Refined Refined

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit.

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion five times during each session.

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good working order."

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection

A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include?

People who practice Judaism stay with the body of the deceased until burial.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day.

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Pull the pin

The nurse overhears two AP's from the medical surgical unit discussing a hospitalized patient while in the cafeteria. Which of the following is the priority nursing action?

Quietly tell the AP's that that this is inappropriate

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head is down, and he is wringing his hands. Which of the following actions should the nurse take?

Remain with the client

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Remove the stockings at least once per shift.

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

The client holds his breath for 10 seconds after inhaling the medication

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."

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you."

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?

Assessment

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water.

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

Use progressive relaxation techniques at bedtime.

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?

WBC 15,000 mm3

a nurse has just inserted an NG tube for a client. Which of the dollowing findings should the nurse expect to confirm correct tube placement?

an x-ray

indwelling urinary catheter

bladder scan

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which manifestations of Hypoglycemia

blurred vision / tachycardia / moist clammy skin

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot.

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

Wear cotton clothing to avoid static electricity.

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Two nurses using a friction-reducing device

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

"All of this equipment can be frightening."

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you."

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

-relief of urinary retention -measurement of residual urine after urination -presence of an open perineal wound

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1) Ask the client if he can bear weight 3) Position the chair on the left side of the bed 4) Have the client sit and dangle his feet at the bedside 2) Use the stand-and-pivot technique to move the client to the chair

A nurse is caring for a client who has diabetes and a new prescriptions for 14 units of regular insulin and 28 units of NPH insulin to be given subcutaneous at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the syringe?

14 + 28 = 42 units.

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/ 1 mL. How many mL should the nurse administer per dose?

40 / 10 = 4 mL

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

A 10-month-old infant can pull up to a standing position.

A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?

A client who has a cast and reports numbness and paresthesia

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

A nurse is admitting a client who has active TB to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for this client?

A room with air exhaust directly to the outdoor environment

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

Airway

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions.

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 providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply)

Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium

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

Droplet

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

Eggs

A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

Evacuate the client

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag two-thirds full with ice.

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with her arms at her side and her feet together.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is planning care for a client who has terminal cancer and a prescription for morphine. Which intervention should the nurse include in the plan of care?

Instruct client to actively cough to prevent buildup of secretions in airway.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and wheelchair

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations.

A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client.

A nurse is reviewing a clients ABG lab results. Which of the following should the nurse report to the provider?

Sodium 126 mEq/L

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia

An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder.

A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown.

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support.

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

evacuate the client

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent?

surgeon

Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers?

a client who has a protein calorie malnutrition a client who has right-sided heart failure and 4+ edema to lower extremities a client who has post operative delirium

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs."

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver Damage

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom. After assessing, the nurse notifies the provider. What documentation should the nurse use?

"The provider was notified."

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing.

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning?

Have the client demonstrates the procedure.

A nurse is reviewing the ABG's for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid base balances?

Respiratory acidosis

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

Wrap blankets around all four sides of the bed

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"When descending stairs, I will first shift my weight to my right leg."

A nurse at an extended-care facility is instructing a class of AP's about the use of assistive devices during ambulation. Which of the following should the nurse give the AP's about the clients' use of a cane?

"When the client moves, he should move the cane forward first."

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown.

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use.

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities

a nurse is giving a change of shift report about a client admitted earlier who has pneumonia

breath sounds