Review

The nurse is triaging several children as they presented to the emergency room after school bus incident. Which child requires the most immediate intervention by the nurse?

A 11-year-old with a headache, nausea, and projectile vomiting

In assessing a client pain which question or statement is likely to elicit the most information?

"describe what the pain feels like"

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." Which question should the nurse asked the client next?

"do you believe the voices are real?"

A client with multiple sclerosis is receiving baclofen 15 mg orally three times daily. The drug is available in 10 mg tablets how many tablets. How many tablets should the nurse administer in a 24 hour period?

5.5

The nurse is caring for a client with chronic bronchitis infection who receives a nebulizer bronchodilator treatment with chest physical indicates to the nurse the intervention was effective?

Absence of fine crackles

Which intervention should the nurse implement when beginning a physical assessment of a 6 month old infant?

Allow the child to remain sitting in the caretakers lap

A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has ask the nursing administration to allow return to work. When the nurse administrators approaches the charge nurse with the impaired nurse's request, which action is best for the charge nurse to take?

Allow the impaired nurse to return to work and monitor medications administration.

Which client should the charge nurse on the oncology unit assign to the RN, rather than a practical nurse (PN)?

An adult client in remission after a series of chemotherapy treatments who is receiving intramuscular iron injections for anemia.

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.

The nurse observes a client sleeping with mouth open with oxygen at 2 liters per nasal cannula. The nurse assesses the client's pulse oxymetry at 88%. Which measure should the nurse implement to improve the client's oxygenation?

Check the oxygen tubing for kinks or loops

Prior to insertion of an indwelling urinary catheter, what client information is most important for the nurse to obtain?

Color, clarity, and order of urine

An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client handwashing is an example of which clinical behavior?

Compulsion

The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected?

Condition of tooth enamel

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding the nurse use in planning the client care?

Confusion

A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?

Demonstrates a willingness to adhere to the diet consistently.

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to sign to the PN?

Diabetic ketoacidosis who Glasgow Coma Scale score changed from 10 to 7

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48 hours. Based on these findings, it is important for the nurse to review the laboratory value for which medication

Divalproex

Assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma has occurred. Which action should the nurse implement?

Document the extent of the bruising in the medical record.

The nurse notes that a client with depression has been more withdrawn and non-communicating during the past two weeks. Which intervention is most important to include in the update plan of care for this client?

Encourage the client to participate in group activites.

In assessing a client 12 hours following transurethral resection of the prostate (TURP) the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and is continuous bladder irrigation is infusing slowly. Which action should the nurse implement?

Ensure that no dependent loops are present in the tubing

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Ensure that the infant crib mattress firm

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record?

Excessive concave curvature of the lumbar spine.

A male client is suspected lung cancer tells the nurse that he does not want to have a schedule biopsy performed and states "They already found the cancer when I had my chest x-ray"Which action should the nurse implement?

Explained that a biopsy is performed to determine if the cancer has spread.

A postpartal client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?

Express a small amount of breast milk by hand

An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

Had a cold and ear infection for the past two days.

a client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Hypokalemia

A 6- week old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?

Initiate a continuous infusion of IV fluids per prescription

What is the priority nursing action when initiating morphine therapy via an intravenous patient- controlled analgesia (PCA) pump?

Initiate the dosage lockout mechanism on the PCA pump

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reported no evidence of watery stools. Which nursing intervention should the nurse implement?

Instruct the mother to change the child's diaper more often.

The nurse is caring for a client with a paralytic ileus who presents with severe, colicky abdominal pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation?

Intestinal volvulus that occurred during surgery.

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Leave the client's room so she can act out her anxiety

An adult client is admitted to the emergency room following an automobile collision in which the client sustained a head injury. What assessment data would provide indication that the client is experiencing increased intracranial pressure (ICP)?

Lethargy

A nurse assesses a client who hand begins to spasm when the blood pressure cuff is inflated. The client complains of paresthesia in the fingers and toes. Which serum laboratory findings should the nurse expect to find?

Low serum calcium

A male client who was discharged three days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg. The nurse is preparing to initiate heparin therapy. What additional intervention should the nurse include in this client plan of care?

Maintain the client on bed rest

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Moderate amount of foul-smelling lochia.

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the clients plan of care?

Monitor for confusion and restlessness

A client with purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has been admitted with a possible resistant enterococci (VRE) infection. Which nursing interventions should the nurse include in the plan of care?

Monitor the client white blood cell count Institute contract precautions for a staff and visitors Send would draining for a culture and sensitivity

The nurse implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective.

More than 50% of at-risk clients were diagnosed early in their disease process.

A preschooler with constipation needs to increase fiber intake. Which airwick suggestion should the nurse provide?

Oatmeal cookies

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

Observe color of urine

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

Obtain vital signs in breath sounds

The family of an older woman reports that they are no longer capable of caring for her at home. While performing the admission assessment at a long- term the nurse determines that the client is incontinent of urine, has dry mucous membranes, and has a large bruise on the coccyx. Which interventions should include in the plan of care?

Offers beverages at frequent intervals, Implement toileting program, Apply a barrier cream to perianal areas.

A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to the client?

One of the medications is used to anesthetize the corneal surface. Pupillary dilation is necessary to access the eye chamber for lens removal. The iris must be paralyzed during surgery to prevent it from reacting to light. These medications assist in obstructing client's vision during the surgery.

The nurse has determined that a client with pernicious anemia has developed glossitis and is losing weight from not consuming foods to meet nutritional needs. Which factor should the nurse identify is most likely the etiology for this problem?

Pain when eating.

The nurse is admitting a client with a history of gout. In assessing the client's hands, how should the nurse assess for the presence of tophi?

Palpate for hard nodules on the fingers

The nurse prepares a defibrillate a client in ventricular fibrillation. Which intervention should the nurse implement during defibillation?

Position the anterior paddle over the mid-sternal area.

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?

Prepare skin for procedure.

The nurse is planning to implement a tuberculosis screening program at a community health clinic. Which technique should the nurse use to screen clients who are non-compromised?

Purified protein derivative (PPD) skin test

The nurse is caring for a client who had a repair of the bleeding gastric ulcer. The client experiencing significant significant blood loss during surgery and receive several blood transfusions. Which intervention is most important for the nurse to include in the client plan of care?

Record the amount of daily wound drainage

Which instruction should the nurse provide to a client who is preparing for preparing to have a cystoscopy?

Report any allergies to shellfish or iodine

An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another clients room in his returning to his room by the unlicensed assistive personnel (UAP). Which action should the nurse take?

Report mental status changed to the healthcare provider. Assess the clients breath sounds and oxygen saturation. Review the clients most recent serum electrolyte values.

The parent bring their one year old child with a ventricular septal defect (VSD) to the clinic for a well child visit. Which assessment finding should a nurse report to the healthcare provider immediately?

Respirations of 26 breath/minute at rest

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client is exhibiting which finding?

Restrained and restless with a low volume alarm sounding.

A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional, assessment should the nurse expect to find during the preicteric phase?

Right upper quadrant abdominal pain.

A female client with dementia who needs assistance with meals and activities of daily living often screams at the staff and threatens to hit those who came near. Which nursing problem should be included in the treatment plan?

Risk for acute confusion

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

Sitting up and leaning foward

The nurse is providing care for a client with serve peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?

Suggest dangling the legs when pain begins.

A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important or the nurse to include in the discharge plan?

Teach tracheal suctioning techniques.

Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease

A client with hyperthyroidism is admitted to the post operative unit after a subtotal thyroidectomy. Which of the clients serum laboratory values requires intervention by the nurse?

Total calcium 5.0 mg/dL (1.25 mmol/L)

A client who is newly diagnosed with type two diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which information should the nurse include in this client teaching plan?

Use sliding scale insulin for fingerstick glucose elevations. Recognize signs and symptoms for hypoglycemia. Take metformin with the morning and evening meal. Report persistent polyuria to the healthcare provider.

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile filed is created. Which nursing intervention should the nurse implement for client safety?

Verify that the client has given informed consent

The nurse is providing intermittent gavage feedings for a 33- week gestational age newborn. The nurse positions the newborn in a right side-lying position with the head slightly elevated and passes the feeding tube through the mouth. Prior to administering the bolus feeding, it is most important for the nurse to obtain which assessment?

Volume of gastric residual

The nurse is caring for a child who takes a methylphenidate extended release for a treatment of attention deficit hyperactivity disorder (ADHD). Which assessment finding indicates to the nurse the other child is experiencing an expected side effects of this medication?

Weight loss of 5 pounds (2.3 kg) in 1 month

A young female adult wanders into the emergency department. She is disheveled and confused and states, "My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me." How should the nurse respond?

Yes I can see. tell me more about what you remember

While taking vital signs a critically ill male client grabs the nurse hand and ask the nurse not to leave. Which action is best for the nurse to take?

allow the client to hold the nurse hand until the vital signs can be completed

Which action should the nurse take first when a client is inadvertently given an incorrect dose of a medication?

assess the client for any adverse effects

The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and other who had a thoracotomy yesterday and is complaining of incision pain. What should the nurse to first?

assess the level of consciousness and vital signs for both clients

A client with diabetes mellitus tells the nurse that she is she uses cranberry juice to help prevent urinary tract infection which instruction should the nurse provide?

be sure to drink sugarfree cranberry juice

A client with a 6cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the clients of blood pressure is 220/112 MM Hg, so an antihypertensive agent is added to the clients IV infusion. Which finding warrants immediate intervention by the nurse

blood pressure reading is 200/100 MMHG 15 minutes later

which information is most important for the nurse to obtain when determining a client risk for obstructive sleep apnea syndrome (OSAS)

breath sounds

which assessment finding of a postmenopausal women necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

cold sensitivity

A male client who had a small bowel resection acquired methicillin-resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released but is admitted today because of diarrhea and dehydration. It is important for the nurse to implement which intervention?

collect serial stool specimens for culture

A client with Alzheimer's disease (AD) is receiving a tradzodone, a recently prescribed atypical anti-depressant. the caregiver tells the home health nurse that the clients mood and sleep patterns are improved, but there is no cognitive ability. How should the nurse respond to this information?

confirmed that the desire effect of the medication has been achieved

An older client who was discharged two weeks ago after hip replacement surgery is brought to the accompanied by his daughter and admitted with a diagnosis of acute onset of delirium. The daughter is very worried about her father and tells the nurse that he has been confused for two days and doesn't recognize her sometimes. Which information should the nurse provide to the daughter?

confusion that suddenly developed may be due to an infection and is potentially reversible

The home Health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which personal information should the nurse obtain to formulate a plan of care?

daily food and fluid intake next scheduled visit with healthcare provider level of physical activity and exercise methods currently used to treat constipation Current prescribe an over-the-counter medication's

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose for this drug classification?

decrease the amount of HCI secretion by the parietal cells in a stomach

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who is prescribed activity is bedrest with the bedside commode to use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client and transferring from the bed to the bedside commode. How should the nurse respond?

determine the clients level of mobility in need for assistance

Prior to surgery, written consent must be obtained. Which is the nurse legal responsibility with regard to obtain a written consent

determined that the surgical consent form has been signed and is included in the clients record

which assessment is more important for the nurse to include in a daily plan of care for a client with burnt extremities?

distal pulse intensity

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that the thirsty is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if the sign of DKA occurs?

drink electrolyte fluid replacements

In evaluating a client at 29 weeks gestation, which finding should the nurse report to the healthcare provider immediately?

edema of ankles, face, and hands

While a child is hospitalized with acute glomerulonephritis, the parent ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

elevated blood pressure must be anticipated and identified quickly

A 12 year old client who had an appendectomy two days ago after is receiving 0.9% normal saline after 50 mL/hour. The client urine specific gravity is 1.035. Which action should the nurse implement?

encourage Popsicles and fluids of choice

An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left side paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the clients plan of care?

facilitate a consultation for speech therapy

When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?

history of intermittent claudication

The client presents the emergency department with a gash on the forehead and appears to be daze and confused. A family member states the client fell and bumped the forehead on a hard surface. The nurse reviews the medication list in the electronic medication record and acknowledge a healthcare power of attorney on file. When reporting to the healthcare provider using SBAR (situation, background, assessment, recommendation), communication which information should the nurse provide first?

increasing confusion of the client

An older client was discharged from the hospital 5 days following surgery for a right total knee arthroplasty. Three days after discharge, the client arrives to the emergency department (ED) reporting severe pain to the right leg and the nurse observes edema and erythema below the knee. The nurse recognizes the client is likely exhibiting symptoms of which condition?

infection

While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produce pink blood tingled sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?

initiate hourly urine output measurement

When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client plan of care?

initiate neurological monitoring every two hours

The mother of a child recently diagnosed with asthma ask the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother?

keep away from pets with long hair stay indoors when grass is being cut close car windows and use air conditioner avoid sudden changes in temperature

When entering a clients room to administer an 0900 IV antibiotic, the nurse finds that the client is engage in sexual activity with a visitor. Which action should the nurse implement?

leave the room and close the door quietly

The nurse is caring for a seated client who is experiencing a tonic- clonic seizure. Which actions should the nurse implement?

loosen restrictive clothing, ease the client to the floor, note the duration of the seizure.

A client who has been mechanically ventilated is receiving continuous enteral feedings through a nasogastric feeding tube. To prevent aspiration, Which intervention most important for the nurse to implement?

maintain head of bed elevated while internal feeding is infusing

Which problem reported by a client taking lovastain requires the most immediate follow up by the nurse?

muscle pain

The nurse is assessing a client who is receiving enteral feedings. Which clinical data indicate the client may not be tolerating the tube feedings?

nausea and vomiting abdominal cramping

The nurse is planning care for a client who admits having suicidal thoughts, which client behavior indicates the highest risk for the client acting on the suicidal thoughts?

neglects personal hygiene and has no appetite

While changing a postoperative dressing, the nurse observes purulent drainage at the site. Before reporting the finding so the healthcare provider, the nurse should note which of the client laboratory values?

neutrophil count

Four hours after surgery, A client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind. which action should the nurse take?

notify the client healthcare provider of the vomiting.

A client was leukemia undergo a bone marrow biopsy. The client laboratory values indicate the client has thrombocytopenia. Based on this data which nursing assessment is most important following the procedure?

observe aspiration site

A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

observe the appearance of the stool

For the second time in four months, an overweight client is seen in the clinic because of vulvovaginitis resulting a infection. Which intervention should the nurse implement first?

obtain the client blood glucose level

A client with eczema is experiencing several pruritus. Which PRN prescriptions should the nurse administer?

oral antihistamine topical alcohol rub

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resources is important in designing this program?

participation of community leader in planning the program

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

provide a bedside commode of toileting

An 18-year-old female client Is seen at the health department for treatment of condylomata acuminata (Perineal warts) caused by the human Papillowmavirus (HPV). Which intervention should the nurse implement?

recommend the use of latex condoms to prevent HPV transmission

A client with a history of gouty arthritis is scheduled for a right total knee arthroplasty. Which laboratory test result is most important for the nurse to report to the surgeon prior to the schedule surgery?

serum creatine 5 mg/dL (442 micromol/L)

The nurse prepares to deliberate a client in ventricular fibrillation. Which intervention should the nurse implement during defloration?

set synchronizer to deliver shock during the QRS complex following the shock shout "all clear" Position the anterior paddle over the midsternal area apply conductive gel on petals before placing on client

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this clients psychosocial need for acceptance?

shaking the client hand during an introduction

A client with a renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

strain the urine for the presence of stones

A female client receives a prescription for alendronate sodium to treat her newly diagnosed osteoporosis. Which instruction should the nurse include in the clients teaching plan?

take on an empty stomach with a full glass of water

A middle-aged male client at the outpatient clinic receives a prescription for tetracycline due to folliculitis of the scalp. Which instruction should the clinic nurse provide?

take the medication with a glass of water two hours after meals

The nurse who works in labor and delivery is reassigned to the cardiac care unit for a day because of the low census and labor and delivery. Which assignment is best for the charge nurse to give this nurse?

transfer a client to another unit

A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is distended, blood pressure is elevated, and 6500 mL were infused while 5500 mL were drained. In response to this finding, which action should the nurse take?

turn the client from side to side

When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

vegetable juice vanilla frozen yogurt

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

withhold food and fluid intake

When should intimate partner violence (IPV) screening occur?

As a routine part of each health care encounter.

After administering a proton pump inhibitor (PPI) which action should the nurse take to evaluate the effectiveness of the medication?

Ask the client about gastrointestinal pain.

The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L); Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L) and Client D, schedule for an appendectomy who has a white blood cell (WBC) count of 14,000mm^3 (14 x 10^9/L). Which intervention should the nurse implement?

Ask the dietitian to add a banana to client C breakfast tray.

Which intervention should the nurse implement during the administration pf a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm?

Asses IV site frequently for signs of extravasation

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care?

Asses pain level and medicate PRN as prescribed, Teach client to use incentive spirometer every 2 hours while awake, Remove urinary catheter as soon as possible and encourage voiding.

A 3 year old child is brought to the emergency department after the mother found the child in the backyard holding a piece of a toy in one hand and in distress the child is dusky with a loud, inspiratory strider and weak attempts to cough. Which action should the nurse implement?

Auscultate all pulmonary lung fields and attempt a Heinrich maneuver