PN Comprehensive Online Practice 2023 B

A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?

"Your oncologist might prescribe a cold cap to wear during treatment to reduce hair loss." The nurse should inform the client that cold caps cause vasoconstriction, which can help to decrease hair loss by reducing the ability of the chemotherapy medication to reach the hair follicles.

A nurse is caring for a client who has a prescription for famotidine 160 mg PO every 6 hr. Available is famotidine oral suspension 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20 mL

A nurse is assisting with the care of a school-age child immediately following surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider?

250 mL of sanguineous drainage over the last 3 hr The nurse should recognize that if more than 3 mL/kg/hr of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately.

A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion?

A client attempts to hit another client during group therapy. The nurse should request a prescription for seclusion for a client who is at risk for harming themselves or others, or who exhibits violent behavior.

A nurse is receiving change-of-shift report for four clients. The nurse should plan to collect data from which of the following clients first?

A client who has asthma and had frequent exacerbations on the previous shift When using the airway, breathing, circulation (ABC) approach to client care, the nurse should prioritize data collection from a client who has asthma. The client experienced several exacerbations of asthma on the previous shift, which can result in an obstruction of the client's airway.

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

A client whose urinary output was 100 mL for the past 12 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a urine output of less than 30 mL/hr due to the risk for fluid imbalance. Therefore, the nurse should see this client first.

A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Observe the client's facial expressions during communication. The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whether the client understands what the interpreter is saying.

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

Obtaining a client's vital signs prior to discharge Obtaining vital signs does not require use of the nursing process and is within the range of function for an AP. Therefore, the nurse should delegate this task to the AP.

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

Open sterile packages. When preparing to perform tracheostomy care, the greatest risk to the client is the transmission of micro-organisms. Therefore, the priority action is to open sterile packages. The nurse should have a sterile bowl in which to pour the sterile solution to prevent the contamination of the sterile gloves.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

Open the outer package flap of the catheterization kit away from their body. The nurse should open the outer package flap of the catheterization kit away from their body to prevent their arm from crossing over the sterile field when opening the remaining flaps.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place an abduction wedge between the client's legs when in bed. The nurse should place an abduction wedge between the client's legs while in bed to prevent adduction of the legs and hip dislocation following a total hip arthroplasty.

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

Place the client in a lateral position. Late decelerations occur due to utero-placental insufficiency. The nurse should assist the client into a lateral position to improve uterine perfusion and oxygen transfer to the fetus.

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

"I should use counterpressure for back pain during labor." Counterpressure is a cutaneous stimulation strategy to decrease pain resulting from pressure of the fetal occiput against the spinal nerves.

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

Muscle weakness The nurse should expect a client who has hypokalemia to have bilateral muscle weakness. Other manifestations of hypokalemia include hyporeflexia, muscle stiffness, cramping, and paralysis.

A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching?

"I should wear a soft scarf around my neck when I am outside." A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun exposure.

A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching?

"You will need to take the medication for the rest of your life." Hypothyroidism is a chronic disorder that requires lifelong thyroid hormone replacement therapy.

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include?

"Apply a water-based lubricant around the nostrils to prevent irritation." The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy.

A nurse in a provider's office is obtaining a health history from a client who is scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the priority for the nurse to ask?

"Do you know if you're allergic to iodine?" The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. Therefore, the priority question is to identify the client's allergies.

A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I should apply sterile saline to lubricate the suction catheter." The nurse should lubricate the suction catheter with sterile saline prior to suctioning.

A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching?

"Your HIV status will be shared with members of your health care team." The diagnosis of HIV or AIDS is shared with every member of the health care team who provides direct care for the client, just like any other diagnosis.

A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

Tomatoes The nurse should recommend tomatoes, which are a food source that is high in vitamin C.

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions?

"I will receive the nutrients I need through my IV fluid." During initial treatment of acute diverticulitis, the client is often kept NPO and receives parenteral nutrition to promote bowel rest. As the client's condition improves, they can progress to a soft, low-fiber diet. A high-fiber diet is prescribed once the client is fully recovered from the acute inflammation.

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

"I will secure the car seat in the car by using the seatbelt." The nurse should instruct the guardian to secure the car seat in the car by using the seatbelt.

A nurse is reinforcing discharge teaching with the parents of a school-age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching?

"I will soak my child's toothbrush in warm water to soften it before my child uses it." The nurse should instruct the parents to soften their child's toothbrush in warm water before they use it or allow them to use a sponge-tipped disposable toothbrush. These actions will minimize trauma to the gums and prevent bleeding of the oral cavity.

A nurse is reinforcing teaching with a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

"I will use condoms in addition to birth control pills to decrease my risk of becoming pregnant." Rifampin can interact with and reduce the effectiveness of oral contraceptives. Therefore, the nurse should instruct the client to use a secondary method to prevent pregnancy.

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

"If I forget to take a dose, I can take it later on the same day." If the client misses a dose of medication, they can take it later the same day but should not double the dose the next day.

A nurse is collecting data from a 5-year-old child at a well-child visit. The parent reports that the child is having frequent nightmares. Which of the following statements by the parent indicates to the nurse that the child is experiencing sleep terrors rather than nightmares?

"My child goes back to sleep right away." The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who is experiencing nightmares has difficulty returning to sleep because of continued fear.

A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

"You should depress the button on the handheld marker when you feel your baby move." The nurse should instruct the client to depress the button on the handheld marker when they feel fetal movement. The nurse will note the mark on the fetal monitor tracing and the provider can review it. This test monitors fetal well-being.

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasonography the following day. Which of the following statements should the nurse include in the teaching?

"You will need to have a full bladder for the procedure." A full bladder is necessary because it moves the uterus upward for optimal visualization of the fetus and stabilizes the uterus for optimal reflection of sound waves.

A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?

"You will need to schedule a bone density test." Long-term use of corticosteroids, such as prednisone, can induce osteoporosis. Therefore, the client should schedule a bone density test to establish a baseline evaluation.

A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following client findings indicates a therapeutic effect of this medication?

Reports a decrease in the number of stools Pancrelipase is administered as replacement therapy for a deficiency in pancreatic enzymes, which results in steatorrhea, or fatty stools. The nurse should monitor for improved nutrition and a decrease in the number of bowel movements, which would indicate a therapeutic response to the medication.

A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching?

Strain the urine to collect stone fragments. The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation.

A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the following instructions should the nurse include?

Administer by subcutaneous injection. The nurse should include that enoxaparin should be injected into the subcutaneous tissue.

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

Apply capsaicin cream four times daily. The nurse should instruct the client to apply capsaicin cream topically to provide warmth and relieve joint pain. The client should apply the cream no more than four times daily to avoid skin irritation.

A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include?

Apply the prosthesis immediately upon waking each day. The nurse should reinforce with the client the importance of applying the prosthesis immediately upon waking to prevent swelling of the residual limb.

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

Applying the stockings before the client gets out of bed The AP should apply antiembolic stockings while the client is in a supine position and before the client gets out of bed. Antiembolic stockings provide pressure to the lower extremities, which promotes venous return and reduces the risk of deep vein thrombosis formation in clients who are immobilized. Allowing the client to ambulate before applying the antiembolic stockings might cause lower extremity edema, making the stockings more difficult to apply.

A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

As soon as the client awakens in the morning Sputum from the base of the lungs provides the best specimen for collection. The AP should obtain the specimen early in the morning because overnight fluid accumulates in the base of the lungs while the client is sleeping.

A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

Avoid foods with a high sugar content. The nurse should instruct the client to avoid sweet foods, which often increase the manifestations of dumping syndrome. These manifestations include nausea, sweating, abdominal pain, diarrhea, and weakness.

A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?

Avoid lying on the affected side. The client should avoid lying on the affected side because this increases intraocular pressure.

A nurse is checking a newborn's vital signs. Which of the following methods of temperature measurement should the nurse use?

Axillary The nurse should obtain the newborn's temperature using the axillary method because this method is accurate and safe for newborns. Axillary temperatures are expected to range from 36.5º to 37.5º C (97.7º to 99.5º F) in newborns.

A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

Capillary refill of 5 seconds to the client's toes A capillary refill of 3 to 5 seconds to the client's toes is an expected finding and indicates adequate circulation in the casted extremity.

A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

Change the appliance two times each week. The nurse should change the appliance two times each week to maintain an effective seal around the stoma. The nurse should remove the appliance carefully and cleanse the client's stoma.

A nurse is talking with a client who says the provider agreed to initiate a do-not-resuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first?

Check for documentation that the provider spoke with the client about the DNR. The first action the nurse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decision and that documentation meets legal requirements.

The nurse is collecting data from the adolescent 4 hr following the fasciotomy. Exhibit 1 Data Collection​ 1400: Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2 Vital Signs1400: Temperature 37° C (98.6° F)Weight 54.5 kg (120 lb)Pulse 89/minRespiratory rate 20/minBlood pressure 124/82 mm HgOxygen saturation 98% on room air1630: Temperature 38° C (100.4° F)Heart rate 94/minRespiratory rate 20/minBloo

Click to highlight the findings below that indicate an improvement in the adolescent's condition. When evaluating outcomes, the nurse should identify the adolescent's extremity pulse, capillary refill, extremity warm to the touch, no numbness or tingling, and a decrease in pain are all findings that indicate the fasciotomy was effective.

A nurse is collecting data on a newborn who is 3 days old. Exhibit 1 History and Physical Newborn was delivered at 37 weeks gestation via cesarean section for fetal distress.Apgar scores 8 at 1 min and 9 at 5 min.Birthweight 2,892 g (6 lb 6 oz)The client who gave birth plans to breastfeed. Exhibit 2 Flow Sheet Day 2 of Life 0900: Temperature 36.7° C (98° F)Heart rate 140/minRespiratory rate 48/minWeight 2,718 g (6 lb), 6% weight lossDay 3 of Life 0800:​ Temperature 36.4° C (97.5° F)Heart rate 140/minRespiratory rate 48/minWeight 2,545 g (5 lb 9 oz), 12% weight loss Exhibit 3 Nurses' Notes Day 3 of Life 0800: Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Small amount of bloody mucus discharge noted from vag

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Temperature 36.4° C (97.5° F) Weight 2,545 g (5 lb 9 oz) 12% weight loss Mild tremors noted when awake. Breastfeeding every 3 to 5 hr for 5 to 10 min. Birth parent reports nipple discomfort throughout the feeding. When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.

A nurse is assisting with the care of a client who has schizophrenia in an inpatient facility. Exhibit 1 Medication Administration Record Day 1 0630: Clozapine 100 mg PO dailyAripiprazole 5 mg PO dailyMultivitamin PO daily Exhibit 2 Laboratory Results Day 1 0630: Sodium 125 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5 mEq/L) Chloride 90 mEq/L (98 to 106 mEq/L) BUN 8 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Total calcium 10 mg/dL (9 to 10.5 mg/dL) Phosphate 4 mg/dL (3 to 4.5 mg/dL) Glucose 70 mg/dL (74 to 106 mg/dL) Exhibit 3 Vital Signs Day 1 0630: Temperature 37.6° C (99.6° F)Heart rate 102/minRespiratory rate 24/minBlood pressure 140/90 mm HgOxygen saturation 98% on room air 1230: Temperature 37.6° C (98° F)Heart rate 98/minRespiratory rate 20/minBlood pressure 142/92 mm HgOxygen saturation 100% on room air 1730: Temperature 37.1° C (98.8° F)Heart rate 104/minRespiratory rate 24

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. When analyzing cues, the nurse should identify that the client is taking a second-generation antipsychotic medication, which can lead to manifestations of tardive dyskinesia, including involuntary tongue movement and foot tremors. Frequent urination and incontinence are adverse effects of aripiprazole and should be reported to the provider. An increase in agitation is a safety risk for the client, staff, and others on the unit and requires immediate de-escalation.

A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

Client reports burning with urination. When using the urgent vs. nonurgent approach to client care, the nurse should determine that dysuria is a manifestation of a urinary tract infection. Therefore, the nurse should identify this as the priority finding to report to the provider.

The nurse is continuing to care for the adolescent. Exhibit 1 Vital Signs​ 1400: Temperature 37° C (98.6° F)Weight 54.5 kg (120 lb)Pulse 89/minRespiratory rate 20/minBlood pressure 124/82 mm HgOxygen saturation 98% on room air1630: Temperature 38° C (100.4° F)Heart rate 94/minRespiratory rate 20/minBlood pressure 126/84 mm HgOxygen saturation 98% on room air

Complete the following sentence by using the lists of options. The client is at greatest risk for developing compartment syndrome as evidenced by the client's severe pain. The nurse should determine that the priority hypothesis is that the adolescent is developing compartment syndrome as evidenced by severe pain following the administration of pain medication. When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is severe pain. This can indicate compartment syndrome, which requires immediate intervention. Therefore, this finding is the highest priority.

A nurse is assisting with the care of a client who is 1 day postoperative following a total thyroidectomy. Exhibit 1 Laboratory ResultsDay 2, 0700: Sodium 143 mEq/L (136 to 145 mEq/L)Potassium 3.5 mEq/L (3.5 to 5 mEq/L)Chloride 104 mEq/L (98 to 106 mEq/L)BUN 15 mg/dL (10 to 20 mg/dL)Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)Total calcium 8 mg/dL (9 to 10.5 mg/dL)Phosphate 4.6 mg/dL (3 to 4.5 mg/dL)Glucose 95 mg/dL (74 to 106 mg/dL)WBC count 9,500/mm3 (5,000 to 10,000/mm3) Exhibit 2 Nurses' Notes​ Day 2, 0700: Client alert and oriented x 3. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all four quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck at 2 on a 0 to 10 scale. Declines pain medication.1100: Client alert and oriented x 3. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all four quadrants.

Complete the following sentence by using the lists of options. The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips The nurse should recognize cues and determine that 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. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest priority, as it requires immediate treatment with calcium gluconate to avoid dysrhythmias and other complications.

A nurse on the medical-surgical unit is assisting with the care of a client who was admitted from the emergency department (ED). Exhibit 1 Vital Signs Vital signs upon admission to the ED: 1400: Temperature 38° C (100.4° F)Heart rate 110/minRespiratory rate 24/minBP 96/58 mm HgPulse oximetry 96% on room air Vital signs upon admission to the medical-surgical unit: 1500: Temperature 37.2° C (98.9° F)Heart rate 96/minRespiratory rate 20/minBP 100/70 mm HgPulse oximetry 97% on room air Exhibit 2 Nurses' Notes 1500: Client admitted from the ED for dehydration. Client is alert and oriented to person, place, and time. Client reports they are feeling "weak." IV dextrose 5% in water (D5W) infusing at 100 mL/hr Exhibit 3 Laboratory Results 1400: Calcium 10.2 mg/dL (9 to 10.5 mg/dL)Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)Potassium 4.7 mEq/L (3.5 to 5 mEq/L)Sodium 150 mEq/L (136 to 145 mEq/L)1700: Calcium 9.5 mg/dL (9 to 10.5

Complete the following sentence by using the lists of options. The client is at risk for developing confusion due to sodium level Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range. Hypernatremia places the client at risk for a decreased level of consciousness, falls, and seizure activity. Therefore, the nurse should assist in monitoring the client's level of consciousness and place the client on fall and seizure precautions.

A nurse is reinforcing teaching with a client who is pregnant. Exhibit 1 Nurses' Notes Week 6 of gestation: Spoke with client over the phone. Client reports nausea and vomiting with a weight loss of 0.9 kg (2 lb) from their pre-pregnancy weight. Client reports no noted change in voiding pattern and denies dry mucus membranes. Reminded client to eat small frequent meals of non-greasy, dry, sweet, or salty foods such as dry toast, crackers, and pretzels. Encouraged client to call back if nausea and vomiting worsens.Week 10 of gestation: Spoke with client over the phone. Client reports a 6.8 kg (15 lb) weight loss over the past month. Client states nausea continues, making it difficult to eat. They describe a diet of water, toast, and pretzels because other foods are unappealing. They report tolerating a cup of black coffee each morning. Encouraged client to be seen by the provider today.

Complete the following sentence by using the lists of options. The client is at risk for experiencing metabolic acidosis due to the client's weight loss When prioritizing hypotheses, the nurse should recognize that the client is at risk for developing metabolic acidosis due to excessive weight loss. The intake and retention of food is not meeting the client's nutritional requirements. Undernutrition can lead to the breakdown of fatty tissue, which increases the release of nonvolatile acids into the blood stream.

A nurse is assisting with the care of a client who has a new diagnosis of anorexia nervosa. Exhibit 1 Laboratory Results Day 1 2030: Sodium 146 mEq/L (136 to 145 mEq/L) Potassium 3.3 mEq/L (3.5 to 5 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Glucose (casual) 75 mg/dL (74 to 106 mg/dL) Total protein 5.8 g/dL (6.4 to 8.3 g/dL) Albumin 3 g/dL (3.5 to 5 g/dL)Day 2 0530: Sodium 150 mEq/L (136 to 145 mEq/L) Potassium 3.1 mEq/L (3.5 to 5 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 25 mg/dL (10 to 20 mg/dL) Magnesium 1 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Fasting blood glucose 65 mg/dL (74 to 106 mg/dL) Total protein 5.5 g/dL (6.4 to 8.3 g/dL) Albumin 2.7 g/dL (3.5 to 5 g/dL) Exhibit 2 Nurses' Notes Day 1 2005: Client alert and oriented with flat affect. Client states, "I cannot gain any mor

Complete the following sentence by using the lists of options. The nurse should first address the client's electrolyte imbalance , followed by the client's fear of weight gain When analyzing cues, the nurse should first address the client's electrolyte imbalance. The client has hypokalemia, which increases the risk for cardiac arrhythmias. Once the client's medical concerns are addressed, the nurse should then focus on the underlying psychological issues behind the eating disorder, such as the client's fear of weight gain.

A nurse is assisting with the care of a newborn. Exhibit 1 History and Physical 41 weeks of gestation Spontaneous vaginal delivery with meconium-stained amniotic fluid at 1350 Apgar 7 at 1 min and 9 at 5 min Birth weight 2,500 g (5 lb 5 oz) Maternal urine toxicology positive for marijuana use during pregnancy Maternal blood type A, Rh negative Group B streptococcus β-hemolytic: positive (expected value: negative) Client who gave birth received three doses of intravenous antibiotics while in labor Exhibit 2 Nurses' Notes 1400: Newborn placed skin-to-skin on parent's chest with light blanket over top. Lusty cry. Acrocyanosis noted. Newborn rooting and attempting to latch onto the breast. 1430: Newborn lying quietly on parent's chest. No latch achieved. Acrocyanosis noted. Expiratory grunting and nasal flaring present. Skin loose and dry. Scant amount of green-stained vernix caseosa noted in skin folds.

Complete the following sentence by using the lists of options. The nurse should plan to first collect data about the newborn's respiratory rate , followed by the newborn's heart rate When generating solutions, the nurse should identify that expiratory grunting and nasal flaring are unexpected findings in a newborn and indicate respiratory distress. The presence of meconium-stained amniotic fluid increases the risk that the newborn will develop meconium aspiration syndrome. Therefore, the first action the nurse should take is to collect data about the newborn's respiratory rate, followed by the heart rate. The nurse should perform noninvasive data collection techniques, such as observing the respiratory rate, before more invasive techniques that might stimulate the newborn, such as auscultating the heart rate, to avoid alteration of data.

A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?

Consumption of contaminated food The nurse should include that hepatitis A is spread via the fecal-oral route through direct contact with stool or consumption of contaminated food and water.

A home health nurse is caring for a client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

Determine the client's mobility status. The first action the nurse should take when using the nursing process is to determine the client's mobility status. The nurse should begin collecting data about the client's ability to move freely within their environment while preventing injury. The nurse should begin by placing the client in the position providing the most support, then moving in increments to positions requiring less support and higher levels of tolerance.

A nurse is collecting data from a client who reports recent methamphetamine use. Which of the following manifestations should the nurse expect?

Dilated pupils The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance.

A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

Drink high-protein and high-calorie nutritional supplements. The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that can lead to hypermetabolism and wasting of the client's muscle mass.

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse include?

Eat a bedtime snack. The manifestations described by the client indicate hypoglycemia. Eating a snack at bedtime will help prevent hypoglycemic episodes during the night.

A nurse is assisting a client who is postoperative to sit on the side of the bed. Which of the following actions should the nurse take?

Elevate the head of the client's bed. The nurse should elevate the head of the client's bed to decrease the distance the client has to move to sit on the side of the bed.

A nurse is reinforcing teaching with a client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Expose the glans of the penis is the first step. The client should expose the glans of the penis to prepare for cleansing of the urinary meatus. Cleanse the penis using an antiseptic swab is the second step. The client should cleanse the area to decrease the levels of bacteria that could contaminate the urine specimen. Begin urination is the third step. The client should begin urinating to eliminate any bacteria or other micro-organisms that have collected in the urethra. Pass the cup into the urine stream is the fourth step. The client should pass the cup into the urine stream and collect 30 to 60 mL of urine. Move the cup out of the urine stream is the fifth step. The client should move the cup out of the urine stream after 30 to 60 mL of urine have been collected and before releasing their hand from the penis. This prevents the contamination of the urine specimen with flora from the client's skin. Replace the foreskin is the sixth step. The client should replace the foreskin over the glans of the penis after the urine specimen is collected to prevent swelling and possible constriction of the area.

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

External rotation Clinical manifestations of a hip fracture include external rotation and shortening of the affected extremity.

A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take?

Flush the feeding tube with water before and after administering the medication. To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administration.

A nurse is caring for a client who is receiving continuous feedings via a gastrostomy tube. Which of the following actions should the nurse plan to take?

Flush the tube with 50 mL of water if it becomes clogged. The nurse should flush the feeding tube with 20 to 50 mL of warm water if the tube becomes clogged to re-establish the patency of the gastrostomy tube.

A nurse is assisting with the care of a client who was admitted to the emergency department (ED). Exhibit 1 Admission Assessment Day 1 1930: Client admitted to the ED by police after report of violent behavior in public. Client smashed a glass window with their hands. Client is stating, "I am Jesus." Client is attempting to hit staff. Client placed in restraints. Neuro: Client is alert and oriented x 0. Client is swinging their arms and shouting. Client is unable to answer questions and their speech is rapid and unorganized. Heart rate is 108/min, regularIntegumentary: Laceration noted to the client's left hand (2 cm x 2.5 cm). Laceration noted to the left forearm (4 cm x 6 cm). Profuse bleeding noted. Multiple small lacerations noted to face, left arm, and right arm. Allergies: Unable to assess Exhibit 2 Vital Signs Day 1 1930: Temperature 36.7° C (98.0° F)Pulse 108/minRespiratory rate 24/minBP 150/92 mm Hg1945: P

For each potential assessment finding, click to specify if the finding is consistent with schizophrenia or bipolar 1 disorder. Each finding may support more than 1 disease process. When analyzing cues, the nurse should distinguish between positive and negative manifestations of schizophrenia and bipolar 1 disorder. The client is displaying positive manifestations of schizophrenia, when compared to the assessment findings of a client who has bipolar 1 disorder.

The nurse is continuing to care for the adolescent. Exhibit 1 Data Collection 1400:Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2 Vital Signs1400: Temperature 37° C (98.6° F)Weight 54.5 kg (120 lb)Pulse 89/minRespiratory rate 20/minBlood pressure 124/82 mm HgOxygen saturation 98% on room air1630: Temperature 38° C (100.4° F)Pulse 94/minRespiratory rate 20/minBlood pressure 126/84 mm HgOxygen saturat

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent. When generating solutions for an adolescent who has compartment syndrome, the nurse should anticipate that the adolescent will need a fasciotomy. A fasciotomy is needed to decrease atrial spasms and increase perfusion within the muscle compartments. The nurse should recognize that elevating the right leg above heart level and applying ice to the affected extremity are all contraindicated for an adolescent who has compartment syndrome. Elevating the right leg above heart level and applying ice to the affected extremity will further compromise blood flow. Removing the splint is part of the immediate treatment for a client experiencing compartment syndrome.

A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects?

Gastric ulcer formation The nurse should monitor the client for indications of a gastric ulcer formation, which is a common adverse effect of prednisone.

A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when which of the following PPE is removed first?

Gloves The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority action for the AP to take is to remove the gloves, which are considered the most contaminated of the PPE.

A nurse is reinforcing teaching with a client about how to replace their two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest?

Hold the skin taut while removing the barrier. Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin.

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Hypervigilance Common manifestations of PTSD include recurrent recollections of the precipitating trauma, hypervigilance, irritability, insomnia, and difficulty concentrating.

A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

INR 5 A client receiving warfarin to prevent clot formation related to atrial fibrillation should have an INR of 2 to 3. An INR of 5 or greater indicates that the client is at risk for bleeding. Therefore, the nurse should notify the provider about this laboratory value.

A nurse is caring for a client who is refusing a prescribed medication. Which of the following actions should the nurse take first?

Identify the client's concerns about receiving the medication. The first action the nurse should take when using the nursing process is to assess the client's concerns. By addressing these concerns using therapeutic communication, the nurse can establish if there are circumstances that make taking prescribed medication difficult, such as financial constraints, or if the client is experiencing adverse effects from the medication.

A nurse is contributing to the plan of care for a client who is postoperative following a rhinoplasty. Which of the following interventions should the nurse recommend?

Instruct the client to avoid the Valsalva maneuver. The nurse should instruct the client to avoid the Valsalva maneuver and other activities that increase pressure at the operative site, resulting in an increased risk for bleeding.

A nurse is collecting data from a newly admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

Irritability An infant who has hypovolemia will experience irritability due to decreased perfusion. The nurse should report this finding to the provider.

A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Lack of sleep The greatest risk for this client is exhaustion or death from lack of sleep; therefore, this is the priority finding. The nurse should encourage frequent periods of rest for the client throughout the day.

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

Maintain a sequential compression device. Sequential compression devices promote venous return by providing intermittent periods of compression on the legs.

A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?

Moist mucous membranes The condition of mucous membranes is an indicator of hydration status. Moist mucous membranes indicate adequate hydration and a positive response to IV fluid therapy.

A nurse is caring for a client who is actively dying from cancer. Which of the following actions should the nurse take?

Moisten the client's conjunctiva with sterile normal saline. If the client's eyes are open, the nurse should moisten the conjunctiva with sterile normal saline, artificial tears, or an ophthalmic lubricating gel.

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse plan to take?

Monitor the client's intake and output. The nurse should ensure that intake and output measurements are accurately obtained to monitor for fluid overload.

A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following information?

Motor response The nurse should collect data about the client's motor response and assign the response a score of 1 to 6, according to the Glasgow Coma Scale.

A nurse is contributing to the plan of care for a client who has a prescription for range-of-motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyperextension?

Move the arm behind the body with the elbow straight. Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow straight.

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider?

Platelet count 95,000/mm3 The nurse should recognize that this platelet count is below the expected reference range for a client who is pregnant and might be indicative of HELLP syndrome. Other manifestations of HELLP syndrome include malaise and epigastric pain. The nurse should immediately notify the provider of this result.

A nurse is receiving change-of-shift report for a group of clients. The nurse should plan to implement which of the following time-management strategies?

Prepare a priority list of client needs for the shift. The nurse should prepare a client priority to-do list, which could include administering time-critical medications. This will allow the nurse to determine which clients should receive care first.

A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take?

Report the observations about the AP to the unit's nurse manager. The nurse should report their observations to the unit's nurse manager because they have a duty to report any behavior that poses a risk to client safety.

A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

Report the situation to the provider who obtained the informed consent. The provider is responsible for obtaining the informed consent and has the legal responsibility to answer any questions or concerns the client has. Therefore, the nurse should report the client's refusal of the procedure to the provider.

A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the guardian's stated cause. Which of the following actions should the nurse take?

Report the suspected child maltreatment to the appropriate agency. It is the nurse's legal and professional responsibility to immediately report suspected child maltreatment to the proper child protective service agency.

A nurse is caring for a client in an inpatient mental health facility. Exhibit 1 Medical HistoryClient is 44 years old, well-nourished, presenting with recurrence of labile behavior involving self-mutilation, recent arrest for reckless driving, stealing money from work for gambling debts, depressive episodes, and binge eating.Provider's skin assessment reveals multiple superficial self-inflicted lacerations to right arm. Client plays golf three mornings per week. Employed as salesperson at a car dealership for 8 years. Exhibit 2 Nurses' Notes Day 1 1500: Client is talkative, well-groomed. Expresses anxiety when left alone and states they would prefer a roommate. The client tends to be the center of attention in the dayroom. 1600: Client assigned a roommate.Day 2 1300: Pacing for last hour and mumbling to self. Argued with staff earlier about going to lunch in the cafeteria. Glaring at staff members with fists clenche

Select the 2 findings from the client's medical record that are manifestations of borderline personality disorder. Behavior toward roommate Skin assessment When recognizing cues, the nurse should identify that the client's skin assessment and behavior toward roommate are indications of borderline personality disorder. Clients who have borderline personality disorder display unstable relationships, labile moods, and impulsivity, such as excessive spending, binging, substance abuse, and reckless driving. They also have recurrent episodes of self-harm and might engage in suicidal actions. They have difficulty controlling their anger and might have paranoid ideations. They have chronic feelings of emptiness and do not like to be alone.

A nurse is assisting in the care of an adolescent. Exhibit 1 Data Collection​1400:Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2 Vital Signs1400:Temperature 37° C (98.6° F)Weight 54.5 kg (120 lb)Pulse 89/minRespiratory rate 20/minBlood pressure 124/82 mm HgOxygen saturation 98% on room air

Select the 4 findings that require follow-up. Capillary refill Pedal pulse Skin temperature Pain When recognizing cues, the nurse should identify the findings that require follow-up in an adolescent who has an injury to the right leg include capillary refill, pedal pulse, skin temperature, and pain. The adolescent rates their pain as 10 on a scale of 0 to 10, which requires follow-up by the nurse. A capillary refill of 4 seconds is outside the expected reference range of less than 2 seconds. A pedal pulse of +1 is diminished and is outside the expected reference range. Skin temperature of the right extremity is cool to the touch, which is an unexpected finding. These findings are indicative of decreased perfusion to the extremity and require follow-up by the nurse.

A nurse is collecting data from a school-age child who has hypoglycemia. Which of the following findings should the nurse expect?

Sweating The nurse should expect a school-age child who has hypoglycemia to have pale, sweaty skin. Other expected findings of hypoglycemia include irritability, tachycardia, tremors, and hunger.

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

Take up to three tablets during a single angina episode. The nurse should instruct the client to take up to three doses of the nitroglycerin, 5 min apart, if chest pain persists.

A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take?

Tell the client they should not experience any discomfort. The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort.

The nurse is assisting with preparing the adolescent for a 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. When taking action for an adolescent who is scheduled for a fasciotomy, the nurse should notify the provider if the parents of the adolescent have questions or concerns regarding the procedure, which could indicate lack of understanding about the informed consent.

A nurse is contributing to an in-service for newly licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

The child was born at 34 weeks of gestation. The nurse should identify that children born prematurely are at an increased risk for physical maltreatment. This increased risk is due to a possible impairment of bonding during infancy and an increased need for care due to medical concerns as a result of their premature birth.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which of the following findings should the nurse notify the provider?

The client has absent bowel sounds. Absence of bowel sounds can indicate absence of peristalsis, which is a manifestation of an ileus. The nurse should report this finding to the provider for reconsideration of the diet prescription.

A nurse is caring for a client who has a phobia of elevators. Which of the following should the nurse recognize as an indication that systematic desensitization has been effective for the client?

The client remains relaxed when thinking of the phobia. The purpose of desensitization therapy is to teach the client to use relaxation techniques to overcome the anxiety caused by the phobia. The nurse should recognize the client's lack of anxiety when thinking about the phobia as a positive response to the therapy.

A nurse is caring for a client who has asthma and has been taking montelukast for 1 month. Which of the following findings should indicate to the nurse that the client is complying with this medication regimen?

The client takes the medication once daily at bedtime. Montelukast, a leukotriene modifier, is taken once daily at bedtime for maintenance.

A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

The nurse administered insulin lispro to a client who has diabetes mellitus and is NPO. Lispro is a rapid-acting insulin given with or just after meals because the onset of action is 15 to 30 min after administration. A client who is NPO will not receive a meal and can have a potentially serious drop in blood glucose levels. Therefore, the nurse should complete an incident report after ensuring the safety of the client and notifying the client's provider.

A nurse in a pediatric clinic is collecting data from a toddler. Which of the following findings should the nurse identify as a possible indication of physical neglect?

The toddler is inadequately dressed for the weather. Inappropriate dress is a suggestive finding of physical neglect. The nurse should collect further data for other indicators of physical neglect.

A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching?

Walk for 1 to 2 hr each day. The nurse should instruct the client to walk for at least 1 to 2 hr per day after surgery to promote venous return.

The nurse is reviewing the client's medical record. Exhibit 1 Data Collection​ 1400: Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.​ Exhibit 2 Vital Signs​1400: Temperature 37° C (98.6° F)Weight 54.5 kg (120 lb)Pulse 89/minRespiratory rate 20/minBlood pressure 124/82 mm HgOxygen saturation 98% on room air Exhibit 3 Provider Prescriptions​1415: X-ray of right legSurgery consultMorphine 4 mg IV every 2 hr

Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply. When analyzing cues for a postoperative adolescent, actions the nurse should take include elevating the adolescent's affected limb at chest level, monitoring neurovascular status every hour, and removing the indwelling urinary catheter when it is no longer indicated. The nurse should elevate the affected limb at chest level to reduce edema. Neurovascular monitoring should be performed every hour for the first 24 hr post-surgery for immediate recognition of neurovascular compromise. For clients who have an indwelling urinary catheter, evidence-based practice indicates the catheter should be removed as soon as possible or within 24 hr if no longer indicated.

A nurse is performing a dressing change for a client who is 3 days postoperative. Which of the following findings should the nurse report to the provider?

Yellow-green drainage at the incision line Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse should report this finding to the provider.