EXIT 3.0

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

"I am thankful I am done having children"

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

"I should keep my baby rear-facing in the car seat until she is 2 years old."

A nurse is reinforcing teaching with a client who is to start taking montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching?

I'll take this medication once a day in the evening

A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

"Move clients to a room above ground with few windows.

A nurse is discussing the meaning of utilitarianism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this ethical theory?

"Utilitarianism provides the greatest good for the greatest number of people."

A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

"We will frequently check the top of his ears for sores."

A charge nurse assigns a nurse to care for a group of clients. Which of the following clients should the nurse ask the charge nurse to reassign to an RN?

A client who has a new diagnosis of diabetes mellitus and needs to learn self-administration of insulin

A nurse is caring for four clients. Which of the following situations require a signed consent form?

Administering an iron injection Z-track method

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram (IVP) Which of the following statements should the nurse include in the teaching?

After the procedure you will be encouraged to drink plenty of fluids "

A nurse is assisting with the green needle examination of a client who is in eight weeks of gestation. The nurse notes the client's vagina and vulva are a purplish color the nurse should document to find them as which of the following?

Chadwick sign

A nurse is preparing to perform a wet to dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing the dressing change?

Clean the wound from center to outer edges

A nurse is reinforcing teaching with the parents of a newborn about me then which of the following instructions should the nurse include in the teaching?

Cleanse the eyes from the inner canthus outward

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

Client's telephone number

A client has just passed away. What actions of the nurse to the dead body before a family visit

Close the eyelid

A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Complete post mortem care for a client who has died

A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hrs. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this error?

Controlled Substance inventory

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement?

Determine the client's ability to use the call light

A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning. Which of the actions should the nurse take?

Discontinue use and tag the IV pump

Hindu post mortem

Don't touch the patient's body

A nurse is caring for an adolescent that states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanism

Sublimation

A community health nurse is a system in the development of a brochure about hypertension. Which of the following actions should the nurse take?

Explain the medical terminology using basic one syllable words

A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively?

Gather supplies prior to completing a dressing change

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicate an understanding of the teaching?

I have to take this medication on an empty stomach

A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new prescription for Timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching?

I should check my heart rate while taking this medicine

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

I should use counter pressure for back pain during labor

A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?

I will mix the medication with water

A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of this medication?

I will place the patch on a hairless area of skin

A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority action on which of the following actions?

Identifying the client's perception of the changes in her physical appearance

A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching?

Information about a client's health can be emailed if encrypted

A nurse is assisting with the admission of a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurse's priority?

Initiate airborne precautions

A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

It enhances quality of life by promoting comfort

A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse's role in obtaining informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching

It is my responsibility to obtain informed consent from the client prior to the procedure

A nurse is completing post mortem documentation for a client. Which of the following information should the nurse include in the documentation?

Last Vitals

A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?

My partner will use condoms with spermicides

Knee arthroplasty complains of pain of 6. Which medication

Oxycodone

A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?

Perform chart audits

nurse in a provider's office is collecting data from a client who was just diagnosed with tuberculosis. Which of the following actions should the nurse take first?

Place a mask on the client.

A nurse answers the room of a school age child and finds some on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the child's head

A nurse is preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take?

Play sterile objects at least 2.5 cm from the edge of the sterile field

A nurse is assisting with a community health course for family members of clients who have Alzheimer's disease. Which of the following should the nurse include?

Provide a stimulating environment

A nurse is collecting data from a client who is 8 hours postoperative following an appendectomy. Which of the following manifestations is the best indication that the client needs a PRN analgesic?

The client reports pain as 7 on a scale of 0-10

A nurse is collecting data from a client who uses a continuous positive airway pressure cap machine at night for sleep apnea. the nurse should identify which of the following indicates proper use?

There is one finger width between he straps and the face

A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

This must be frightening to you let's talk more about it

A nurse is preparing to give a change of shift report on a client who is today's postoperative following total knee arthroscopy. Which of the following information about the client should the nurse include in the report?

Time of last pain medication

A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

Use a moisture barrier on the client's skin

A nurse is caring for an older adult client who is post op following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

Use a moisture barrier on the client.

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for administration of TPN. Which of the following should the nurse take?

Verify the amount of TPN solution the client is receiving every 4 hours

A nurse is administering a client's morning oral medications. Which of the following actions should the nurse t

Verify the medication three times with the medication administration record.

A nurse is assisting with staff education about hand hygiene. Which of the following should the nurse include in the teaching?

Wash your hands with soap and water for 20 seconds

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

Wear shoes with rubber soles.

Maintenance for hearing aid?

Wipe with soft cloth

A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should I expect

fruity breath odor

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

grapes

What is drink option less caffeine

hot cocao

A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?

tachycardia

A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?

Request the AP to provide a return demonstration of the task

A nurse is assisting with monitoring a client who has preeclampsia and is receiving an infusion of magnesium sulfate. for which of the following findings should the nurse prepare to stop the infusion and notify the charge nurse?

Respiratory rate 10/minute

Position of lumbar puncture

Side lying or lateral recumbment

A nurse is collecting data from a client who has a urinary tract infection and is taking Ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?

Discontinue the medication I will ask your provider for another antibiotic

a nurse is caring for a client who is so hours. For the following surgical creation of a tracheostomy which of the following is she should the nurse take to help promote the client's recovery?

Keep suction equipment at the bedside

A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states I am so tired all the time but mom needs me. Which of the following responses should the nurse make

Let me give you some information about respite care for your mother

A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include?

Leukorrhea

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

Loss of taste

A nurse is contributing to the plan of care for a client who has ascites Due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

Measure the client's abdominal girth daily

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following intervention should the nurse recommend

Remind the client of the day and time often

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Skin rash with fever

A nurse is collecting data from a client who is having difficulty coping with the death of his child. Which of the following questions by the nurse is the priority?

do you think about harming yourself