RN A

A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? Select all that apply.

"A speech pathologist will be performing a swallowing study for you." "You should rest before eating a meal." "Thicken your beverages before drinking."

A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching?

"I should have my child avoid sun exposure between 10 am and 2 pm."

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?

Aspirate contents from the tube and verify the pH level.

A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism?

A client who channels their energy into a new hobby following the loss of their job The nurse should identify that this client is using the defense mechanism of sublimation by channeling negative feelings over the loss of their job into a new hobby.

A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?

Decreased central vision

A nurse is providing phone advice for a client who is pregnant. Complete the following sentence by using the lists of options.

Dropdown 1: Metabolic acidosis Dropdown 2: Weight loss

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

Insert a lubricated gloved finger and advance along the rectal wall.

A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. which of the following findings should the nurse include in the teaching?

Nausea The nurse should instruct the client to monitor for and report manifestations of digoxin toxicity, such as nausea, anorexia, abdominal pain, bradycardia, and visual changes.

A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement?

Place ice packs on the breasts for 15 min several times per day. The client should place ice packs on the breasts to reduce swelling and relieve the pain caused by engorgement.

A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take?

Use 0.9% sodium chloride for irrigation of the NG tube. The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube. After instilling the lavage solution, the nurse should manually withdraw the solution and blood from the client's NG tube.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?

Use a reward system to modify the child's behavior. Children who have autism spectrum disorder respond well to a reward system, which can provide structure and expectations for behavior.

A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching?

"I will bend at my knees when picking an object up off the floor." The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object. The nurse should instruct the client to expect eye itching and recommend the use of a cool compress to ease the discomfort of the itching.

A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make?

"When crusts have formed on every lesion." The child should return to school once all the lesions have crusted over. Varicella is no longer contagious after crusts have formed on all lesions.

A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include?

"You will receive fingersticks for blood glucose testing."

A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain Using the urgent vs. nonurgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. The nurse should notify the provider immediately.

A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?

Absence of symptoms A client without symptoms might not understand the need for treatment, which would indicate the greatest barrier for adherence.

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer high-dose antibiotic therapy. The nurse should include administering high-dose antibiotic therapy in the child's plan of care. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections such as B. cepacia. The nurse should insert a lubricated gloved finger and advance it along the rectal wall when digitally evacuating stool. Eliciting a vagal response by performing rectal stimulation is unsafe because it can cause cardiac dysrhythmias.

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted births?

Cervical laceration The nurse should assess the client for complications associated with a vacuum-assisted birth such as perineal, vaginal, or cervical lacerations.

A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?

Check the client's oxygen saturation level. Restlessness and lightheadedness are indications of hypoxia. Therefore, the nurse should check the client's oxygen saturation level.

A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?

Check the insulin dose with another licensed nurse. The greatest risk to the client is injury due to a medication error. Therefore, the priority action is for the nurse to validate the correct dose of insulin with another licensed nurse prior to administration. Insulin is a high-alert medication and incorrect dosages can be fatal for the client.

A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take?

Clear objects from the client's walking area. The nurse should plan to clear objects from the client's walking area because CN II is the optic nerve and a deficit can result in visual impairment, which can lead to falls.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. Which of the following precautions should the nurse implement?

Contact The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA.

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?

Continue observing the fetal heart rate. Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing.

A nurse is caring for a client who has potassium level of 3 mEq/L (3.5 to 5 mEq/L). For which of the following manifestations should the nurse monitor?

Decreased deep tendon reflexes A client who has hypokalemia can have muscle weakness and decreased deep tendon reflexes.

A nurse in a provider's office is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Complete the following sentence by using the lists of options.

Dropdown 1: Delayed wound healing Dropdown 2: Glucose level

A nurse is assessing a client who is scheduled for surgery. Click to highlight the assessment findings that the nurse should notify the provider about prior to the procedure.

Hemoglobin level Allergies Family history

A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis?

Investigate environmental factors that might be contributing to client injury during these hours.

A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect?

Partial-thickness skin loss The nurse should expect to see partial-thickness skin loss or blister formation in a client who has a stage II pressure injury.

An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene?

Places a pillow under the client's right arm The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder.

A nurse is caring for a newly admitted client. Select the 2 findings that require immediate follow-up.

Platelet count Hemoglobin

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect?

Rapid speech

A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Seizures Blood pressure

A nurse working on an inpatient mental health unit is caring for a client who is experiencing active suicidal ideations. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?

Serve meals with plastic utensils. The nurse should recommend serving meals with plastic utensils because harmful objects, such as metal utensils, should not be accessible to the client.

A nurse is providing teaching to a client who is scheduled for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?

Short-term memory loss The nurse should inform the client that short-term memory loss is a common adverse effect of ECT.

A nurse is caring for a 3-year-old child who has a gastrostomy tube. Drag words from the choices below to fill in each blank in the following sentence.

Skin breakdown An infection

A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex?

Stroke the infant's cheek. The nurse should stroke the infant's cheek to assess the rooting reflex, which should cause the infant to turn towards that side and suck.

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene?

Tells the hospital chaplain a client's diagnosis Discussing a client's diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPAA.

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. For each assessment finding, click to specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis. Each finding may support more than one disease process.

Temperature - Crohn's disease, Ulcerative colitis, and Peritonitis. Weight - Crohn's disease, and Ulcerative colitis. Bowel pattern - Crohn's disease. WBC - Crohn's disease, Ulcerative colitis, and Peritonitis. Heart rate - Peritonitis. Albumin level - Crohn's disease, and Ulcerative colitis. Abdominal pain - Crohn's disease.

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?

The time of the client's last dose of pain medication The nurse should recognize that an effective change-of-shift report provides a baseline of the client's status for comparison and should include any recent changes or priority situations affecting the client's condition. Therefore, the time of the client's last dose of pain medication is important to include so the receiving nurse can anticipate what time to give the next dose.

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

aPTT Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40 seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80 seconds, which is 1.5 to 2 times the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value.

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?

"My child has only a small amount of mucus after percussion therapy." The nurse should recommend a high-frequency chest compression vest for a child who has inadequate results from other airway clearance therapy techniques. Older children often require other techniques in addition to percussion and postural drainage to achieve adequate mucus expectoration.

A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching?

"Secure the retainer clip at the level of your baby's armpits." The nurse should instruct the parent to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs.

A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?

"Tell me more about your understanding of the options." This response by the nurse is therapeutic because it is offering a general lead that facilitates communication between the nurse and the client and will help the nurse to explore the client's feelings about the treatment options.

A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give?

"There's a protocol for reviewing your medical record, and I can initiate the process." The client's record is the legal property of the facility, but the client has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the client with access to the medical record.

A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?

Agency for Healthcare Research and Quality The nurse should gather data from the Agency for Healthcare Research and Quality (AHRQ) regarding health care services for migrant farmworkers. The goal of AHRQ is to improve the quality of health care services for all populations, including low-income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations.

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

Allow for frequent rest periods throughout the day. The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion.

A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition?

An adolescent client who has foodborne botulism The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Clients who ingest the botulism toxin can develop dysphasia, drooping eyelids, and vision changes, and in 12 to 36 hr can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?

Fever unresponsive to antipyretics The nurse should expect a child who has acute Kawasaki disease to have a high fever that is unresponsive to antibiotics or antipyretics.

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

Fiber The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation.

A nurse is caring for a client who is 1 hr postpartum. Select the 6 actions the nurse should take.

Firmly massage the uterine fundus. Administer methylergonovine. Weigh the perineal pads. Provide emotional support. Insert indwelling urinary catheter. Administer oxygen.

A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering?

Flumazenil The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to support the client's respirations with a bag-valve mask.

A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first?

Gather more information about the staff nurse's actions. The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action.

A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress?

Guided imagery Helping clients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist clients who have PTSD by relieving anxiety and pain.

A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis?

Hematuria The nurse should identify hematuria as a manifestation of vaso-occlusive sickle cell crisis resulting from ischemia of the kidneys.

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

Implement fall precautions for the client.

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Increase the client's dietary iron intake. Clients who have rheumatoid arthritis require foods high in protein, vitamins, and iron to promote tissue repair. The nurse should encourage the client to increase their intake of dietary iron.

A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?

Increased opacity of the lens A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration.

A nurse on a mental health unit is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Initiate suicide precautions - Anticipated Potassium 40 mEq PO daily - Anticipated Low-sodium diet - Contraindicated Fluoxetine 20 mg PO daily - Contraindicated

A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held The nurse should recognize that irritability is a manifestation of increased intracranial pressure, which is an indication that the VP shunt is malfunctioning. This finding should be reported to the provider immediately.

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

Monitor the client's mouth every 8 hr. The nurse should monitor the client's mouth at least every 8 hr for manifestations of an infection, such as sores or lesions.

A nurse is caring for a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Monitor the client's physical manifestations. Assess the client for a secondary gain from illness. Somatic symptom disorder Vital signs Pain

A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan?

Notify the incident commander.

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

The client is pacing around the chair in which their partner is sitting. Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences.

A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse?

The client needs assistance when transferring from the bed to a wheelchair. The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers.

A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. Which of the following information should the nurse plan to include?

The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body.

A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make?

"I will provide you with information about medical treatment to include in your living will." The nurse's responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themselves by providing information about what end-of-life preferences to document.

A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make?

"It seems like you feel your visits are a waste of time." The nurse is using a clarifying technique that facilitates the nurse's understanding of the adult child's feelings.

A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Arrange the lunch tray for a client who has a hip fracture.

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

Ask another nurse to witness the disposal of the new patch. The nurse should have another nurse witness the waste of the fentanyl patch. The nurse should then waste the medication in a secure receptacle, according to agency policy, when disposing of any unused portion of a controlled substance.

A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes?

Ask the nurse about their knowledge of the procedure. The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs.

A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first?

Assess the client for functional limitations. When using the nursing process, the first action the nurse should take is to assess the client's functional limitations to determine how much the client can assist with the transfer.

A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care?

Avoid venipunctures when possible. Clients who have thrombocytopenia have a decreased platelet count and are at risk for bleeding. To reduce the risk for bleeding, the nurse should avoid venipunctures when possible.

A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure?

Latex allergy The nurse should assess the client for a latex allergy prior to the insertion of an indwelling urinary catheter due to the risk of an allergic reaction.

A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication?

Maintain hydration with liberal fluid intake. The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?

Making a list of activities to complete According to evidence-based practice, planning is the most important step in managing time effectively. Therefore, the nurse manager should include making a list of activities to complete as the priority. Other planning activities include setting goals, establishing priorities, and scheduling activities.

A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include?

Empty the appliance when it is one-third to one-half full. The ileostomy pouch should be emptied when it is one-third to one-half full to prevent stool leakage and skin irritation.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider?

Axillary temperature 36.2C (97.2F) The expected reference range for the axillary temperature of a newborn is between 36.5° C to 37.5° C (97.7° F to 99.5° F). An axillary temperature of 36.2° C (97.2° F) or below in a newborn who is 2 hr old indicates cold stress and should be reported to the provider.

A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following?

Bleeding The nurse should have another nurse witness the waste of the fentanyl patch. The nurse should then waste the medication in a secure receptacle, according to agency policy, when disposing of any unused portion of a controlled substance.

A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the following should the nurse plan to take?

Enter the plasma product number into the client's medical record. The nurse should complete documentation following blood product therapy, which includes recording the type of product, amount administered, product number, infusion time, and client response.

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

Ensure that the client understands the medication regimen. The priority action the nurse should take when using the safety vs. risk reduction approach to client care is to ensure the client understands the medication regimen. The greatest risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly.

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend?

Diced steamed carrots Diced steamed carrots are a safe food choice for toddlers because they are soft and do not present a choking hazard.

A nurse is caring for a preschooler on the pediatric unit. After reviewing the assessment findings, which of the following actions should the nurse take? Select the 4 actions the nurse should take.

Discontinue the IV medication. Administer 0.9% sodium chloride IV. Administer epinephrine IM. Monitor vital signs frequently.

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend?

Double-bag soiled dressings in plastic bags for disposal. The client should double-bag soiled dressings in plastic bags to prevent the spread of micro-organisms to other household members.

A nurse is caring for a client who is on 24-hr observation. Complete the following sentence by using the lists of options.

Dropdown 1: Hemorrhage Dropdown 2: Thrombocytopenia

A nurse is caring for a client who is in the spinal cord injury (SCI) unit. Complete the following sentence by using the list of options.

Dropdown 1: Oxygen saturation Dropdown 2: Urinary output

A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?

Edema Compartment syndrome causes increased pain, pallor, and paresthesia from increased edema in the compartment involved.

A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Elevate the affected leg. The nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency.

A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan?

Provide a staff member to stay with the client continuously. A staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment, if necessary, due to the risk of injury.

A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging?

Rapid decrease in blood pressure

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication?

Reduce environmental stimuli. When caring for a client who has hearing loss the nurse should reduce background noise to improve communication. Excessive stimuli in the environment can increase sensory alterations.

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Strict adherence to routines The nurse should identify that a child who has autism spectrum disorder can exhibit strict adherence to routines or rituals, a fixation to specific objects, and resistance to change.

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Support the client's left arm on a pillow while sitting.

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

Take the medication 15 min before playing sports. The nurse should instruct the child to take the medication 5 to 20 min prior to exercise to promote bronchodilation. The medication's effects begin immediately, peak in 30 to 60 min, and can last for up to 5 to 6 hr.

A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take?

Tell the nurses to stop the discussion. The nurses are violating client confidentiality by having the discussion in a public hallway. The charge nurse should tell the nurses to stop the discussion to prevent any further breach of confidentiality.

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

Tension pneumothorax The nurse should identify that tension pneumothorax is a possible adverse effect of PEEP. The nurse should monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins.

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene?

The LPN and the AP grasp the client under their arms to lift him up in bed.

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

Time the medication was given The nurse should document the time, the name of the medication, the dose, and the route in which the medication was given on the client's medication administration record immediately after it was administered. The nurse should also document the time that the incorrect medication was administered to the client in the incident report, as this is a fact directly related to the occurrence.

A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

Wheezing The nurse should recognize that wheezing can indicate the client is experiencing an adverse reaction to the medication.

A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take?

Withhold the heparin infusion. The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced, or the infusion withheld, until the aPTT returns to the therapeutic range.