Quiz 1

The nurse is educating a new registered nurse (RN) about the Healthy People 2020 goals. Which statements by the RN indicate that teaching has been effective? Select all that apply.

"Healthy People 2020 aims to promote healthy behaviors." "Healthy People 2020 aims to create social and physical environments that promote good health for all." "Healthy People 2020 aims to eliminate preventable disease, disability, injury, and preventable death."

The nurse is caring for a client with a latex allergy. Upon entering the client's room, the nurse should plan to take which action as the priority?

remove the banana from the client's breakfast tray

The nurse provides information to an assistive personnel (AP) about caring for a client with neutropenia. Which statements by the AP indicate that teaching has been effective? Select all that apply.

"Any sores or skin irritations should be reported right away." "I should practice good hand washing." "The client may not have a high fever if infection occurs."

The nurse is attending a teaching session on communicating with the ill child. Which statement by the nurse indicates that the teaching has been effective? Select all that apply.

"Complete honesty may cause problems for some family and staff members." "I will strive to maintain honesty and trust with each child." "To prevent misunderstandings, I should ask the child to explain what is known."

The nurse is caring for a client in the hospital and is reconciling the client's home medications. The client is taking Lactobacillus,a probiotic over-the-counter medication. The nurse is discussing the supplement with the client. What statement by the client would warrant the need for further teaching? Select all that apply.

"I can take my probiotic at any time of day or night" "I should take this supplement to prevent gas and bloating." "Because I'm lactose intolerant, a probiotic would not benefit me."

The nurse is caring for a client with joint pain and is educating the client on pharmacological management of pain with acetaminophen. What statements made by the client would indicate a need for further teaching? Select all that apply.

"I should not take this medication more often than 3 times per day." "To prevent stomach ache, i should take this medication with food." "I should avoid eating grapefruit while taking this medication."

The nurse is educating a client on how to prevent altitude sickness. Which statements indicate that the teaching has been effective? Select all that apply.

"I will refrain from consuming alcohol when I am at a high altitude." "I will pay attention to the manifestations of altitude-related illnesses." "I will wear sunscreen and high quality goggles"

The nurse is educating a client on how to self-manage care at home, following an admission to the hospital for heart failure. Which statements by the client indicate that teaching has been effective? Select all that apply.

"I will wear my oxygen at night as prescribed." "I will follow up with my health care provider (HCP) as scheduled."

The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should the nurse give to the client? Select all that apply.

"It has been shown that leflunomide can cause birth defects." "You may lose your hair." "Leflunomide is a potent medication that is generally tolerated."

The nurse is educating a client on obesity. Which statements by the client indicate a need for further teaching? Select all that apply.

"It is unlikely that I will develop peripheral artery disease". "My heart and lungs are mildly affected by obesity".

The nurse is evaluating a client who is four weeks post-partum. Which statement by the client would indicate a need for intervention? Select all that apply.

"My baby will not stop crying and I can't take it anymore." "My husband never helps me with the baby." "I feel like giving up."

The nurse is working in the emergency department when a client with heat exhaustion is brought in. Which actions would be the appropriate in order to effectively treat the client? Select all that apply.

Apply cool packs to the client's neck and groin. Remove any restrictive clothing. Apply cool water soaks to the client. Give the client an oral rehydrating solution.

The nurse is caring for a client who has just come in to the emergency department to receive treatment. The client reports a bite from a brown recluse spider. The nurse assesses the bite mark and notes that it is possibly infected. Which actions should the nurse take? Select all that apply.

Assess the date of the client's last tetanus immunization. Cleanse the area with a topical antiseptic. Apply ice to the site.

A client with anxiety has just been seen by the health care provider and has been prescribed alprazolam. A week later, the client is brought to the emergency room, after consuming a large number of tablets in an attempt to overdose. The client is unresponsive and has gasping respirations. Which action should the nurse take first?

Assist with intubation of the client

The nurse notices that an older client's skin is very dry. What actions would be appropriate for the nurse to implement into the care plan? Select all that apply.

Ensure adequate hydration Instruct the client to avoid caffeine and alcohol

The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply.

Ensure that the child's family is able to read the written discharge instructions. Create a medication schedule that fits the parent's lifestyle Assist the child's parents in obtaining the medication at an affordable cost. Provide the child's parents with a simple dosing schedule.

The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply.

Evaluate the client's venous access. Obtain and assess vital signs. Assess laboratory values. Check the health care provider's prescriptions with another nurse.

The client is being discharged home after the delivery of a healthy infant. The nurse is educating the client on how to prevent postpartum depression. Which activities are the most appropriate for the nurse to suggest? Select all that apply.

Exercise on a regular schedule Don't overcommit yourself to activities that will be tiring Eat a healthy, well-balanced diet

Which actions should the nurse take to adequately prepare a client for a thoracentesis? Select all that apply.

Explain the procedure to the client Tell the client to expect a stinging sensation from the anesthetic Inform the client that it is common to feel pressure from the needle insertion

The nurse is caring for a client in the emergency department who is being treated for major burns and smoke exposure. What information in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to chart.

Hoarse voice

The nurse is providing discharge education to a client who was admitted for treatment with Addison's crisis and is reviewing the medication hydrocortisone. What statements made by the client would indicate teaching was effective. Select all that apply.

I should take this medication twice a day." "If I notice any swelling of fluid retention, I should notify my healthcare provider."

The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40 mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart.

Potassium level of 3.5 mEq/L

The nurse is preparing to administer oral potassium chloride to a client. What should the nurse keep in mind about this medication? Select all that apply.

Potassium may be taken in a liquid or solid form. Potassium chloride can cause nausea and vomiting.

The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply.

The length of time for the administration The route and frequency of administration The generic medication name

The nurse is caring for a postoperative client with a patient controlled analgesia (PCA) pump. When creating the client's plan of care, which opiate-induced side effects should the nurse monitor? Select all that apply.

nausea and vomiting sedation

The nurse educator is presenting a lecture on child neglect. Which statement by one of the students indicates that the teaching has been effective? Select all that apply.

"A sign of neglect are bruises on the child's body." "Neglect is parental failure to meet a child's basic needs." "Neglected children often have learning problems and low self-esteem." "Neglect occurs when a parent does not seek medical attention for a sick child."

The nurse is educating an older client on sources of stress. Which statements by the client indicate that the teaching has been effective? Select all that apply.

"Financial hardships can be a cause of stress." "Relocating to a nursing home causes stress." "A lifestyle change such as retiring can cause stress."

The nurse is presenting information to a new nursing employee regarding a thoracentesis that will take place later today. Which instructions should the nurse provide regarding signs/symptoms of a pneumothorax? Select all that apply.

"Frequent coughing should be reported." "Presents of a slanted trachea in the neck region need to be reported." "Be sure and report any bluish color to the skin."

The nurse is obtaining the medical history from an older client with a black eye and bruising to the head. The nurse suspects that the client has been abused, and that there may be a history of abuse. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply.

"Perhaps I somehow did this to myself." "Sometimes my grandson becomes angry with me when I can't give him money." "Well, I don't remember anything that would have caused the injuries." "I tripped over a rug and now I have a black eye."

The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an understanding of a PICC? Select all that apply.

"The tip of the PICC line sits in the superior vena cava." "PICCs can accommodate infusions of all types of therapy." "PICCs with a lumen size of 14 Gauge or larger can be used for blood sampling."

The post-operative client is experiencing moderate pain and requests pain medication from the nurse. The prescription reads: morphine 4 mg intravenous (IV) push every three hours as needed. The morphine is supplied in an ampule of 10 mg/mL. How many milliliters should the nurse administer? Fill in the blank and record your answer using the one decimal place.

0.4

The client has been prescribed amoxiciilin 250 mg three times daily for sinusitis. The medication is supplied in a 500 mg tablet. How many tablet(s) would the nurse prepare every 8 hours to administer the correct dose? Fill in the blank. Record the answer using one decimal place. tablet(s)

0.5

A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT). The client will be discharged home on oral anticoagulants. What information in the client's medical record would warrant the need for teaching? Refer to chart.

10 pack year history of smoking

The nurse is meeting with an older client who was brought into the health care facility for evaluation. According to the family member, the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply.

Determine the fit of the client's dentures. Assess the client's eyesight. Assess the client for mental status changes.

The nurse is caring for a 55-pound child on the pediatric medical surgical unit being treated for Lyme disease. The health care provider has prescribed ceftriaxone intramuscular 50 mg/kg/day in two divided doses. The nurse should administer how many milligrams per dose? Fill in the blank.

625

The client with heart failure is preparing to be discharged from the hospital. Which interventions should the nurse include in the client's discharge teaching plan? Select all that apply.

Develop a regular exercise program Provide the client with a list of current medications and dosing times Educate the client about dietary restrictions

The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular stent graft. What priority actions should the nurse include in the plan of care? Select all that apply.

Administer analgesics as needed Assess for pedal pulses Encourage use of an abdominal pillow when coughing or deep breathing Monitor urinary output

Which interventions should be included in the care of a client with a chest tube? Select all that apply.

Alert the health care provider (HCP) if drainage in the tube stops in the first 24 hours. Assess the insertion site for signs of infection. Keep the drainage system lower than the level of the client's chest.

The nurse is planning care for a client who is confused. The nurse should include which actions in the client's care plan? Select all that apply.

Allow a pet visit Play soft, calming music Evaluate the client for signs of pain Toilet the client every 2 to 3 hours

The nurse is caring for a client with a blood pressure of 80/54 mmHg. Which actions should the nurse take because of the risk of hypovolemic shock? Select all that apply.

Anticipate administering Ringer's lactate solution Insert a large-bore intravenous (IV) line Perform assessments and monitor the client closely

The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action?

Check for a pulse

The nurse is caring for an older client who is being treated for malnutrition. Which actions by the nurse would be the most appropriatewhen providing for this client's care and comfort? Select all that apply.

Determine if the client qualifies for any food services. Ask if the client lives alone. Evaluate the fit of the client's dentures. Educate the client on how to choose healthy foods.

The nurse is educating a child's parents on using the behavior modification technique of discipline. Which statement should the nurse make to the parents?

Corporal punishment should not be used to encourage good behaviors

The nurse is caring for a client on a ventilator. Which symptoms should alert the nurse to the possibility of absorption atelectasis? Select all that apply.

Crackles in the lungs Diminished lung sounds

The nurse is providing care to a client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply.

Cyanosis of the skin in the affected extremity Skin temperature cool to touch in the affected extremity Complaints of sudden and severe pain in the affected extremity

The nurse is providing care to a client. After assessing the client, the nurse determines that the client's self ability to change position is compromised. Which actions should the nurse take to reduce the risk of skin break down? Select all that apply.

Document skin breakdown prevention measures in the plan of care Keep the client's skin clean and dry Implement a turning schedule

The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. When creating a plan of care for the client, which interventions should the nurse include in the plan? Select all that apply.

Educate the client about the signs and symptoms of infiltration Understand the vesicant potential before administering the infusion Assess the skin integrity Monitor the site frequently

The nurse is creating a plan of care for a client that will undergo a total joint replacement. What should the nurse include in the client's plan of care? Select all that apply.

Educate the client on what to expect after surgery Complete a physical assessment before the surgery Teach interventions to reduce client anxiety

A nurse employed at a long-term care facility is caring for a client who has recently been transferred from the hospital. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply.

Encourage friends and family to visit frequently. Establish a trusting relationship with the client as soon as possible. Ensure the client is an active part of decision making regarding their care.

Which manifestations are specifically noted in a client with right-sided heart failure.? Select all that apply.

Hepatomegaly Dependent edema Neck vein distention

The nurse is creating a plan of care for a client with a respiratory infection. Which actions should the nurse include in the plan of care to prevent the spread of infection? Select all that apply.

Keep fingernails short and without nail polish Clean the client's room daily Place a mask on the client's face when transporting to other departments

The nurse is caring for a client with cancer who has a sealed implant of a radioactive source. Which actions should the nurse take to promote safety for staff and visitors? Select all that apply.

Keep the client's door closed Wear a lead apron while providing care

The nurse is caring for a client in active labor. The nurse notices that the fetal heart rate pattern is demonstrating late decelerations. Which position should the nurse assist the client into? Refer to figures 1-4.

Lateral recumbent

A client is being discharged home after a routine hip replacement surgery. The nurse is instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply.

Limiting fiber is necessary to avoid diarrhea Avoiding pain medication will prevent constipation I should drink plenty of liquids like iced tea or coffee

The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. After assessing the client, the nurse administers furosemide as prescribed. Which actions by the nurse are the most important after administering the medication? Select all that apply.

Measure urine output Obtain and monitor vital signs Assess lung sounds

The nurse is caring for a client who expresses an interest in alternative therapies to reduce the risk of illness and disease. What noninvasive activities should the nurse recommend to the client? Select all that apply.

Meditation Biofeedback Yoga

The nurse is caring for a malnourished client with dementia and a history of rheumatoid arthritis, and is creating a plan of care for the client's nutrition. Which nursing actions are most appropriate for increasing the client's caloric intake? Select all that apply.

Play soft, calming music during mealtimes. Serve the food at the appropriate temperature. Provide pain medications as needed

The nurse is caring for a client with heat stroke, who is being cooled with a cooling blanket. Which actions should the nurse take to ensure that the intervention is effective? Select all that apply.

Prepare to insert an intravenous line for administration of fluids as needed. Monitor temperature continuously until it is stable Monitor for patency of the airway and prepare for intubation if necessary

A client has come to the emergency department complaining of burning with urination. What should the nurse consider a priority when providing care in order to maintain the client's psychosocial integrity?

Provide the client with as much privacy as possible during the examination

When conducting the preoperative interview with the client, the client reports an allergy to shellfish. Which agent is most likely to cause an allergic reaction in this client?

Providone-Iodine

A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply.

Stating that family was not supportive of the pregnancy. Making statements about being fat and unattractive now. Crying after talking with spouse on the phone. Not responding to the infant's cries.

The nurse is caring for an older Japanese American man being treated in the oncology unit for prostate cancer. In order to provide culturally competent care, the nurse should include what actions in the care plan? Select all that apply.

Routinely assess for pain, as Japanese Americans often remain stoic Provide personal space boundaries if client is in a semi-private room Allow for family to visit and participate in the decision-making process

The client has been diagnosed with valvular disease. Which interventions should the nurse be prepared to discuss with the client? Select all that apply.

Surgical management Placing limits on physical activity Monitoring for an irregular heart rhythm

The nurse is completing a health history on a client who is 12 weeks pregnant. Which findings should alert the nurse to the risk of potential parenting problems? Select all that apply.

The client states that the father is not supportive The client is homeless and often stays in local shelters The client reports feeling depressed

The nurse is caring for a client with bipolar disorder. When creating a care plan for this individual, which should the nurse include as appropriate goals? Select all that apply.

The client will perform activities of daily living (ADLs) independently. The client will understand what bipolar disorder is. The client will be able to manage the symptoms of bipolar disorder. The client will state the importance of taking medications as prescribed.

The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the mostaccurate information? Select all that apply.

Urge all family and close contact community members to seek and complete treatment to enhance compliance Encourage family members to obtain a tuberculosis skin test Provide culturally sensitive education

The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply.

a child with autism a child with generalized anxiety disorder

The nurse is caring for a client who has been diagnosed with bladder cancer. Which action should the nurse take as a priority when planning psychosocial care for this client?

assess the client's ability to cope with the diagnosis

The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first?

clarify the prescription

A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply.

environmental exposure to toxins low birth weight chronic illness income