magic 1

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 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 collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

, Increased urinary output

A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?

, Muscle pain

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

, Secure the tubing to the child's abdomen.

A nurse is observing assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

, The AP pulls the pinna up and back.

A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching?

,"I will put soiled dressings in a tied plastic bag before placing them in the trash."

1. A nurse is assisting with the care of a client in a PACU. Provider Prescriptions 1100: Oxygen 2 to 5 L/min via nasal cannula to maintain oxygen saturation greater than 92%. Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

-Add a humidifier to the oxygen device. -Encourage client to perform deep breathing exercises. -Examine the client's nail beds.

1. A nurse is assisting with the care of a client in a medical-surgical unit. Vital Signs 05:00 Temperature 36.6 C (97.9 F) Heart rate 100/min Respiratory rate 22/min Blood pressure 160/98 mm Hg Oxygen saturation 96% on oxygen 2 L/min via nasal cannula 14:00 Temperature 36.8 C (98.3 F) Heart rate 90/min Respiratory rate 18/min Blood pressure 138/88 mm Hg Oxygen saturation 97% on oxygen 2 L/min via nasal cannula Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.

-Empty the drainage bag when it is half-full. -Review the need for the indwelling urinary catheter daily. -Use soap and water to provide perineal care. -Encourage the client to drink 3,000 mL of fluid daily.

1. A nurse is assisting with the care of a client. Laboratory Results 1100: Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

-Provide the client with written information about advance directives -Instruct the client that an advance directive is a legal document and must be honored by care providers -Initiate a power of attorney for health care document -Communicate advance directives status via the medical record and shift report

Nurses Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions." Select the three actions the nurse should take.

-Report suspected maltreatment to the appropriate agency. -Ask the client how the fracture occurred. -Conduct the interview with the client privately.

A nurse is assisting in the care of a client. Nurses' Notes 2000: Client presents to emergency department and states, "I have been assaulted." Client was immediately placed in a treatment room. 2015: "Client states they were out with friends this evening and had "a little too much to drink." Client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." Client reports history of depression. Client is a full-time college student who lives with roommates. Client admits to drinking socially but denies illicit drug use and tobacco use. Which of the following interventions should the nurse plan to implement?

-Request a consult for case management -Maintain a safe and private environment for the client -Administer sexually transmitted infection prophylaxis -Provide resources for local support services

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to assistive personnel? (Select all that apply.)

-Transfer a client who is receiving radiation therapy to radiology. - Record urine output for a client who has a suprapubic catheter. -Measure vital signs for a client who requires contact precautions.

A nurse is assisting with the plan of care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional conference?

. A client who has a spinal cord injury.

A nurse is reinforcing teaching with a client who is at 16 weeks of gestation and has a prescription for ferrous sulfate to treat iron-deficiency anemia. Which of the following recommendations should the nurse make to improve the absorption of the medication?

. Avoid drinking milk with the iron supplement.

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5° C (90.5° F). Which of the following data is the priority for the nurse to monitor?

. Heart rhythm

A nurse is reinforcing teaching with a client who has Crohn's disease. Which of the following statements by the client indicates an understanding of the teaching?

. I know that I will have episodes of remission.

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 indicates an understanding of the teaching?

. I should check my heart rate while taking this medication.

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

. I will check my oxygen equipment at least once daily.

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 overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

. Tell the APs to stop the conversation.

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

. sounds are high-pitched.

A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should include that which of the following is an acceptable weight gain for this client?

16 Ib.

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

A client who has a femur fracture and reports numbness of the toes.

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

A social worker who is assigned to an involuntarily committed school-age client

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

Abnormal Involuntary Movement Scale

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

Anaphylactic

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Anterior fontanel closed

A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?

Apply pressure to the lacrimal punctum after administering the drops.

A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

Apply support stockings.

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

Apply the gown before the gloves.

A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?

Are the voices you are hearing telling you to hurt yourself or someone else?

A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

Are you thinking of hurting yourself?

A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?

Avoid exposing the neck to the cold.

. A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

Believes his bad behavior is causing his brother's death

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

Boundary crossing

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

Bright red vaginal bleeding

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

Chadwick's sign.

A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

Check the child for oral injuries.

A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Chemotherapy treatments

. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Clean the stoma using an inward to outward circular motion.

A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-month-old toddler. Which of the following instructions should the nurse provide?

Clean the teeth with a small, soft-bristled toothbrush.

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 this dressing change?

Clean the wound from the center to the outer edges.

A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

Clenched teeth.

A nurse is gathering data from a client who has severe anxiety. Which of the following findings should the nurse identify as an indication that the client is experiencing a crisis?

Client isolates themselves from their family and friends

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom!"

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?

Close your mouth around the mouthpiece

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

Compare bilateral pedal pulses.

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

Consume soft, bland foods.

A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

Cover the wound with sterile, saline-soaked gauze.

A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?

Dark red urine

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 on which of the following actions?

Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds

A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

Determine the client's level of consciousness.

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

Determine the client's pattern for voiding.

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?

Displacement

A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?

Elevated lipase

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

Encourage the client to be assertive.

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

Encourage the family to express their feelings of loss.

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

Engage in low-impact aerobic exercises.

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Ensure that the client gave informed consent

A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Ensure the client swallows each dose of medication.

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Ensure the device is kept below the level of the client's chest.

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

Explain medical terminology using basic, one-syllable words.

A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

Fidelity involves keeping promises made to clients.

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

Fruity breath odor

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

Gently stroke her abdomen during contractions.

A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?

Have your child wear a medical identification wristband.

A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain. Which of the following conditions in the client's history should the nurse identify as a contraindication?

Hepatitis C

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz. of which of the following beverages contains the least amount of caffeine?

Hot cocoa

A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?

Hypertension

A nurse is collecting data from a client who reports difficulty sleeping at night. Which of the following client statements indicates an understanding of sleep promotion?

I am going to bed at the same time every night

A nurse in an inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the client indicates an understanding of the procedure?

I might have short-term memory loss after the procedure.

A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?

I should practice pursed lip breathing exercises.

A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?

I will apply pressure with gauze if I see bleeding

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

I will get you information about some head-covering options."

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

I will make sure that I can fit one finger between the mattress and the side of my newborn's crib.

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

I will need to remain upright for 1 hour after taking the medication.

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

I will place my baby on his back for sleeping."

A nurse in a mental health facility is reinforcing teaching with a client about panic attacks. Which of the following statements by the client indicates an understanding of the instructions?

I will use abdominal breathing at the first sign of a panic attack.

A home health nurse is reinforcing teaching with a client who has diabetes mellitus. Which of the following statements should the nurse make to evaluate the client's use of a glucometer?

I would like to observe you using your glucometer

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

Incident report

A nurse is contributing to the plan of care for a client who was newly admitted and has tuberculosis. Which of the following actions should the nurse recommend including in the plan of care?

Increase the client's daily intake of vitamin D.

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 regarding client health can be e-mailed if encrypted.

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Initiate contact precautions for the client.

A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

Inserting an NG tube for a client who needs continuous enteral feedings.

A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

Instruct the client to exhale while inserting the rectal tube.

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

Instruct the client to hold the drainage bag at waist height when ambulating

A nurse is collecting data from a client who is 18 hr. postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?

Is eager to review the birth experience

A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?

Keep the finger in a dependent position.

A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?

Let's discuss how you feel when you leave your house

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

Limit the number of choices for the client.

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

Location of the identification tag on the client's body.

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

Maintain the client in high-Fowler's position.

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 including in the plan?

Measure the client's abdominal girth daily.

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Measure the client's vital signs.

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

Memory loss that disrupts ADLs

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching?

Music will distract my husband's awareness of the pain.

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

Neisseria gonorrhoeae

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

New onset of hearing loss

A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

Notify the charge nurse about the situation.

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

Observe the client during and after meals.

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

Open the outermost flap of the sterile kit away from the nurse's body.

A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?

Perform sponge baths until the baby's umbilical cord falls off."

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

Performing indwelling urinary catheter care.

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Physical assessment findings

A nurse enters the room of a school-age child and finds them 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 planning care for a client who is 6 hr postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?

Place a pillow under the client's surgical knee.

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Plan to remove the restraints as soon as the client is calm.

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Position the client in semi-Fowler's position.

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Productive cough with thick mucus

A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?

Prothrombin time

A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse recommend including in the plan?

Provide frequent reorientation after ECT.

A nurse is supervising assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

Raises all four side-rails on the client's bed.

A nurse in an acute care facility is reviewing medication administration protocol with another nurse. Which of the following information should the nurse include in the review?

Read medication labels twice before administration.

A nurse is administering phacelias to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Reduced fat in the stools.

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

Remove the nurse from the client care area.

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

Roasted salmon

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

Semi-Fowler's

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

Support the client's decision to stop the treatment.

A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take?

Switch the client to a formula containing less protein.

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

The client has decreased energy level

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

The headaches should decrease as you get used to the medication

A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly?

The restraints are secured with a quick-release knot.

A nurse determines that clients who receive zolpidem postoperatively have an increased fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings?

The risk manager

A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?

The telephone numbers of the clients.

A nurse is caring for a client who asks why her newborn is receiving a phytonadione injection. Which of the following statements should the nurse make?

This medication prevents your baby from developing bleeding problems.

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

This must be very frightening for you. Let's talk more about it.

A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report?

Time of last pain medication

A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?

To cremate the client's body.

A nurse is supervising assistive personnel (AP) who is applying ant embolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Turning the stockings inside out before applying them.

A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Urinary retention

A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

Use symbols in the communal room signage.

A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?

Uses a firm-bristled toothbrush.

A nurse is providing postmortem care for a client. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Verify that the provider has certified the client's death. 1 Remove all equipment and tubes from the client's body. 2 Clean the client's body. 3 Determine the family's preferences about care of the body. 4 Apply identifying name tags onto the client.5

A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?

Verify the medication three times with the medication administration record.

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Wear a gown when assisting the client with personal hygiene.

A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take?

Wipe any excess medication from the inner canthus outward.

A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?

Wrap the leg with an elastic bandage.

A nurse is collecting data from a client. The nurse should identify that which of the following manifestations is an indication of a candida infection?

Yellow patches in the mouth

A nurse is reinforcing discharge teaching with a client who has a prescription for antibiotic therapy. The client reports experiencing diarrhea when taking antibiotics. Which of the following foods should the nurse recommend to lessen the occurrence of diarrhea?

Yogurt

A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hr creatinine clearance test. Which of the following statements should the nurse include in the teaching?

You can begin collection of urine after discarding your first morning void.

A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching?

You can sign the informed consent form after the provider explains the pros and cons of the procedure.

A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?

You have a right to change your mind.

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

You will need to urinate before the procedure

A nurse is monitoring a client's arterial pulses. The nurse should check for a dorsalis pedis pulse in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

above/upward from toe

A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider?

blurry vision

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

diminished pulses on the affected extremity

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

initiate droplet precautions

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

muscle cramps

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

placement of a central venous catheter

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

seizures

A nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

shortness of breath

A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

should discuss this document with my family after I sign it

A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?

social worker

A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?

somnolence

A nurse and assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions?

stand next to the client's shoulders.

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

stop the infusion

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in potassium?

sweet potato

1. A nurse is assisting with the care of a client. Admission Assessment 12:00 58-year-old client reporting chest pain is admited to the emergency department. Client states chest pain began this morning after breakfast and pain radiates to left arm. Client rates pain as 4 on a scale of 0 to 10. Client has medical history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. Social history: denies alcohol use, smokes 1 pack per day for 35 years. Current medications. Lisinopril 20 mg PO daily. Glucophage 500 mg PO BID. Simvastatin 20 mg PO daily. Complete the following sentence. After notifying the provider, the nurse should first______and then_______.

the nurse should first administer nitroglycerin and then obtain an\r\electrocardiogram (ECG).

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

will have an identification band that matches the one my baby wears."

A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

will notify my doctor if the stoma starts to look purple