NCLEX Study

A nurse is caring for a client who is in spinal cord injury (SCI) unit. Complete the following sentence by using the list of options.

1. Oxygen saturation 2. urinary output The nurse should first address the client's oxygen saturation followed by the client's urinary output.

A nurse is caring for a client. Complete the following sentence by using the list of options.

1. anorexia nervosa 2. arrhythmia The client is exhibiting manifestations of anorexia nervosa and is at risk for arrhythmia

The nurse is continuing to care for the adolescent. Complete the following sentence by using the lists of options

1. compartment syndrome 2. paresthesia The client is at highest risk for developing compartment syndrome as evidenced by the client's drop paresthesia.

A nurse on the medical-surgical unit is caring for a client who was admitted from the emergency department (ED).

1. confusion 2. sodium level The client is at risk for developing confusion due to sodium level.

A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

1. hemorrhagic stroke 2. autonomic dysreflexia The client is at risk for developing hemorrhagic stroke due to a sudden increase in blood pressure caused by autonomic dysreflexia.

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy

1. hypocalcemia 2. client's report of muscle spasms, numbness around lips, and decreased calcium level The client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level.

A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG). Complete the following sentence by using the lists of options.

1. hypokalemia 2. laboratory report and the client's report of muscle cramping The client is at greatest risk for developing hypokalemia as evidenced by laboratory report and the client's report of muscle cramping.

A nurse is caring for a client who has bulimia nervosa. Drag words from the choices below to fill in each blank in the following sentence.

1. hyponatremia 2. cardiovascular abnormalities The client is at risk for developing hyponatremia and cardiovascular abnormalities.

A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

1. seizures 2. blood pressure The client is at risk for developing seizures as evidenced by the client's blood pressure.

a nurse is preparing to administer lactated ringers 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to nearest whole number. Use a leading zero if it applies. Do not use a trailing zero).

13

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer?

18 g

The nurse is continuing to care for the adolescent. Which of the following prescriptions should the nurse anticipate form the provider? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent.

Apply ice to the affected extremity - contraindicated Elevate the right leg about heart level - contraindicated Prepare the adolescent for surgery - anticipated Remove the splint - anticipated

A nurse is caring for a client who is pregnant. The nurse is providing discharge teaching to the client. For each discharge instruction, click to specify if each action is recommended or contraindicated for the client.

Drink warm ginger ale when nauseated - recommended Increase intake of high-fat foods - contraindicated Eat every 2 to 3 hr - recommended Alternate eating solid foods and liquids - recommended

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. the first day of her last menstrual period LMP was May 8. According to Nagele's rules, which of the following dates should the nurse document as the clients estimated date of birth EDB?

February 15

A nurse is caring for a client who has active tuberculosis TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Have the client wear a surgical mask while being transported outside the room

A nurse is caring for a school-age child. For each assessment finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process.

Impaired language skills - Intellectual impairment - ADHD Hyperactivity to sensory input - ADHD Interrupting others - ADHD Losing necessary things - ADHD When analyzing cues, the nurse should identify that manifestations of ADHD include losing necessary things, interrupting others, intellectual impairment, and hyper reactivity to sensory input. In ADHD, the client often loses necessary things in daily life, such as pencils, erasers, and books. The client often interrupts others and has difficulty waiting for their for their turn in conversation. The client might have an intellectual impairment, which can lead to poor academic performance and difficulties with socialization. The client might exhibit hyper reactivity to stimuli.

A nurse is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Keep the client supine - contraindicated oxygen therapy to keep oxygen saturation about 95% - anticipated monitor blood glucose every 4 hr - anticipated maintain the client's hips in flexion - contraindicated cluster nursing care - contraindicated keep the lights in the client's room dim - anticipated

A nurse is planning to delegate client care tasks to an assistive personnel AP. Which of the following tasks should the nurse plan to delegate to the AP?

Perform gastrostomy feedings through a client's established gastrostomy tube

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. For each assessment finding, click to specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis. Each finding may support more than one disease process.

Weight - Crohn's, ulcerative colitis Albumin level - Crohn's, ulcerative colitis Heart rate - peritonitis Abdominal pain location - Crohn's WBC - all Bowel pattern - Crohn's Temperature - all

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

a client who has cellulitis and is receiving oral antibiotics every 8 hr

An antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions?

a client who is at 33 weeks of gestation and has severe gestational hypertension

A nurse has just received change of shift report on four clients. Which of the following clients should the nurse assess first?

a client who is postoperative with abdominal distention and no bowel sounds

A nurse has received change of shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

a client who is receiving an MAOI and is requesting a cheeseburger for dinner

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

a client who was abused as a child describes the abuse as if it happened to someone else

A home health nurse is caring for a group of older adult clients. the nurse should initiate a referral to the program of all-inclusive care for the elderly (PACE) for which of the following clients?

a client whose caregiver requests adult day care services

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

aPTT

A nurse in a community center is providing an educational session to a group of client about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?

abdominal bloating

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?

administer high dose antibiotic therapy

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should indicate which of the following information in the teaching?

advocacy is a leadership role that helps others to self-actualize

A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?

agency for healthcare research and quality

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

allow for frequent rest periods throughout the day

aA nurse is caring for a client who is in the fourth stage of labor and is reviewing oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

amount of vaginal bleeding

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

an older adult client who is anxious and attempting to pull out an IV line

A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?

apply a cold pack to the client's ankle for 30 min every hour

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

arrange the lunch tray for a client who has a hip fracture

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. after the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

ask another nurse to witness the disposal of the new patch

A charge nurse is speaking with the partner of a client. the partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

ask the partner to list specific concerns

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?

aspirate contents from the tube and verify the pH level

A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?

assign the client to a private room with negative air pressure

A nurse is caring for a client who has abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

assist with deep breathing and coughing

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

auscultate the apical pulse at least 1 min

A nurse manager is reviewing client's rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

autonomy

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

borderline

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make?

broccoli, yogurt, cream cheese

A nurse is caring for an adolescent. Select the 4 findings that require followup.

capillary refill, skin temperature, pedal pulse, pain

A nurse is caring for a client following a vacuum assisted birth. The nurse should monitor the client for which of the following complications related to vacuum assisted birth?

cervical laceration

A nurse in an emergency department is assessing a school age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

contact child protective services

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

decreased hallucinations

A nurse manager is preparing an educational session for nursing staff about how to provide cost effective care. Which of the following methods should the nurse include in the teaching?

delegate non-nursing tasks to ancillary staff

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

dyspnea

A nurse is caring for an adolescent. Which of the following actions should the nurse take after the adolescent returns from surgery?

elevate affected limb at chest level perform neurovascular assessments every hour removing indwelling urinary catheter when it is no longer indicated

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

ensure that the client understands the medication regimen

A nurse is caring for a client who has acute blood loss following a trauma. the client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?

explore the client's reasons for refusing the treatment

The nurse is assessing the adolescent 4 hr following fasciotomy. Click to highlight the findings below that indicate the adolescent's condition is improving.

extremity puls +3 capillary refill 2 seconds right extremity is warm to the touch adolescent reports no numbness or tingling adolescent reports pain as 2 on a scale 0 to 10

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The clients family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?

facilitate an interdisciplinary conference at the new facility for the family

A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.

fever, heart rate, blood pressure, and mental status

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

fiber

A nurse is caring for a client who is 1 hr postpartum. Select the 6 actions the nurse should take.

firmly massage the uterine fundus, administer methylergonovine, weigh the perineal pads, provide emotional support, inserting an indwelling urinary catheter, administer oxygen

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

flight of ideas

A nurse manager in a long term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?

form a committee of staff members to investigate current staffing issues

A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

hemoglobin 14.9 g/dL

A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?

hold the insulin pen device perpendicular to the client's skin to inject the medication

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

implement fall precautions for the client

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

increase the client's dietary iron intake

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?

initiate continuous cardiac monitoring

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

insert a lubricated gloved finger and advance along the rectal wall

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

instruct the client to void

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

irritability

A nurse is caring for a client who is taking valproic acid for seizure control. for Which of the following adverse effects should the nurse monitor and report?

jaundice

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

maintain sterile objects within the line of vision

A nurse on a medical surgical unit is caring for a client who has a new diagnosis of terminal cancer. the client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

make a referral for social services

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?

making a list of activities to complete

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel?

measure the client's daily weight

A nurse is caring for a client who is postoperative following an appendectomy. Which of the following 4 client findings should the nurse report to the provider?

pain level, nausea, heart rate, and oxygen saturation

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure? ICP

place the client in a quiet environment

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. the nurse is unable to locate members of the clients family to obtain consent. Which of the following actions should the nurse take?

proceed with provision of medical care

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

radial vein of the inner arm

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

report of chest pain

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, psco2 of 60 mm Hg, nd HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid base imbalances?

respiratory acidosis

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

restlessness, auditory hallucinations, speech

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

strict adherence to routines

A nurse is creating a plan of care for a client who has left sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

support the client's left arm on a pillow while sitting

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. upon arrival at the playground, which of the following actions should the nurse take first?

survey the scene for potential hazards to staff and children

A nurse is providing teaching to a school age child who has asthma about using albuterol metered dose inhaler. Which of the following instructions should the nurse include?

take the medication 15 min before playing sports

A nurse is caring for a client who is receiving positive end expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

tension pneumothorax

An RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed. For which of the following situations should the nurse intervene?

the LPN and the AP grasp the client under his arms to lift him up in bed

A nurse is continuing to care for the adolescent. The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?

the adolescent's parents have concerns regarding the surgery

A nurse is the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

the child exhibits discomfort while walking

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

the client is pacing around the chair in which their partner is sitting

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

turn off the CPM machine during mealtime

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?

use a reward system to modify the child's behavior

A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place a new prescription for crutches. The client is non weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?

use a three point gait

A nurse is conducting group therapy with clients who have breast cancer. the nurse should recognize which of the following statements by a client as an example of altruism?

"I told my doctor that I would like to start a support group for other women who are sick in my community"

A nurse is providing education to the parent of a school age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

"I will make sure my child receives a yearly influenza vaccination"

A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?

"Tell me more about your understanding of the options"

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

"We can expect the hospice nurse to provide support for us after our mother's death"

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy. The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?

"You have the right to change your mind about this procedure at any time"

A nurse is providing teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?

"Your body temperature might decrease slightly just prior to ovulation"

A nurse is providing phone advice for a client who is pregnant. Complete the following sentence by using the lists of options

1. metabolic acidosis 2. weight loss The client is at risk for experiencing metabolic acidosis due to excessive weight loss.

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

monitor the client's mouth every 8 hr

During a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. which of the following actions should the day shift nurse take?

move the client to a room near the nurses' station

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

nasal flaring

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

noting the progress of the group toward assigned goals

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

pH 7.31

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

pink, frothy sputum

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?

sedentary lifestyle

A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?

seeks input from the other nurses

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

serum liver enzyme levels

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?

starts a task then determine what supplies are needed

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?

the client reports a decrease in episodes of nausea

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change of shift report?

the time of the client's last dose of pain medication

A nurse administers an incorrect dose of medication to a client. the nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

time the medication was given

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

tremors

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

use the ventrogluteal site

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

verify the client and blood product information with another licensed nurse

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?

wear clothing made with cotton fabrics while oxygen is in use

A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

wheezing

A nurse is caring for a client who has pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take?

withhold the heparin infusion

A nurse on a pediatric unit has received change of shift report for four children. Which of the following children should the nurse assess first?

a 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain

A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?

a middle adult client who has unstable vital signs

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

avoid including raw fruits in the client's diet

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

blurred vision

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

cough

A nurse is updating the plan of care for a client who is 48 hr post operative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

determine the client's reading skills

A nurse on a medical surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

difficulty performing ADLs

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

droplet

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

dry mouth

A nurse is caring for a client following a laparoscopic cholecystectomy. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

encourage deep breathing exercises every hour - anticipated change dressing when soiled - anticipated apply heat for abdominal pain as needed - anticipated ondansetron 4mg PO for nausea - contraindicated

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understandings of isolation precautions?

"A client who requires airborne precautions should be placed in a negative pressure airflow room"

A nurse in a providers office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for adverse effect of this medication?

"Have you had any stomach pain or bloody stools"

A nurse is admitting a client to the psychiatric unit after attempting suicide. the client states "My family does not care whether I live or die", which of the following responses should the nurse make?

"How does this make you feel?"

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

"I can designate my partner as my health care surrogate"

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

"I will be checking you once with your eyes open and once with them closed"

A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? select all

"I will cover my baby's body when I wash her hair" "I will use the bulb syringe first in her mouth then in her nose"

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

"I will need to measure your weight daily"

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome SIDS. Which of the following guardian statements indicates an understanding of the teaching?

"I will not allow anyone to smoke near my baby"

A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will wear a supportive bra overnight"

A charge nurse notices that one of the nurses on the shift frequently violates unit polices by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

"I would like to talk to you about the unit polices regarding break time"

A home health nurse is evaluating a school age child who has cystic fibrosis. The nurse should initiate a request for high frequency chest compression vest in response to which of the following parent statements?

"My child has only a small amount of mucus after percussion therapy"

A nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? select all

"shake the medication bottle well before each dose is given" "store the medication in the refrigerator" "report diarrhea to the provider immediately"

A nurse is caring for a client who is postoperative following administration of general anesthesia. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Action To Take 1. Administer dantrolene 2. Administer oxygen Condition Most Likely Experiencing 1. Malignant hyperthermia Parameter To Monitor 1. Hypercapnia 2. Muscle rigidity

A nurse in an emergency department (ED) is assessing a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Action To Take 1. Hold all antipsychotic medications 2. Provide a cooling blanket Condition Most Likely Experiencing 1. Neuroleptic malignant syndrome Parameter To Monitor 1. Temperature 2. Hydration status

A nurse is caring for a 68-year-old client who is 2 days postoperative following surgical repair of a left hip fracture. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor for that condition.

Actions to Take 1. Assist client to semi-Fowler's position 2. Prepare to administer IV fluids Potential Condition 1. Intestinal obstruction Parameters to Monitor 1. Bowel sounds 2. Urine output

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. Which of the following interventions should the nurse implement?

Administer IV fluids, use humidification with oxygen therapy, assess peripheral circulation hourly, assess the client's mouth every 8 hr

A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feedings?

Albumin 2.8 g/dL

A nurse is caring for a 2 month old infant who has Hirschsprung disease HD. Which of the following areas should the nurse assess for manifestations of HD?

C

A nurse on a mental health unit is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Initiate suicide precautions - anticipated Low-sodium diet - contraindicated Fluoxetine 20 mg PO daily - contraindicated Potassium 40 mEq PO daily - anticipated

A nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

Initiate transmission-based precautions

A nurse is performing an abdominal assessment on a client. identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps).

Inspection Auscultation Percussion Palpation

A nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs, which of the following images indicates the adolescent is abducting the hip joint?

Moving the leg away from the midline of the body (off to the side, not to the front)