine. The nurse should encourage the client to increase fiber and fluid intake as well as their activity level. However, another finding is the priority for the nurse to report. Dry mouth is a common adverse effect of chlorpromazine. The nurse should encourage the client to chew sugarless gum to help moisten the mouth. However, another finding is the priority for the nurse to report.

A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? Contractions will be felt primarily in the upper abdomen. The cervix transitions to an anterior position. Contraction intensity decreases with ambulation. The cervix progressively thickens.

The cervix transitions to an anterior position. In true labor, the cervix transitions to an anterior position and begins to dilate in preparation for birth. --- In true labor, the client should feel contractions primarily in the lower abdomen and back. In true labor, contraction intensity increases with ambulation. In true labor, the cervix progressively shortens and thins.

A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? The client needs assistance when transferring from the bed to a wheelchair. The client will have a visit by a home health nurse tomorrow. The client's partner will bring clothes for the client to change into prior to discharge. The client often needs encouragement to engage in personal hygiene activities.

The client needs assistance when transferring from the bed to a wheelchair. The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers. --- This information is important for the nurse to communicate because it will affect the client's care at home. However, this is not the priority information for the nurse to communicate. This information is important for the nurse to communicate because it concerns the client's preparation for discharge. However, this is not the priority information for the nurse to communicate. This information is important for the nurse to communicate because it can affect the care the nurse gives the client. However, this is not the priority information for the nurse to communicate.

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 reports leg itching under the cast around the mid-upper thigh area. The client reports increased pain when the leg is lowered below the level of the heart. The client's cast became wet during a sponge bath. The client's heel is reddened and tender.

The client's heel is reddened and tender. The greatest risk to this client is injury from a pressure injury. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel. --- The client is at risk for dry, itching skin so the nurse should offer the client a hair dryer to use on the cool setting to blow air on the skin to relieve the itching. However, there is another finding that is the priority. The client is at risk for swelling that can cause pain when the leg is in the dependent position so the nurse should elevate the client's leg to reduce edema and pain. However, there is another finding that is the priority. The client is at risk for skin breakdown caused by a wet cast so the nurse should make sure the cast is completely dry to reduce the risk of skin breakdown. A fiberglass cast is waterproof, and water will not affect the integrity of the cast. However, there is another finding that is the priority.

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 nurse should intervene? While performing a breast examination, the newly licensed nurse discusses techniques of breast self-examination with the client. The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. The newly licensed nurse uses a penlight to assess for changes in the contour of the body. The newly licensed nurse uses the dorsal surface of the hand to assess skin temperature.

The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. The newly licensed nurse should record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment. --- Discussing self-examination techniques with the client while performing the breast examination provides the opportunity to demonstrate correct technique. The newly licensed nurse should use a penlight to provide adequate lighting when assessing contours. The newly licensed nurse should use the dorsal surface of the hand to assess skin temperature because it is sensitive to temperature changes.

A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? Amylase Troponin T Low-density lipoprotein (LDL) Homocysteine

Troponin T Troponin T is a myocardial muscle protein that is released into circulation after cardiac injury. The nurse should expect increases in the client's troponin level within 2 to 3 hr following a myocardial injury. --- An increase in amylase can indicate acute pancreatitis, cholecystitis, or renal failure. Elevated LDL values indicate the risk of coronary artery disease and peripheral vascular disease, which can increase the client's risk for development of a myocardial infarction; however, levels do not increase with myocardial tissue injury. Elevated homocysteine levels indicate the client is at risk for the development of ischemic heart disease, cerebrovascular disease, and peripheral vascular disease; however, levels do not increase with myocardial tissue injury.

A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO3- 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values? Uncompensated metabolic acidosis Uncompensated respiratory acidosis Compensated respiratory acidosis Compensated metabolic acidosis

Uncompensated respiratory acidosis A pH of 7.3 is below the expected reference range and indicates the client has acidosis. The PaCO2 of 54 mm Hg is above the expected reference range, which, when combined with the low pH, indicates that the acidosis has a respiratory origin. The HCO3- of 26 mEq/L is within the expected reference range, indicating that the acidosis is not metabolic in origin and the body has not yet corrected the imbalance through compensation. --- An HCO3- of 26 mEq/L is within the expected reference range. In metabolic acidosis, the HCO3- and the pH are below the expected reference range. Therefore, these laboratory values do not indicate metabolic acidosis. In compensated respiratory acidosis, the pH is within the expected reference range. The laboratory values do not indicate compensation has occurred. An HCO3- of 26 mEq/L is within the expected reference range. In compensated metabolic acidosis the HCO3- is below the expected reference range and the pH is within the expected reference range. Therefore, these laboratory values do not indicate metabolic acidosis.

The nurse should instruct the parent to place a blanket over the newborn once secure in the car seat. Blankets, coats, or heavy clothing can make it difficult to secure the shoulder harnesses tightly, leading to injury in the event of a collision. Instill chilled lavage solution into the client's NG tube. Attach the client's NG tube to low intermittent suction. Use 0.9% sodium chloride for irrigation of the NG tube. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time.

Use 0.9% sodium chloride for irrigation of the NG tube. The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube. --- The nurse should use lavage solution that is at room temperature to reduce the risk of injury to the client. After instilling the lavage solution, the nurse should manually withdraw the solution and blood from the client's NG tube. The nurse should instill the solution in volumes of 200 to 300 mL at a time to reduce the risk of injury to the client.

A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? Use hydrogen peroxide to clean kitchen surfaces. Seal nonwashable items in a plastic bag for 2 weeks. Wear a surgical mask when in public. Limit family visits to 30 min periods.

Use hydrogen peroxide to clean kitchen surfaces. The client should clean kitchen surfaces with hydrogen peroxide to kill the virus and prevent transmission. --- A client who has pediculosis capitis should seal nonwashable items in a plastic bag for 2 weeks. The client does not need to wear a surgical mask, because hepatitis A is not an airborne infection. Limiting family visits to 30 min does not reduce the risk of transmitting hepatitis A. Instead, the nurse should encourage safe food handling and appropriate hand hygiene techniques.

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? Encourage friends and family to visit the child. Withhold administering the varicella vaccine to the child. Collect a daily urine specimen from the child to check for proteinuria. Provide a low-protein diet for the child.

Withhold administering the varicella vaccine to the child. A child who has severe immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed. --- The nurse should advise limited contact with friends or family and the avoidance of crowded areas to decrease the risk of spreading infection to a child who is immunosuppressed. A child who has severe immunodeficiency should be monitored for the presence of hematuria, not proteinuria, as an adverse effect of chemotherapy. A child who has severe immunodeficiency should eat a high-calorie, high-protein diet to provide adequate nutrients to rebuild WBCs and fight infection.

A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (Select all that apply.) "A speech pathologist will be performing a swallowing study for you." "You should rest before eating a meal." "You should restrict foods that are high in vitamin D." "Reduce your intake of dietary fiber." "Thicken your beverages before drinking."

"A speech pathologist will be performing a swallowing study for you." "You should rest before eating a meal." "Thicken your beverages before drinking." The nurse should instruct the client that a swallowing study will be performed to determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. The nurse should encourage the client to rest before each meal. Clients who have multiple sclerosis often report weakness and are easily fatigued. The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. --- The nurse should instruct the client to maintain adequate vitamin D levels, because vitamin D deficiency is a risk factor for multiple sclerosis. The nurse should instruct the client to increase dietary fiber and fluids to decrease the risk of constipation, which is a manifestation of multiple sclerosis.

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 had any food cravings." "The spotting I was having has stopped." "I don't feel depressed anymore." "I have not vomited as much recently."

"I have not vomited as much recently." Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies pressure to a specific part of the body and can be used to alleviate nausea and vomiting. ---

A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? "I will make sure my 4-year-old child wears a helmet when using a skateboard." "I should have my child avoid sun exposure between 10 am and 2 pm." "I can give my 2-year-old child a whole hotdog on a bun." "When my infant is in the carrier, I will place it on a raised, flat surface whenever possible."

"I should have my child avoid sun exposure between 10 am and 2 pm." To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400. --- Guardians should prevent children who are younger than 5 years old from skateboarding because they are not able to adequately protect themselves from skateboard-related injuries. The guardians should cut a hotdog lengthwise for toddlers to prevent choking. Guardians should avoid placing carriers on raised surfaces to reduce the risk for falls.

A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? "I should administer the ear drops as soon as I remove them from the refrigerator." "I should pull the top of the ear upward and back while instilling the medication." "I should massage behind the ear after I instill the drops." "I should have my child lie on the affected side for a few minutes after I put the drops in the ear."

"I should pull the top of the ear upward and back while instilling the medication." The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back. --- The nurse should instruct the parent to allow otic medication stored in the refrigerator to warm to room temperature prior to administration to prevent dizziness and pain. The nurse should instruct the parent to gently massage the tragus on the area anterior to the ear to allow the medication to reach the entire canal. The nurse should instruct the parent to have the child remain lying on the unaffected side for a few minutes after instilling the medication to allow the medication to remain in the ear canal.

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 avoid eating smoked meat, cheeses, and ripe avocados while taking this type of medication." "I should watch for common reactions like dry mouth and constipation." "I will be at increased risk for high blood pressure while taking this medication." "I will take my daily dose of this medication every morning before breakfast."

"I should watch for common reactions like dry mouth and constipation." The nurse should reinforce that increasing dietary fiber, fluid intake, and chewing sugar-free gum can alleviate the anticholinergic effects of dry mouth and constipation. --- A client who is taking an MAOI should avoid foods that contain tyramine. Clients who are taking amitriptyline should monitor for hypotension and change positions slowly. The client should take a daily dose of amitriptyline, a tricyclic antidepressant, at bedtime to promote sleep and minimize drowsiness during the day.

A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? "I can resume my daily aspirin therapy." "I will contact my provider if my eye feels itchy." "I will bend at my knees when picking an object up off the floor." "It's okay for me to pick up my grandchild who weighs 20 pounds."

"I will bend at my knees when picking an object up off the floor." The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object. --- The client should avoid taking aspirin because of its anticoagulant effect. The nurse should instruct the client to expect eye itching and recommend the use of a cool compress to ease the discomfort of the itching. The client should avoid lifting anything that weighs more than 4.5 kg (10 lb) because it can increase intraocular pressure and damage the suture of the new lens.

A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? "You will need to draft a health care proxy so a designee can make this decision for you." "I will make sure that no one performs any lifesaving measures if your heart stops." "Your provider determines if you should have lifesaving measures if your heart stops." "I will provide you with information about medical treatment to include in your living will."

"I will provide you with information about medical treatment to include in your living will." The nurse's responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themself by providing information about what end-of-life preferences to document. --- A health care proxy is not necessary if the client is alert and able to document their own wishes in a living will. The nurse cannot ensure that no one will perform lifesaving measures unless the client has a living will, a health care proxy is in place, or if the provider has written a do-not-resuscitate order at the client's request. The provider does not decide what lifesaving measures to perform. The client decides and documents these decisions in a living will or verbally informs the provider.

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? "Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner." "Let's go on that family vacation we've got planned. We will deal with this when we return." "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." "This isn't possible. Just last week the doctor said that the cancer was responding well to treatment."

"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." By justifying the adolescent's prognosis by searching for a more personally acceptable explanation for the impending loss, the parent is using the defense mechanism of rationalization. --- By attributing the cause of the adolescent's prognosis to the provider's failure to diagnose the illness sooner, the parent is using the defense mechanism of displacement. By exhibiting a conscious denial of the adolescent's prognosis until the family returns from vacation, the parent is using the defense mechanism of suppression. By focusing on disbelieving the news about the adolescent's prognosis, the parent is using the defense mechanism of denial.

A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority? "Will my husband be able to continue as the executor of his parents' estate?" "One of my husband's coworkers visited last week to tell me my husband might lose his job." "Do you think it is necessary to postpone our daughter's wedding until my husband is feeling better?" "My husband doesn't know that I've already moved out of the house and filed for a divorce."

"My husband doesn't know that I've already moved out of the house and filed for a divorce." A lack of social support and isolation indicates the client is at greatest risk for another suicide attempt. Therefore, this is the priority concern that the nurse should report to the provider. --- The nurse should report this concern to the provider, so the provider can determine if the client has the mental capacity to function in this role. However, another concern is the priority for the nurse to report. The nurse should report this concern to the provider because unemployment is a risk factor for attempting suicide. However, another concern is the priority for the nurse to report. The nurse should report this concern to the provider because this type of event can cause additional stress to the client. However, another concern is the priority for the nurse to report.

A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? "Place your baby's car seat at a 30-degree angle." "Your baby's car seat should be rear-facing until he is 6 months old." "Swaddle your baby in a light blanket before placing him in the car seat." "Secure the retainer clip at the level of your baby's armpits."

"Secure the retainer clip at the level of your baby's armpits." The nurse should instruct the parent to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs. --- The nurse should instruct the parent to place the newborn's car seat at a 45° angle. Newborns' heads are large in proportion to their body and they do not have the muscle strength to hold their heads upright. The nurse should instruct the parent that the newborn should remain rear-facing in the back seat of the vehicle until the age of 2 or until reaching the age and weight the car seat manufacturer recommends. In a collision, this position decreases the force on the newborn's head and neck. The nurse should instruct the parent to place a blanket over the newborn once secure in the car seat. Blankets, coats, or heavy clothing can make it difficult to secure the shoulder harnesses tightly, leading to injury in the event of a collision.

A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? "If you suspect you are pregnant, stop taking this medication." "You cannot become physically dependent on this medication." "Sedation is a common adverse effect of this medication." "If you forget a dose, you can double your next dose."

"Sedation is a common adverse effect of this medication." Sedation and drowsiness are common adverse effects of methadone. Sedation most frequently occurs at the beginning of treatment or during dosage increases. --- A client can take methadone to treat opioid withdrawal symptoms during pregnancy. A client can develop physical dependency with long-term use of methadone. Methadone can cause respiratory depression. The client should not take more than the prescribed dose at any time.

A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? "Set your hot water heater temperature at or below 120 degrees Fahrenheit." "Cover your baby with a light blanket while sleeping." "Make sure the slats on the baby's crib are no more than 3 inches apart." "Place your baby's car seat rear-facing until the age of 1 year old."

"Set your hot water heater temperature at or below 120 degrees Fahrenheit." The nurse should instruct the client to set the maximum hot water temperature to no more than 49° C (120° F). The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn. --- The nurse should instruct the client that there should not be blankets, pillows, or stuffed toys in the newborn's crib. These items increase the risk for suffocation. The client should dress the newborn in a sleep sack or one-piece sleeper for naps and nighttime sleeping. The nurse should instruct the client that the crib slats should be no more than 5.7 cm (2.25 in) apart. Slats that are further apart increase the risk of injury. The nurse should instruct the client that the newborn's car seat should remain rear-facing until the age of 2 years old or the child exceeds the height and weight limit of the car seat according to the manufacturer. Maintaining a rear-facing position decreases the risk of head and neck injuries to the child in the event of a collision.

A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? "Estrogen levels decrease during pregnancy, causing the stool to become hardened." "Decreased water absorption in the intestine during pregnancy causes constipation." "The intestine absorbs iron less efficiently during pregnancy, leading to constipation." "The enlarged uterus compresses the intestines and causes constipation."

"The enlarged uterus compresses the intestines and causes constipation." During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation. --- Estrogen and progesterone levels increase during pregnancy, leading to decreased peristalsis and relaxation of the smooth muscles of the intestine, which can result in constipation. The intestine absorbs more water from the stool during pregnancy, leading to constipation. The small intestine absorbs iron more readily during pregnancy due to increased maternal needs, leading to constipation.

A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicates an understanding of the teaching? "We will let our child watch a favorite video before bed." "We should read a story together every night before bedtime." "We can let our child fall asleep in our room, and then move to her to her own bed." "We should change the bedtime to be an hour later."

"We should read a story together every night before bedtime." Preschoolers respond to rituals that prepare them for bed, such as hearing a story or taking a bath. --- The nurse should inform the parents that videos, television, or computer games provide increased stimulation, which can make it more difficult for the child to fall asleep. Allowing the child to fall asleep in the parents' room can result in sleep problems for a preschooler, such as frequent awakenings during the night along with fear and confusion when the child awakens in a different environment. Delaying the child's bedtime can prevent the child from receiving an adequate amount of sleep, which is approximately 12 hr each night for preschoolers. A lack of sleep can lead to problems such as altered behavior, hyperactivity, and poor impulse control.

A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make? "When the lesions no longer itch." "Three days after the lesions appeared." "When crusts have formed on every lesion." "When the lesions disappear."

"When crusts have formed on every lesion." The child should return to school once all the lesions have crusted over. Varicella is no longer contagious after crusts have formed on all lesions. --- Pruritus has no bearing on communicability. The child might still be contagious when pruritus subsides. Communicability is not determined by when the lesions appeared. The child does not have to wait until the lesions disappear to return to school.

A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? "You don't need advance directives now because you are competent and can make decisions for yourself." "You must wait for a period of 6 months after your diagnosis before initiating advance directives." "You will have to speak to an expert who works in the social service department." "You should complete advance directives in the event you cannot express your own wishes."

"You should complete advance directives in the event you cannot express your own wishes." The client should prepare advance directives to make their wishes known should they be unable to communicate them in the future. --- The nurse should instruct the client to complete advance directives while they are competent to make decisions. The client has the right to acknowledge their preferences regarding medical decisions, which will be effective immediately without a waiting period. The nurse has a responsibility to respond to any questions the client has about the purpose of advance directives. Informing the client about advance directives is within the scope of practice of the nurse.

A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child? "You should leave your glasses off throughout the testing." "You should stand 15 feet away from the chart." "You should get three symbols on a line correct to pass the line." "You should keep both eyes open during the testing."

"You should keep both eyes open during the testing." The nurse should instruct the child to keep both eyes open during visual acuity testing. --- The nurse should screen the child with visual correction first, then repeat the screening without visual correction. The nurse should instruct the child to stand 3 m (10 feet) away from the chart during testing. The nurse should tell the child that in order to pass a line, the child should identify four of the six symbols correctly.

A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure-sensitive valve. Which of the following information should the nurse include in the teaching? "You should flush the catheter with 0.9% sodium chloride solution daily when not using it regularly." "You should keep the catheter clamped when not in use." "You should swim twice weekly to prevent tissue from adhering to the cuff." "You should change your dressing every 10 days."

"You should keep the catheter clamped when not in use." The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled catheters have a pressure-sensitive valve that prevents blood reflux. --- The nurse should instruct the adolescent to flush the catheter daily with heparin when not using it regularly. The nurse should instruct the adolescent to restrict physical activities until the tissue adheres to the cuff. The adolescent should not participate in water sports because of the risk of infection. The nurse should instruct the adolescent to change the dressing at least every 5 to 7 days.

A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? "This type of nutrition is more effective than eating by mouth." "You will receive fingersticks for blood glucose testing." "TPN is a way to provide vitamins and minerals without increased calories." "Taking TPN can increase the risk of developing a latex allergy."

"You will receive fingersticks for blood glucose testing." A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring. --- The client should receive oral or enteral nutrition whenever possible because it enhances the immune system and maintains intestinal motility. However, the client should receive TPN when nutritional needs are greater than oral or enteral nutrition can provide, such as in a client who has burn injuries. TPN provides calories to clients who are unable to eat or who do not have a functioning gastrointestinal tract. A client who has a burn injury is in a hypermetabolic state and requires additional calories, carbohydrates, proteins, and fats. The nurse should check the client for an egg allergy, because this can result in an intolerance of the lipid solution and many lipids are composed of egg phospholipids.

A nurse is preparing to administer heparin 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 mL (5,000 units) x (mL/10,000 units) = 1/2 mL = 0.5 mL

A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? 1 medium raw carrot 1/2 cup cooked spinach 1/2 cup cooked butternut squash 1 cup sliced cantaloupe

1 medium raw carrot The nurse should identify that 1 medium raw carrot contains 2,025 mcg/dL of vitamin A and is therefore the best food to recommend to the client. --- The nurse should recommend a different food, because 1/2 cup cooked spinach contains 737 mcg/dL of vitamin A. The nurse should recommend a different food, because 1/2 cup cooked butternut squash contains 714 mcg/dL of vitamin A. The nurse should recommend a different food, because 1 cup sliced cantaloupe contains 516 mcg/dL of vitamin A.

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 client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings A client who was admitted for dehydration and is receiving a continuous IV infusion A client who has a history of two prior miscarriages and has ruptured membranes at 38 weeks of gestation

A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support. --- A client who is being proactive in the management of their alcohol use disorder does not require an interprofessional care conference. A client who has dehydration, which is an acute condition, does not require an interprofessional care conference at the time of admission. A client who has ruptured membranes at 38 weeks of gestation is not a complicated obstetrical client and does not require an interprofessional care conference.

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 has a temperature of 38.2° C (100.8° F) and requests a cup of ice chips A client who is postoperative and reports a pain level of 5 on a scale from 0 to 10 A client who has voided and is ready for a bladder scan A client who is confused and has been attempting to get out of bed

A client who is confused and has been attempting to get out of bed The nurse should recognize that a client who is confused and has been attempting to get out of bed is at greatest risk for injury from a fall. Therefore, the nurse should attend to this client first. --- The nurse should provide ice chips to this client to provide hydration. However, there is another client the nurse should attend to first. The nurse should recognize this as a moderate pain level and administer pain medication to maintain a level of comfort. However, there is another client the nurse should attend to first. The nurse should perform the bladder scan to determine the amount of residual urine. However, there is another client the nurse should attend to first.

A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? A client's IV pump delivers an inadequate dose of medication. A nurse follows a client's advance directives and discontinues enteral feedings. A nurse discards unused, expired bags of IV fluids. A client refuses an IV bolus of pain medication.

A client's IV pump delivers an inadequate dose of medication. The nurse should complete an incident report to record occurrences which resulted in a medication error, such as a failure of the IV pump, as part of the quality improvement process. Other situations requiring an incident report include significant complaints about care quality and visitor or client injury. --- The nurse is legally responsible for adhering to the instructions in a client's advance directives. The nurse should discard any materials that have met their expiration date to prevent injury to clients. The client has the right to refuse treatment and the nurse should document the refusal in the medical record.

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? Withdraw the catheter if the client begins coughing. Apply suction for 10 seconds. Advance the catheter 2 cm (0.8 in) after resistance is met. Use medical asepsis when performing the procedure.

Apply suction for 10 seconds. The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss. --- Suctioning can initiate the cough reflex as it opens the airway further and allows for more effective removal of mucus. Once resistance is met, the nurse should withdraw the catheter 1 to 2 cm (0.4 in to 0.8 in) to prevent damaging bronchial tissues. The nurse should use surgical asepsis when suctioning a newly created tracheostomy to reduce the risk for infection.

A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take? Ask the caller for verification of their identity. Give the caller limited information about the client. Transfer the phone call to the client's room. Inform the caller that they should obtain permission from the client's provider.

Ask the caller for verification of their identity. According to HIPAA, if someone requests information about a client it is the nurse's duty to protect that information. Therefore, the nurse should inform the caller that nurses cannot release any client information over the phone without the permission of the client. The nurse should ask for verification of the caller's identity to determine if they have been authorized by the client to receive information. --- This action by the nurse violates HIPAA because the client's personal health information is protected legally by the facility and the nurse should not disclose information, even in a limited form. According to HIPAA, if someone requests information about a client, it is the nurse's duty to protect that information. Therefore, the nurse should inform the caller that they cannot transfer the call or release any client information over the phone without the permission of the client. The client's provider must receive permission from the client to release specific medical information to family members. Therefore, this action by the nurse violates the client's right to privacy.

A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? Ask the client to rate their pain level. Assist the client in changing positions. Administer a PRN analgesic medication. Explain the importance of early ambulation.

Ask the client to rate their pain level. Using the nursing process, the first action the nurse should take is to assess the client's level of pain. If indicated, the nurse should administer an analgesic, then wait 30 to 45 min to allow the analgesic to take effect before encouraging the client to ambulate. Management of the client's pain is a priority for encouraging postoperative activity. --- The nurse should assist the client in changing positions to promote comfort. However, there is another action the nurse should take first. The nurse should administer a PRN analgesic medication to promote comfort. However, there is another action the nurse should take first. The nurse should explain the importance of early ambulation to promote the client's adherence. However, there is another action the nurse should take first.

A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? Refer the nurse to the procedure manual. Use a diagram to explain the procedure to the nurse. Demonstrate the procedure to the nurse. Ask the nurse about their knowledge of the procedure.

Ask the nurse about their knowledge of the procedure. The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs. --- The charge nurse should instruct the newly licensed nurse to consult the procedure manual for further information about chest tubes. However, there is another action the charge nurse should take first. The charge nurse should use a diagram to explain the procedure and enhance the nurse's understanding. However, there is another action the charge nurse should take first. The charge nurse should use a demonstration to model the procedure to the newly licensed nurse. However, there is another action the charge nurse should take first.

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? Notify the provider if a thrill is palpated at the fistula. Auscultate the affected extremity for a bruit. Discourage range-of-motion exercises in the affected extremity. Perform venipuncture in the affected extremity.

Auscultate the affected extremity for a bruit. The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency. --- The nurse should expect to palpate a thrill at the AV fistula, which indicates patency. The nurse should report the absence of a thrill to the provider. The nurse should encourage the client to perform range-of-motion exercises in the affected extremity to maintain muscle strength. The nurse should not perform a venipuncture in the client's affected extremity to prevent circulatory complications.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? Slightly blue hands and feet Respiratory rate 40/min Axillary temperature 36.2° C (97.2° F) Apical pulse 136/min

Axillary temperature 36.2° C (97.2° F) The expected reference range for the axillary temperature of a newborn is between 36.5° C to 37.5° C (97.7° F to 99.5° F). An axillary temperature of 36.2° C (97.2° F) or below in a newborn who is 2 hr old indicates cold stress and should be reported to the provider. --- Acrocyanosis, or slightly blue hands and feet, is an expected finding for a newborn who is 2 hr old. A respiratory rate of 40/min is within the expected reference range of 30 to 60/min for a newborn who is 2 hr old. An apical pulse of 136/min is within the expected reference range for a newborn who is 2 hr old. The newborn pulse rate can range from 80 to 100/min when asleep and up to 180/min when crying.

A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? Butterfly rash over the cheeks and nose Report of pain in the joints of the lower extremities Blanching of the fingers and toes Scaly patches over the knees and elbows

Blanching of the fingers and toes A client who has Raynaud's disease can have blanching of the fingers and toes in response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone. --- A client who has lupus erythematosus is likely to have a butterfly rash over the cheeks and nose. A client who has osteoarthritis is likely to have pain in the joints of the lower extremities. A client who has psoriasis is likely to have scaly patches over the knees and elbows.

A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? Bleeding Potassium deficiency Infection Hyperbilirubinemia

Bleeding The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding. --- Vitamin K does not prevent potassium deficiency in a newborn. Vitamin K does not prevent infection in a newborn. Vitamin K does not prevent hyperbilirubinemia in a newborn.

When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? Coloring with crayons in a coloring book Deep breathing and "going limp as a rag doll" Blowing bubbles with liquid soap to "blow the hurt away" Taking a warm bath and playing with a bath toy

Blowing bubbles with liquid soap to "blow the hurt away" Having the child blow bubbles is a visualization technique that can help to decrease the child's discomfort. The child can visualize the pain as the bubble that they blow away from themself and into the air. --- This activity provides distraction for the child. This activity uses relaxation techniques to help the child cope with pain. This activity uses cutaneous stimulation to help the child cope with pain.

A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? Intermittent cramping Moderate lochia rubra Boggy uterus Perineal edema

Boggy uterus When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi have formed at the placenta. --- Intermittent cramping, also known as afterpains, is nonurgent because it is an expected finding for a client who is in the immediate postpartum period. To ease the cramping, the nurse can apply heat or instruct the client to lie prone. However, there is another finding that is the nurse's priority. Moderate lochia rubra is nonurgent because it is an expected finding for a client who is in the immediate postpartum period. The nurse should report excessive lochia rubra and large clots to the provider. However, there is another finding that is the nurse's priority. Perineal edema is nonurgent because it is an expected finding for a client who is in the immediate postpartum period. Perineal edema occurs due to the excessive amount of pressure experienced during vaginal birth. The nurse can offer ice packs or sitz baths to relive the perineal discomfort. However, there is another finding that is the nurse's priority.

A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Teach the client reportable adverse effects from the medication. Check the insulin dose with another licensed nurse. Administer the insulin at a 90° angle. Clean the insertion site.

Check the insulin dose with another licensed nurse. The greatest risk to the client is injury due to a medication error. Therefore, the priority action is for the nurse to validate the correct dose of insulin with another licensed nurse prior to administration. Insulin is a high-alert medication and incorrect dosages can be fatal for the client. --- The nurse should teach the client adverse effects to report to reduce harm to the client; however, there is another action the nurse should take first. The nurse should administer the insulin at a 90° angle to ensure subcutaneous administration; however, there is another action the nurse should take first. The nurse should clean the insertion site before injecting the medication to prevent an infection; however, there is another action the nurse should take first.

A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information? Increase intake of fluids and fiber to prevent constipation. Complete a serum pregnancy test before taking the medication. This medication coats stomach ulcers so that they can heal. Take a magnesium-containing antacid along with this medication.

Complete a serum pregnancy test before taking the medication. Misoprostol can induce uterine contractions. Clients of childbearing age must rule out pregnancy before taking misoprostol. --- Misoprostol tends to cause diarrhea rather than constipation. Misoprostol does not coat the stomach. Misoprostol reduces gastric acid secretion so ulcers can heal and reduces the risk of new ulcer development. Magnesium-containing antacids increase the risk of diarrhea and the client should avoid these when taking misoprostol.

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? Lethargy Confusion Polyuria Fine hand tremors

Confusion When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is confusion because it is an early manifestation of lithium toxicity. The nurse should monitor the client for additional indications of lithium toxicity, including coarse hand tremors, incoordination, ECG changes, and sedation. --- Lethargy is a nonurgent finding because it is an expected adverse effect of lithium therapy. Therefore, there is another finding that is the priority. Polyuria is a nonurgent finding because it is an expected adverse effect of lithium therapy. Therefore, there is another finding that is the priority. Fine hand tremors are a nonurgent finding because they are an expected adverse effect of lithium. Therefore, there is another finding that is the priority.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement? Airborne Droplet Contact Protective environment

Contact The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA. --- The nurse should implement airborne precautions for a client who has an infection spread by air, such as tuberculosis or measles. The nurse should implement droplet precautions for a client who has an infection spread by droplets, such as pneumonia and influenza. The nurse should implement a protective environment for a client who has immunosuppression caused by conditions such as cancer treatment.

A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? Contact Droplet Airborne Protective environment

Contact The nurse should initiate contact precautions because clients transmit HSV by direct and indirect contact with others and the environment. The nurse should wear gloves when in close contact with the newborn. --- The nurse should initiate droplet precautions for clients who have an infection that is transmitted via particle droplets larger than 5 microns, such as pertussis, rubella, and streptococcal pharyngitis. The nurse should initiate airborne precautions for clients who have an infection that is transmitted via droplet nuclei smaller than 5 microns, such as varicella, rubeola, and tuberculosis. The nurse should initiate protective environment precautions for clients who have a severely compromised immune system, such as a client who has had a hematopoietic stem-cell transplant.

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? Continue observing the fetal heart rate. Assist the client to a knee-chest position. Prepare the client for continuous internal monitoring. Prepare for an emergency cesarean birth.

Continue observing the fetal heart rate. Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing. --- The nurse should assist the client into a knee-chest position if the umbilical cord prolapses. There is no indication for the client to have internal monitoring. The nurse should prepare for an emergency cesarean birth if the monitor indicates late or variable decelerations despite interventions.

A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Increased intraocular pressure Floating dark spots Decreased central vision Double vision

Decreased central vision The nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina. --- An increase in intraocular pressure is a manifestation of glaucoma. Floating dark spots are a manifestation of retinal detachment. Double vision is a manifestation of cataracts.

A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? Decreased blood pressure Increased cardiac output Increased oral temperature Decreased lung expansion

Decreased lung expansion Older adult clients are more likely to have decreased lung expansion due to decreased mobility of the ribs. --- Older adult clients are more likely to have an increased systolic blood pressure with a diastolic pressure that does not change. Older adult clients also have increased incidence of orthostatic hypotension. Older adult clients are more likely to have decreased cardiac output. Older adult clients are more likely to have decreased oral temperature.

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? Offer a referral to the client for social services. Develop a safety plan with the client. Encourage the client to reach out to family and friends. Provide the client with a list of support groups.

Develop a safety plan with the client. The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is to develop a safety plan with the client. --- A client who has experienced intimate partner abuse can benefit from a referral to social services, but offering a referral is not the first action the nurse should take. The client can benefit from the support of family and friends when the client is ready, but encouraging this behavior is not the first action the nurse should take. The client can benefit from attending a support group, but providing this information is not the first action the nurse should take.

A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? Document the client's refusal of the medication. Administer the medication that the provider prescribed. Request consent from the client's family to administer the medication. Administer an oral dose of the medication.

Document the client's refusal of the medication. The client has the right to refuse medication. The nurse should document the refusal in the client's medical record. --- The nurse should withhold the medication. Administering the medication against the client's wishes is an intentional tort called battery. A client who is competent provides their own consent regarding health care decisions, and consent is not the responsibility of the client's family. The nurse should not change the route of the medication without a prescription from the provider.

A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? Maintain the client on bed rest. Restrict the client to 1 L of fluid per day. Place cool compresses on the edematous area. Elevate the affected leg.

Elevate the affected leg. The nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency. --- The nurse should encourage the client to ambulate once an anticoagulant is initiated, as walking does not increase the risk for pulmonary emboli, nor does it worsen the deep-vein thrombosis once an anticoagulant is initiated. The nurse should encourage the client to drink 2 to 3 L of fluid daily to decrease platelet aggregation and prevent dehydration. The nurse should place warm compresses on the affected area to reduce swelling and promote comfort.

A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the following actions should the nurse plan to take? Allow the plasma to warm for 30 min before transfusion. Confirm the client's identification by checking the room number. Enter the plasma product number into the client's medical record. Administer each unit of plasma over 4 hr.

Enter the plasma product number into the client's medical record. The nurse should complete documentation following blood product therapy, which includes recording the type of product, amount administered, product number, infusion time, and client response. --- The nurse should transfuse the plasma immediately after obtaining it from the blood bank to maintain integrity of the clotting factors. The nurse should confirm the client's identification by verifying that the client's name and facility-assigned number on the identification bracelet match the information provided on the units of plasma. The nurse should plan to administer each unit of plasma over 30 to 60 min. The nurse should slow the rate of infusion if the client shows indications of fluid overload.

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? Tell the client to self-report to the state health department. Require that the client speak with a public health nurse. Explain to the client why this information will be shared. Refer the client to a social worker for counseling.

Explain to the client why this information will be shared. It is the responsibility of the nurse to advocate for the client, provide confidential information, and explain legal requirements. Reporting communicable disease occurrences helps with identifying outbreaks and overall disease trends. --- It is not the client's responsibility to report this information to the local public health department. The client is not required to speak with a public health nurse. The client does not need to be referred to a social worker for counseling. The nurse should provide information about the prevention of spreading the STI.

A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply.) Nystagmus Facial flushing Diplopia Nasal congestion Headache

Facial flushing Nasal Congestion Headache The nurse should expect a client who has autonomic dysreflexia to have facial flushing. Flushing occurs from the point of the lesion upward. The nurse should expect a client who has autonomic dysreflexia to have nasal congestion. The nurse should expect a client who has autonomic dysreflexia to have a severe headache. --- The nurse should expect a client who has autonomic dysreflexia to experience spots in the visual field. The nurse should expect a client who has autonomic dysreflexia to have blurred vision.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? Fever unresponsive to antipyretics Pain in weight-bearing joints Decreased heart rate Peeling of the soles of the feet

Fever unresponsive to antipyretics The nurse should expect a child who has acute Kawasaki disease to have a high fever that is unresponsive to antibiotics or antipyretics. --- The nurse should expect the child to report pain in the weight-bearing joints during the subacute phase of Kawasaki disease. The nurse should expect tachycardia during the acute phase of Kawasaki disease. The nurse should expect peeling of the palms of the hands and soles of the child's feet during the subacute phase of Kawasaki disease.

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. Crush the client's medications and mix them in with the tube feeding formula prior to administration. Change the client's feeding bag every 72 hr. Administer multiple prescribed medications at the same time.

Flush the client's gastrostomy tube with 30 mL of water before administering the medication. The nurse should flush the gastrotomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency. --- The nurse should crush each medication and administer each separately from the tube feeding formula to decrease the risk of residual forming, which can clog the tube. The nurse should change the feeding bag and tubing every 24 to 48 hr to prevent clogging and to reduce the risk of infection. The nurse should administer each prescribed medication separately to reduce the risk of clogging of the tube.

A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? Ensure that the staff nurse changes the dressing. Notify the nurse manager. Complete an incident report. Gather more information about the staff nurse's actions.

Gather more information about the staff nurse's actions. The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action. --- It is the charge nurse's role to advocate for the client to receive the care the provider prescribed. However, this is not the first action the charge nurse should take. The charge nurse should notify the nurse manager that the occurrence happened. However, this is not the first action the charge nurse should take. The charge nurse should complete an incident report describing the occurrence. However, this is not the first action the charge nurse should take.

A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? Spinal manipulation Acupuncture Therapeutic touch Guided imagery

Guided imagery Helping clients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist clients who have PTSD by relieving anxiety and pain. --- Spinal manipulation is not a therapy the client can learn to self-perform to relieve manifestations of PTSD. Spinal manipulation involves adjusting and aligning the spine, which can help with back pain, asthma, and allergies. Performing acupuncture requires special training. It is not a therapy the client can self-perform to relieve manifestations of PTSD. Needle placement can alter and improve immune, neurologic, cardiac, and endocrine function. It can also help relieve pain and assist with substance withdrawal. Although touch therapies are helpful for inducing relaxation in general, therapeutic touch specifically addresses pain, depression, healing of body tissues, and physiological needs such as reducing blood pressure, fever, and nausea. It is not a therapy the client can learn to self-perform.

A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? Hypotension Headaches Bruising Oliguria

Headaches The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. --- The nurse should instruct the client to monitor for and report hypertension. The nurse should instruct the client to monitor for swelling and tenderness of an extremity or fluid retention. Bruising is not an adverse effect of this medication. The nurse should instruct the client to monitor for the development of genitourinary candidiasis. Oliguria is not an adverse effect of this medication.

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? Decreased activity Hemoptysis 275 mL/24 hr Fever Weight loss 2.3 kg (5 lb)

Hemoptysis 275 mL/24 hr Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report. --- The nurse should report decreased activity to the provider because it can be an indication of pulmonary infection. However, another finding is the priority. The nurse should report fever to the provider because it can be an indication of pulmonary infection. However, another finding is the priority. The nurse should report anorexia and weight loss to the provider because it can be an indication of pulmonary infection. However, another finding is the priority.

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? Check the client's temperature every 2 hr. Initiate fall precautions for the client. Monitor the client's urine for discoloration. Limit the client's fluid intake to 1 L per day.

Initiate fall precautions for the client. The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy. --- Alprazolam does not affect temperature regulation. Therefore, monitoring the client's temperature as often as every 2 hr is not necessary. Urine discoloration is not an adverse effect of alprazolam. Therefore, monitoring the client's urine is not necessary. The nurse should encourage the client to increase fluid intake while taking alprazolam because an adverse effect of this medication is constipation.

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? Include chicken broth in the toddler's diet. Feed the toddler the BRAT diet. Initiate oral rehydration therapy for the toddler. Offer the toddler flavored gelatin.

Initiate oral rehydration therapy for the toddler. Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed. --- The nurse should identify that chicken and beef broths contain excessive amounts of sodium and very few carbohydrates. The BRAT diet (bananas, rice, applesauce, and toast) contains little nutritional value, inadequate amounts of protein and electrolytes, and is high in simple carbohydrates. It is contraindicated for a child who has acute diarrhea. Gelatin is high in carbohydrates, low in electrolytes, and high in osmolality, which can prolong diarrhea and electrolyte imbalance.

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. Shake the NPH insulin vial vigorously to mix the insulin. Use a new needle to draw up the insulin from the second vial. Draw the longer-acting insulin into the syringe first.

Inject 20 units of air into the NPH insulin vial. The nurse should inject 20 units of air into the NPH insulin vial and withdraw the needle without touching the insulin, then proceed to inject 15 units of air into the regular insulin vial. --- The nurse should roll the NPH insulin between the palms of the hands to mix the cloudy solution. Shaking the NPH insulin can make the solution frothy and difficult to measure an accurate dose. The nurse should use the same needle and syringe to draw up the insulin from both vials. The nurse should draw the short-acting regular insulin into the syringe first. This prevents the longer-acting NPH insulin from contaminating the short-acting insulin.

An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? Collection of a stool specimen Preparation of a client's postoperative bed Preparation of a teaching plan about pneumonia Insertion of a nasogastric tube

Insertion of a nasogastric tube The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the LPN's scope of practice. --- The nurse should delegate collection of a stool specimen to an AP because this task is within the AP's range of function. The nurse should delegate preparation of a client's postoperative bed to an AP because this task is within the AP's range of function. The RN should prepare the teaching plan because creating a teaching plan is not within the scope of practice for an LPN or the range of function for an AP.

A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? Provide the infant with 1 cup of cereal. Give the infant 240 mL (8 oz) of juice per day. Introduce new foods one at a time over 5 to 7 days. Give whole milk first, then small amounts of solid food.

Introduce new foods one at a time over 5 to 7 days. The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies. --- Infants' portion sizes in general should be 1 Tbsp per year of age. For infants under 12 months of age, 1/2 to 3/4 Tbsp is appropriate. The parents should offer the infant 100% fruit juice, not to exceed 120 to 180 mL (4 to 6 oz) per day, after 6 months of age. The parents should not offer the infant whole milk, because the majority of the infant's calories should come from human milk or commercial, iron-fortified formula.