NGN: Practice A

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

A charge nurse is discussing responsibility of nurses caring for clients who have clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions to the nurse take?

Pad the client's wrist before applying the restraints.

A nurse in the emergency department is caring for a client. Complete the following sentence by using the list of options The nurse should first afresh the clients ——————- followed by the clients —————-

Physical safety Positioning

The nurses reviewing the clients medical record. Which of the following actions should the nurse take? Select all that apply. Presumptive bacterial pneumonia.

Place the client on droplet, isolation precautions Applied oxygen at 2 L per minute via nasal cannula Requested prescription for an anti-pyretic medication Remain 1 m from the client

A nurse is reviewing a clients fluid electrolyte status. Which is the following findings of the nurse report to the provider?

Potassium 5.4 mEq/L This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.

A nurse and altered care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should before the following steps.

1. Obtain the pronouncement of death from the provider. 2. Remove tubes and indwelling lines. 3. Wash the client's body 4. Ask the client's family members if they would like to view the body. 5. Place a name tag on the body.

A middle adult client tells the nurse," I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?

People in middle adulthood often find satisfaction in nurturing and guiding young people."

Complete the following sentence The nurse should first ________________ followed by ______________

1 review medications that might be causing confusion 2 using nother methods to keep the client safe

A nurse, this discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates and understanding of herbal supplement use?

"I can take echinacea to improve my immune system

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vitals signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nurse manager

A nurse is talking with a partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experience which of the following types of role-performance stress?

Role overload

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendation should the nurse make?

maintain a consistent time to wake up each day

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

subtract the amount of irrigation used from the client's urine output

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the pre operative teaching they received about pain management?

It might help to listen to music while lying in bed

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask outside her room if there is construction in the area.

A nurse is assessing clients readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

"You should receive a pneumococcal vaccine when you are 65 years old."

A nurse is repairing to administer 0.9% sodium chloride 750 MLIV to infuse over seven hours. The nurse should set the infusion pump to deliver how many ml/hr? (Round the answer to the nearest whole number. Using a leading zero if it applies. Do not use a tri zero.)

107 ml/hr

A nurse is assessing a client who received an IV fluid bolts for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is caring for a client who has nasal gastric tube and receiving intermittent feedings through open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30°

A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider.

Temperature WBC count Pre albumin level Pain level Odor of wound

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses see made my the nurse is appropriate?

Would you like it if we discussed the transfer with your family member?

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following action should the nurse add to the clients plan of care?

Wrap blankets around all four sides of the bed

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and taped them in place

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

abdominal cramping This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

contact precautions

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?

droplet

A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

encourage the use of a trapeze bar for changing positions.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

hydrocolloid

A nurse has just inserted, a nasal gastric tube for a client. Which of the following findings should the nurse expect to confirm correct to placement?

x-ray that the tube end is above the pylorus and the aspirate of the tube has a pH level of less than 6

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following action should the nurse take?

Instruct the family to refrain from pushing the button for a client while she is asleep.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients paint?

Is your pain sharp or dull?

A nurse is caring for a client who requires a 24 hour urine collection. Which of the following statements by the nurse indicates and understanding of the teaching?

A flushed what I urinated at 7:00 am and have saved all urine since

After reviewing the assessment findings, which of the following actions should the nurse plan to take? Select 3 actions.

Administer analgesic prior to planned activities Assist client to dangle their legs at bedside prior to standing Delegate the application of sequential compression devices to assistive personnel

A nurse is caring for a client who is postoperative. When the nurse prepares to change the client dressing, they say, every time you change my bandage, it hurts so much. Which of the following interventions is the nurses priority, action?

Administer pain medication 45 min before changing the client's dressing.

A nurse is planning care for an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Allow the adolescent to make decisions regarding their daily routine

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative

A nurse is planning care for client who has vision loss. Which of the following interventions to the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the clients plate

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via nasal cannula. Which of the following g interventions should the nurse take first?

Assist the client to an upright position

A nurse is planning care for a client and had a stroke, resulting an aphasia and dysphasia. Which of the following task to the nurse assigned to the assistive personnel?

Assist the client with partial bed bath Measure the clients BP after the nurse administers an anti hypertensive medication Using a communication board to ask what the client wants for lunch

Highlight the findings that indicate the client is malnourished

Cachectic with flaccid muscle tone Skin is dry and scaly with bruises on extremities Pulse rate 118/min Abdomen distended BMI 17

A nurse enters a clients room and finds them on the floor. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

Client found lying on the floor

A nurse is admitting a new client. Which of the following action should a nurse take while performing medication reconciliation?

Compare the client of medication's with the providers prescriptions

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes to the nurse identify as an indication that the treatment was successful?

Decreasing heart rate

A nurse is admitting client who is having an exacerbation of heart failure. in planning this client care, when should the nurse initiate discharge planning?

During the admission process

The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching.

Eat probiotic foods, such as yogurt Avoid alcohol while experiencing diarrhea Avoid caffeine while experiencing diarrhea Follow a low fiber diet

A nurse is assessing for adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuffs around 80% of the clients arm

A client who is nonambulatory notices the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client

A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching?

I know to call my doctor if I gain 3 Ora more pound in two days I am eating fewer potato chips and more fruit for snacks I am limiting my sodium

A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?

I want you to tell me about measures available to keep me comfortable.

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

Place the client in a room with negative-pressure airflow Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene

A nurse is completing admission assessment for a client who reports vomiting and diarrhea for the last three days. Which is the following fighting should the nurse expect?

Rapid heart rate

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following action, should the nurse take when lifting this object?

Stay close to the cabinet when lifting it

The nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as a proper safety protocol?

The client identifies the location of a fire extinguisher

Click to highlight the assessment findings below that the nurse should report to the provider.

Urinary output Reported pain level Vital signs

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements to the nurse manager plan to include in the teaching?

Use a complete name of the medication, magnesium sulfate

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

Wear a gown when caring for the client

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion.