RN Comprehensive Online Practice

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Have the client wear a surgical mask while being transported outside the room

A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? Hypotension Headaches Bruising Oliguria

Headaches The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events

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? Diminished reflexes Hematuria Hyperglycemia Hearing loss

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

A nurse is assessing a client who received 2 units of packed RBC's 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Hemoglobin 14.9 g/dL Normal levels - females: 12 to 16 g/dL males: 14 to 18 g/dL

A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? Decreased activity Hemoptysis 275 mL/24 hr Fever Weight loss 2.3 kg (5 lb)

Hemoptysis 275 mL/24 hr Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report

A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?

Hold the insulin pen device perpendicular to the client's skin to inject the medication - the nurse should hold the pen in place briefly for 6 to 10 seconds after injecting the insulin into the subcutaneous skin to ensure that the insulin is received.

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? Weight loss Urinary retention Hypertension Hypoglycemia

Hypertension The nurse should assess the client for hypertension, a complication of obstructive sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias

A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect?

Hyponatremia The nurse should expect the client to have a decrease in sodium levels because sodium is drawn to the edematous burn area and lost through plasma leakage.

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect? I have not had any food cravings The spotting I was having has stopped I don't feel depressed anymore I have not vomited as much recently

I have not vomited as much recently Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies pressure to a specific part of the body and can be used to alleviate nausea and vomiting

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 will make sure my 4 year old child wears a helmet when using a skateboard I should have my child avoid sun exposure between 10 am and 2 pm I can give my 2 year old child a whole hotdog on a bun When my infant is in the carrier, I will place it on a raised, flat surface whenever possible

I should have my child avoid sun exposure between 10 am and 2 pm To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400

A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? I should administer the ear drops as soon as I remove them from the refrigerator I should pull the top of the ear upward and back while instilling the medication I should massage behind the ear after I instill the drops I should have my child lie on the affected side for a few minutes after I put the drops in the ear

I should pull the top of the ear upward and back while instilling the medication The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back

A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? I should report a change in the color of my stools I can take acetaminophen to treat a headache I will take a calcium supplement while taking this medication I will return in a month to have my blood tested

I should report a change in the color of my stools The nurse should inform the client that red, black, or tarry stools can indicate bleeding, an adverse effect of warfarin, and the client should report these findings to the provider

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching? I should avoid eating smoked meat, cheeses, and ripe avocados while taking this type of medication I should watch for common reactions like dry mouth and constipation I will be at increased risk for high blood pressure while taking this medication I will take m

I should watch for common reactions like dry mouth and constipation The nurse should reinforce that increasing dietary fiber, fluid intake, and chewing sugar-free gum can alleviate the anticholinergic effects of dry mouth and constipation

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 can resume my daily aspirin therapy I will contact my provider if my eye feels itchy I will bend at my knees when picking an object up off the floor It's okay for me to pick up my grandchild who weighs 20 pounds

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

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? You will need to draft a health care proxy so a designee can make this decision for you I will make sure that no one performs any lifesaving measures if your heart stops Your provider determines if you should have lifesaving measures if your heart stops I will provide you with information about medical treatment to inc

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 themself by providing information about what end-of-life preferences to document

A home health nurse is providing teaching about infection prevention to a client who has cancer and receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature I will clean my toothbrush in my dishwasher once each month I will take my temperature once each week and let my doctor know if it is high I will walk short distances throughout

I will walk for short distances throughout the day The client should ambulate for short distances as tolerated throughout the day. This will help reduce pulmonary stasis and prevent the development of respiratory infections

A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?

Ideas of self-harm

A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? Identify health-related issues within the community Develop measurable health goals for community residents Create safety education classes for the program Enlist volunteers from the rural community to promote the program

Identify health-related issues within the community The first action the nurse should take when using the nursing process is to assess the clients living in the community to identify the prevalent health problems

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 Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls.

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 food high in protein, vitamins, and iron to promote tissue repair.

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 charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? Document the actual time of medication administration Notify the risk manager Complete an incident report Inform the nurse manager of the issue

Inform the nurse manager of the issue The greatest risk to clients is injury from not receiving medications on time and developing a medical complication. Therefore, the priority intervention the charge nurse should take is to follow the chain of command and contact the nurse manager

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?

Initiate continuous cardiac monitoring The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.

A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? Check the client's temperature every 2 hr Initiate fall precautions for the client Monitor the client's urine for discoloration Limit the client's fluid intake to 1 L per day

Initiate fall precautions for the client The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? Include chicken broth in the toddler's diet Feed the toddler the BRAT diet Initiate oral rehydration therapy for the toddler Offer the toddler flavored gelatin

Initiate oral rehydration therapy for the toddler Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed.

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

Initiate transmission-based precautions The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection.

A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? Inject 20 units of air into the NPH insulin vial Shake the NPH insulin vial vigorously to mix the insulin Use a new needle to draw up the insulin from the second vial Draw the longer-acting insulin into the syringe first

Inject 20 units of air into the NPH insulin vial The nurse should inject 20 units of air into the NPH insulin vial and withdraw the needle without touching the insulin, then proceed to inject 15 units of air into the regular insulin vial

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

An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (A). Which of the following tasks should the RN delegate to the LPN? Collection of a stool specimen Preparation of a client's postoperative bed Preparation of a teaching plan about pneumonia Insertion of a nasogastric tube

Insertion of a nasogastric tube The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the LPN's scope of practice

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Inspection Auscultation Percussion Palpitation

A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? Install a raised toilet seat at home Maintain the hip at an angle greater than 90 degrees Minimize the use of a walker Place a pillow under the knees when lying down

Install a raised toilet seat at home The client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?

Instruct the client to avoid coughing during the procedure

A nurse is caring for a client who has a deep-vein thrombosis. Which of the following actions should the nurse take?

Instruct the client to elevate the affected extremity when sitting The nurse should instruct the client to elevate the affected extremity to reduce edema and facilitate venous return

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Instruct the client to void

A nurse is providing dietary teaching to the parents of a 6-month old infant. Which of the following instructions should the nurse include? Provide the infant with 1 cup of cereal Give the infant 240 mL (8 oz) of juice per day Introduce new foods one at a time over 5 to 7 days Give whole milk first, then small amounts of solid food

Introduce new foods one at a time over 5 to 7 days The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies

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 Review the performance evaluations of nurses who work during these hours Implement a plan to transition from team nursing to primary care nursing during these hours Discuss a pla

Investigate environmental factors that might be contributing to client injury during these hours When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can include environmental factors that might be causing the problem

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? Initiate the referral at the time of discharge Have the client contact a physical therapist when feeling ready to begin therapy Verify that insurance will pay for outpatient physical therapy Involve the client in selection of a physical therapy provider

Involve the client in selection of a physical therapy provider The nurse should involve the client in the referral process, including selection of the physical therapist and the location

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?

Irrigate the catheter with 0.9% sodium chloride irrigation Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter and notify the provider if the obstruction does not clear.

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 Irritability is a manifestation of increased ICP, which is an indication that the VP shunt is malfunctioning.

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? Your mother might still know you are here Why do you feel that way It seems like you feel your visits are a waste of time Are you sure you would not want to see your mother again?

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 caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?

Jaundice Clients who take valproic acid are at risk for liver damage, which can lead to jaundice.

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure Instills 100 mL of air into the NG tube after checking for residual Flushes the NG tube with 0.9 % sodium chloride irrigation every 2 hr Adds 20 mL of blue dye to each feeding to help detect aspiration Keeps the head of the bed elevated to 45 for 1 hr after feedings

Keep the head of the bed elevated to 45 for 1 hr after feedings The nurse should keep the client's head elevated to 30 to 40 degrees for 1 to 2 hour after feedings to decrease the risk for aspiration

A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? Lack of remorse Sensitivity to rejection Extreme mood swings Self-mutilating behavior

Lack of remorse A client who has antisocial personality disorder is more likely to show a lack of remorse

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? Ketonuria Fecal impaction Latex allergy Tachycardia

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 assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? Bradycardia Low back pain Hypertension Distended jugular veins

Low back pain The nurse should expect low back pain in a client who is having a hemolytic transfusion 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? Give an antiemetic 30 min after medication administration Monitor blood glucose levels Maintain hydration with liberal fluid intake Monitor for tumor lysis syndrome

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 manger is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills? Compare the nurses's time management skills to the skills of coworkers Review client satisfaction reports about the nurse's performance Ask another staff nurse to evaluate the nurse's time management skills Maintain regular notes about the nurse's time management skills

Maintain regular notes about the nurse's time management skills Maintaining notes over a period of time provides a comprehensive view of the nurse's abilities so the manager can identify trends in the nurse's overall performance

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?

Maintain sterile objects within the line of vision

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

Make a referral for social services

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

A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? Propranolol Phenytoin Lorazepam Mannitol

Mannitol The client should receive mannitol, an osmotic diuretic to reduce intracranial pressure caused by cerebral edema

A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? Mark the edges of stairs for contrast Cover exposed extension cords with throw rugs Use 40-watt bulbs in lighting fixtures Instruct the client to obtain vision testing once every other year

Mark the edges of stairs for contrast Marking the edges of stairs with pain or colored tape for contrast can help older adult clients who have impaired vision prevent injury by decreasing the risk of falls

A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? Administer oxygen Initiate an infusion of oxytocin Massage the uterus to expel clots Obtain a CBC

Massage the uterus to expel clots Using the evidence-based practice approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner Let's go on that family vacation we've got planned. We will deal with this when we return Maybe this is better for our child because we don't want any

Maybe this is better for our chid because we don't want any suffering through chemotherapy treatments By justifying the adolescent's prognosis by searching for a more personally acceptable explanation for the impending loss, the parent is using the defense mechanism of rationalization

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an AP?

Measure the client's daily weight

A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? Measure the client's vital signs Reposition the client Encourage the client to use an incentive spirometer Administer pain medication

Measure the client's vital signs The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4 hr for the next 48 hr

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

A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? Provide an opportunity for the client to express their feelings Move the client to a quiet place away from others State expectations that set limits on the client's behavior Administer a PRN dose of haloperid

Move the client to a quiet place away from others The client's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other clients by moving the client to a quiet place away from others

During the change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Move the client to a room near the nurses' station

A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority? Will my husband be able to continue as the executor of his parents estate? One of my husbands coworkers visited last week to tell me my husband might lose his job Do you think it is necessary to postpone our daughter's wedding until my husband is feeling better? My husband doesn't known that I've already moved out of the hou

My husband doesn't known that I've already moved out of the house and filed for a divorce A lack of social support and isolation indicates the client is at greatest risk for another suicide attempt. Therefore, this is the priority that the nurse should report to the provider

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

Nasal flaring The nurse should report any indications of respiratory distress such as nasal flaring, retractions, and grunting

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? Constipation Nausea Wheezing Muscle rigidity

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 assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider? Pain level 6 on a scale of 0 to 10 Neurologic status; responds to verbal stimuli, speech slurred, hand grasps are weak and unequal Laboratory results: HGB 15 g/dL, HTC 45% Urinary output: 70 mL/2 hr

Neurologic status The client is experiencing slurred speech and extremity weakness, which are indications of a stroke, a potential complication of cardiac catheterization. The nurse should report these findings to the provider

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? Contact the triage officer Implement the client tracking system Ask the communications officer to release a press statement Notify the incident commander

Notify the incident commander The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

Noting the progress of the group toward assigned goals

A nurse is assessing a school age child who has bacterial meningitis. Which of the following findings should the nurse expect?

Nuchal rigidity

A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? Abdominal striae Masklike face Nystagmus Ptosis

Nystagmus Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis

A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Obtain the client's blood pressure before the nurse administers medication Initiate a referral with a dietician for the client Inform the client about the adverse effects of the medication Recommend a salt substitute to the client

Obtain the client's blood pressure before the nurse administers medication The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of function for an AP

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

Occlusive dressing on the insertion site Occlusive dressing on the insertion site prevents air from leaking and is an expected finding

A nurse is planning teaching about allowable foods for a client who has a history of uric-acid based urinary calculi formation. Which of the following foods should the nurse include in the teaching? Liver Oranges Chicken Red wine

Oranges A client who is prone to uric acid calculi formation can eat citrus fruits

A nurse is caring for a client who has had nausea and vomiting for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit? Shortness of breath Visual disturbances Decreased BUN levels Orthostatic hypotension

Orthostatic hypotension Clients who have a fluid volume deficit can experience orthostatic hypotension, which is a result of the body's inability to maintain adequate blood pressure following position changes

A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer?

Oxytocin

A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? Muscle damage Partial-thickness skin loss Visible subcutaneous tissue Tendon exposure

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

A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the nurse plan to delegate to the AP?

Perform gastrostomy feedings through a client's established gastrostomy tube

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? Performing a rapid needs assessment Organizing an immunization campaign Identifying the specific roles of disaster workers Conducting home visits to identify health hazards

Performing a rapid needs assessment Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage

A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect? Persistent uterine contractions Bright red vaginal bleeding Hyperactive deep-tendon reflexes Fundal height of 40 cm

Persistent uterine contractions The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding

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

Pink, frothy sputum due to fluid leaking across the pulmonary capillaries and into the lung tissue

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? Allow the newborn to breastfeed temporarily Relieve pressure by expressing milk daily Place ice packs on the breasts for 15 min several times per day Sleep with a loose-fitting bra to prevent nipple stimulation

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 relive the pain caused by engorgement

A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? Place the BP cuff in a labeled bag to send it for decontamination Immediately rinse the BP cuff in hot running water Dispose of the contaminated BP cuff in the bag lining the trash can Clean the BP cuff with a chlorine bleach solution

Place the BP cuff in a labeled bag to send it for decontamination The nurse should place the BP cuff in a labeled bag before removing it from the client's room and sending it to the proper facility location for decontamination

A nurse is caring for a child who is experiencing a tonic-clonic seizure. Which of the following action should the nurse take next? Insert a padded tongue blade into the child's mouth Place the child in a side-lying position Administer rescue breaths until the seizure subsides Obtain an ECG during the seizure

Place the child in a side-lying position The nurse should place the child in a side-lying position during a seizure to maintain a patent airway, decrease the risk of aspiration, and facilitate drainage of oral secretions

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased ICP?

Place the client in a quiet environment - Limit suctioning the client's airway to 15 seconds at a time to reduce the risk of hypoxia and increased ICP. Spread out nursing activities throughout the day to minimize fatigue and the risk of increasing ICP. Avoid flexing the client's neck to reduce the risk of reduced cerebral venous outflow.

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? Cleanse the skin at the stoma site with povidone-iodine for 15 seconds Dampen the skin before applying the skin barrier and ostomy pouch Place the skin barrier over the stoma and hold it for 30 seconds Cut the skin barrier opening 0.6 cm larger than the stoma

Place the skin barrier over the stoma and hold it for 30 seconds The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds

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? Uses a draw sheet to move the client to the left side of the bed Raises the total height of the bed to waist level Places a pillow under the client's right arm Lowers the side rails on the left side of the bed

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 in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse in unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Proceed with provision of medical care

A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? Uric acid crystals Protein WBCs Nitrites

Protein A client who has glomerulonephritis has increased glomerular permeability, which allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the urinalysis report

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? Remove the client's restraints while sleeping Document the client's status every 60 min Check for a new prescription every 6 hours Provide a staff member to stay with the client continuously

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 caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? Administer the TPN solution at the same rate using manual drop tubing Offer the client oral fluids in place of the TPN solution Infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr Provide dextrose

Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr The nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water at the same rate as the TPN solution

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take? Provide information about scheduling issues to the staff Ask staff members to participate in a trial of the new scheduling system Encourage staff to offer alternate scheduling solutions Develop goals to implement the new scheduling system

Provide information about scheduling issues to the staff The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? Carotid bruit Tracheal deviation Pulsus paradoxus Heart murmur

Pulsus Paradoxus The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Radial vein of the inner arm

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 is blood pressure

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? Projecting blame Excessive clinging Rapid speech Social awkwardness

Rapid speech Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns

A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? Report of persistent constipation Hgb 14 g/dL Albumin 4.2 g/dL Recent weight loss

Recent weight loss Weight loss can increase the risk for pressure injury. Inadequate nutrition will cause decreased nutrients for the skin and tissues and increases the chance for shearing against the bony prominences

A nurse in a provider's office is caring for an 18 month old toddler who has a blood lead level of 3 mcg/dL. Which of the following actions should the nurse take?

Recommend rescreening in 1 year - A blood lead level of 3 mcg/dL is within the expected reference range. The nurse should schedule chelation therapy for a blood lead level greater than 45 mcg/dL. The nurse should contact the poison control center for a blood lead level that is greater than 20 mcg/dL. The nurse should consider a referral to social services for a blood lead level greater than 5 mcg/dL.

A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies." Which of the following actions should the nurse take? (SATA) Refer the client to a community-based social worker Initiate a consult with a home health care provider Provide the client with information about the American Red Cross Postpone the discharge until someone can sta

Refer the client to a community-based social worker Initiate a consult with a home health care provider Give the client information about local support groups

A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. Clean the stoma with 0.9% sodium chloride irrigation Remove the inner cannula Change the tracheostomy collar Remove the soiled dressing

Remove the inner cannula Remove the soiled dressing Clean the stoma with 0.9% sodium chloride irrigation Change the tracheostomy collar

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Report of chest pain Epinephrine increases cardiac workload and oxygen demand, which can result in angina.

A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first? Ask a social worker to identify the client's insurance eligibility for rehabilitation services Request a referral for the client to receive physical therapy Arrange for the delivery of prescribed medications to the client's home Provide the client with a list of community resources

Request a referral for the client to receive physical therapy The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for physical therapy

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60, and HCO3 of 25. The nurse should identify that the client has which of the following acid-base imbalances?

Respiratory acidosis A client who has respiratory acidosis will have a decreased pH below the expected reference range of 7.35, and increased PaCO2 above the expected reference range of 35 to 45, and an HCO3 within the expected reference range of 22 to 26.

A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection? SQ in periumbilical area IM deltoid IM ventrogluteal SQ anterior thigh

SQ in periumbilical area

A nurse is providing discharge teaching to a new parent about care seat safety. Which of the following statements should the nurse include in the teaching? Place your baby's care seat at a 30 degree angle Your baby's car seat should be rear-facing until he is 6 months old Swaddle your baby in a light blanket before placing him in the car seat Secure the retainer clip at the level of your baby's armpits

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 teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? If you suspect you are pregnant, stop taking this medication You cannot become physically dependent on this medication Sedation is a common adverse effect of this medication If you forget a dose, you can double your next dose

Sedation is a common adverse effect of this medication Sedation and drowsiness are common adverse effects of methadone. Sedation most frequently occurs at the beginning of treatment or during dosage increases

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?

Sedentary lifestyle

A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?

Seeks input from the other nurses

A nurse is caring for a school age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?

Serum liver enzyme levels

A nurse is caring for a child who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?

Serum sodium 1.36 mEq/L A child who has hypotonic dehydration has a serum sodium level below 130 mEq/L. A serum sodium level of 136 mEq/L, which is within the expected reference range of 135 to 145, indicated that this child is responding well to the oral rehydration solution.

A nurse is preparing a sterile field in order to insert an indwelling catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique? Open the top outer flap of the package toward the body Clean the penis with the non-dominant hand Don sterile gloves after opening the lubricant packet Set the catheter tray on the overbed table at waist height

Set the catheter tray on the overbed table at waist height To maintain sterility, the nurse should place the catheter tray on a work surface at or above waist level

A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? Set your hot water heater temperature at or below 120 degrees Fahrenheit Cover your baby with a light blanket while sleeping Make sure the slats on the baby's crib are no more than 3 inches apart Place your baby's car seat rear-facing until the age of 1 year old

Set your hot water heater temperature at or below 120 degrees Fahrenheit The nurse should instruct the client to set the maximum hot water temperature to no more than 49 degrees Celsius, or 120 degrees Fahrenheit. The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn

A nurse is providing teaching to a client who is schedule 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

A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?

Sodium 148 mEq/L normal range: 135-145 Clients who have kidney disease often retain sodium and require sodium-restricted diets.

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?

Starts a task then determines what supplies are needed

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

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 Depress the infant's tongue Turn the infant's head to one side Tap on the bridge of the infant's nose

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 is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? Displacement Regression Suppression Sublimation

Sublimation The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hours. Which of the following findings should the nurse identify as an indication that the client has developed oxygen toxicity? Wheezes Tachycardia Restlessness Substernal pain

Substernal pain The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased work of breathing, such as in a preschooler who has cystic fibrosis

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care? Give the client a choice of foods and beverages Supervise the client during and after eating Encourage casual conversation about food during meal times Provide opportunities for the client to choose their own meal times

Supervise the client during and after eating The nurse should monitor the client during and for 1 hr after meals to prevent the client from hiding food or purging

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 school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Survey the scene for potential hazards to staff and children

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 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 bronchodilator. The medication's effects begin immediately, peak in 30 to 60 min, and can last for up to 5 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? Apologize to the client for the nurses' actions Advise the nurses that they are being insubordinate Tell the nurses to stop the discussion Document the incident in the client's medical record

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 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? Informs the provider about a client's suicide plan Notifies the health department of a client's diagnosis of chlamydia Reports suspected child maltreatment to social services Tells the hospital chaplain a client's diagnosis

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 HIPPA

A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report to the provider? Temperature 39.5 C (102.9 F) Headache Constipation Dry Mouth

Temperature 102.9 F The greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temperature, dysrhythmia, decreased LOC, and a labile blood pressure. Therefore, the priority finding for the nurse to report to the provider is a fever.

A nurse is caring for 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 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 LPN and an 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 his arms to lift him up in bed

A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? Contractions will be felt primarily in the upper abdomen The cervix transitions to an anterior position Contraction intensity decreases with ambulation The cervix progressively thickens

The cervix transitions to an anterior position In true labor, the cervix transitions to an anterior position and begins to dilate in preparation for birth

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

The child exhibits discomfort while walking

A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? The client's partner tells the nurse that the client understands the procedure The nurse locates the provider's prescription for the surgical procedure The nurse witnesses the provider's explanation of the procedure The client is able to accurately describe the upcoming procedure

The client is able to accurately describe the upcoming procedure The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent form

A nurse on an impatient 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 client will have a visit by a home health nurse tomorrow The client's partner will bring clothes for the client to change into prior to discharge The client often needs encouragement to engage in perso

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 nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?

The client reports a decrease in episode of nausea

A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? The client reports leg itching under the cast around the mid upper thigh area The client reports increased pain when the leg is lowered below the level of the heart The client's cast became wet during a sponge bath The client's heel is reddened and tender

The client's heel is reddened and tender The greatest risk to this client is injury from a pressure injury. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel

A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? Estrogen levels decrease during pregnancy, causing the stool to become hardened Decreased water absorption in the intestine during pregnancy causes constipation The intestine absorbs iron less efficiently during pregnancy, leading to constipation The enlarged uterus compresses the intestines and causes

The enlarged uterus compresses the intestines and causes constipation During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation

A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? Choosing to donate organs can delay the timing of the child's funeral The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body The family should understand that an autopsy is mandatory prior to organ

The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral

A home health nurse is assessing a 2 week old newborn who had a birth weight of 8 lb and is being breastfed. Which of the following findings indicates effective breastfeeding? The newborn nurses every 4 hr during the day and sleeps through the night The newborn has six to eight wet diapers per day The newborn's current weight is 7 lb The newborn has sticky, greenish stools

The newborn has six to eight wet diapers per day Measuring the number of wet diapers per day is an effective measurement of adequate intake. Six to eight wet diapers each day after the fourth day of life indicates effective breastfeeding

A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? While performing a breast examination, the newly licensed nurse discusses techniques of breast self-examination with the client The newly licensed nurse writes detailed notes while performing the head-to-toe assessment The newly licensed nurse uses a penlight to assess for changes in the contour of the body

The newly licensed nurse writes detailed notes while performing the head to toe assessment The newly licensed nurse should record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment

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

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 medical record has a lot of medical terminology, and it might be difficult for you to understand You should really talk to your provider if you have any questions about your treatment Some parts of your medical record are restricted, but I an show you the parts th

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 nurse administers an incorrect dose of medication to a client. The nurse recognized the error immediately and completes and 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

A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?

Tremors Tremors are a manifestation of hyperthyroidism along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia.

A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? Amylase Troponin T Low-density lipoprotein (LDL) Homocysteine

Troponin T Troponin T is a myocardial muscle protein that is released into circulation after cardiac injury. The nurse should expect increases in the client's troponin level within 2 to 3 hr following a myocardial injury

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

Turn of the CPM machine during mealtime

A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCO3 26 mEq/L, SaO2 87%. Which of the following is the correct interpretation of these values? Uncompensated metabolic acidosis Uncompensated respiratory acidosis Compensated respiratory acidosis Compensated metabolic acidosis

Uncompensated respiratory acidosis A pH of 7.3 is below the expected reference range and indicates the client has acidosis. The PaCO2 of 54 mm Hg is above the expected reference range, which, when combined with the low pH, indicates that the acidosis has a respiratory origin. The HCO3 of 26 mEq/L is within the expected reference range, indicating that the acidosis is not metabolic in origin and the body has not yet corrected the imbalance through compensation

A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? Muscle spasms of the affected extremity A pain rating of 6 on a scale from 0 to 10 Upper chest petechiae Ecchymosis over the fractured area

Upper chest petechiae The greatest risk to this client is organ damage from fat embolism syndrome, a life-threatening complication of fractures. In fat embolism syndrome, a fat embolus enters the blood stream and can obstruct blood vessels of a major organ, such as the lung, kidney, or brain. Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and confusion. Therefore, the nurse should identify this as the priority finding

A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?

Urine specific gravity 1.052 The nurse should recognize this urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates dehydration from vomiting.

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? Instill chilled lavage solution into the client's NG tube Attach the client's NG tube to lower intermittent suction Use 0.9% sodium chloride for irrigation of the NG tube Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time

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

A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?

Use a protective cover on the scale when weighing the infant

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

A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?

Use a three-point gait

A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? Use hydrogen peroxide to clean kitchen surfaces Seal nonwashable items in a plastic bag for 2 weeks Wear a surgical mask when in public Limit family visits to 30 min periods

Use hydrogen peroxide to clean kitchen surfaces The client should clean kitchen surfaces with hydrogen peroxide to kill the virus and prevent transmission

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Use the ventrogluteal site

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

Verify the client and blood product information with another licensed nurse

A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? BP 150/87 mm Hg WBC count 2,800 Auditory hallucinations Nausea

WBC count 2,800 Clozapine can cause agranulocytosis, which can be life-threatening. Therefore, a WBC count of less than 3,000 is a contraindication for the client to receive clozapine. The nurse should withhold the medication and notify the provider of the client's WBC count

A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicates an understanding of the teaching? We will let our child watch a favorite video before bed We should read a story together every night before bedtime We can let our child fall asleep in our room and then move her to her own bed We should change the b

We should read a story together every night before bedtime Preschoolers respond to rituals that prepare them for bed, such as hearing a story or taking a bath

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?

Wear clothing made with cotton fabrics while oxygen is in use

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

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 the lesions no longer itch Three days after the lesions appeared When crusts have formed on every lesion When the lesions disappear

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 creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm^3. Which of the following interventions should the nurse include in the plan? Encourage friends and family to visit the child Withhold administering the varicella vaccine to the child Collect a daily urine specimen from the child to check for proteinuria Provide a low-protein diet for the child

Withhold administering the varicella vaccine to the child A child who has severe immunodeficiency should not receive a lie vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed.

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 and INR 1.8. 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.

A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? You don't need advance directive now because you are competent and can make decisions for yourself You must wait for a period of 6 months after your diagnosis before initiating advance directives You will have to speak to an expert who works in the social service department You should complete advance directives in the event you cannot express your

You should complete advance directives in the event you cannot express your own wishes The client should prepare advance directives to make their wishes known should they be unable to communicate them in the future

A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child? You should leave your glasses off throughout the testing You should stand 15 feet away from the chart You should get three symbols on a line correct to pass the line You should keep both eyes open during the testing

You should keep both eyes open during the testing The nurse should instruct the child to keep both eyes open during visual acuity testing

A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure-sensitive valve. Which of the following information should the nurse include in the teaching? You should flush the catheter with 0.9% sodium chloride solution daily when not using it regularly You should keep the catheter clamped when not in use You should swim twice weekly to prevent tissue from adhering to the cuff You should change your dressing every 10 days

You should keep the catheter clamped when not in use The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled catheters have a pressure sensitive valve that prevents blood reflux

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? This type of nutrition is ore effective than eating by mouth You will receive fingersticks for blood glucose testing TPN is a way to provide vitamins and minerals without increased calories Taking TPN can increase the risk of developing a latex allergy

You will receive fingersticks for blood glucose testing A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring

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

A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which interventions should the nurse include in the plan of care? maintain the client on bed rest restrict the client to 1 L of fluid per day place cool compresses on the edematous area elevate the affected leg

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 nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

irritability

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

pH 7.31 Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35 to 7.45. A pH level less than 7.35 indicated acidosis. For a client who has COPD a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45, indicating respiratory acidosis.

A nurse is preparing to perform an intermittent urinary catheterization for a client who has urinary retention. Which of the following indicates the catheter the nurse should use? indwelling catheter three-way catheter specimen catheter straight catheter

straight catheter Should be used to perform an intermittent catheterization for a client who has urinary retention

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicated an understanding of isolation precautions?

"A client who requires airborne precautions should be placed in a negative pressure airflow room"

A nurse in a provider's office is assess an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

"Have you had any stomach pain or bloody stools?"

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

"How does this make you feel?"

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

"I can designate my partner as my health care surrogate"

A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism?

"I told my doctor that I would like to start a support group for other women who are sick in my community"

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

"I will be checking you once with your eyes open and once with them closed"

A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching?

"I will cover my baby's body when I wash her hair" "I will use the bulb syringe first in her mouth and then in her nose"

A nurse is providing education to the parent of a school age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

"I will make sure my child receives a yearly influenza immunization"

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

"I will need to measure your weight daily"

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?

"I will not allow anyone to smoke near my baby"

A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will wear a supportive bra overnight"

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

"I would like to talk to you about the unit policies regarding break time"

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"

A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience increased thirst" The nurse should recognize that an increase in thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider.

A nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? SATA

"Shake the medication bottle well before each dose is given "Store the medication in the refrigerator" "Report diarrhea to the provider immediately"

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"

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

"We can expect the hospice nurse to provide support for us after our mother's death"

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?

"You have the right to change your mind about the procedure at any time"

A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?

"You seem to be having a difficult time right now"

A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule for a 3 hour oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?

"You will need to fast the night before the test"

A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donator states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make?

"You're afraid that your other kidney will fail at some point after the organ donation"

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?

"Your body temperature might decrease slightly just prior to ovulation" - Body temperature rises after ovulation and remains elevated until 2 to 4 days prior to the start of menstruation. The client should measure their body temperature upon waking each morning prior to getting out of bed.

A nurse is preparing to administer heparin 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose?

0.5 mL

A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer?

0.6 mL

A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? 1 medium raw carrot 1/2 cup cooked spinach 1/2 cooked butternut squash 1 cup sliced cantaloupe

1 medium raw carrot The nurse should identify that 1 medium raw carrot contains 2,025 mcg/dL of vitamin A and is therefore the best food to recommend to the client

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?

13 gtt/min

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer?

18 g

A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect?

45 seconds This value is above the expected reference range of 30 to 40 seconds and indicates a risk for spontaneous bleeding, which is a manifestation of hemophilia A.

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

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

A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (A) to assist with meals? A client who has Alzheimer's disease and is demonstrating aphasia A client who has asthma and an increased respiratory rate A client who had a stroke and is to start oral intake A client who had diabetic ketoacidosis and is difficult to rouse

A client who has Alzheimer's disease and is demonstrating aphasia Aphasia impairs the client's ability to communicate but does not interfere with nutritional intake or place the client at an increased risk for aspiration while eating. Therefore, assisting the client with meals is within the AP's range of function

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

A client who has cellulitis and is receiving oral antibiotics every 8 hr

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings A client who has admitted for dehydration and is receiving a continuous IV infusion A client who has a history of two prior miscar

A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? A client who is alert and has a 2.5 cm laceration on the forehead A client who has significant head trauma and agonal respirations A client who has an open fracture of the right forearm A client who is unconscious and has a rapid, thready radial pulse

A client who has significant head trauma and agonal respirations The nurse should place a black tag on a client who has significant head trauma and agonal respirations because this client is not likely to recover or will require extensive resources for care

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

A client who is at 33 weeks of gestation and has severe gestational hypertension

A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first? A client who has a temperature of 100.8 F and requests a cup of ice chips A client who is postoperative and reports a pain level of 5 on a scale from 0 to 10 A client who has voided and is ready for a bladder scan A client who is confused and has been attempting to get out of bed

A client who is confused and has been attempting to get out of bed The nurse should recognize that a client who is confused and has been attempting to get out of bed is at greatest risk for injury from a fall. Therefore, the nurse should attend to this client first

A nurse has just received change of shift report on four clients. Which of the following clients should the nurse assess first?

A client who is postoperative with abdominal distention and no bowel sounds - abdominal distention and no bowel sounds indicates a paralytic ileus

A nurse has received change of shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A client who is receiving an MAOI and is requesting a cheeseburger for dinner - The client's food selection contains tyramine. Clients prescribed an MAOI must restrict intake of foods that contain tyramine due to adverse effects, such as HTN

A nurse at a mental health clinic is caring for four clients. The nurse should recognize the following clients is using dissociation as a defense mechanism?

A client who was abused as a child describes the abuse as if it happened to someone else

A home health nurse is caring for a group of older adult clients. The nurse should indicate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A client whose caregiver requests adult day care services PACE provides adult day care services along with in-home assessments and supportive services

A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? A client's IV pump delivers an inadequate dose of medication A nurse follows a client's advance directives and discontinues enteral feedings A nurse discords unused, expired bags of IV fluids A client refuses an IV bolus of pain medication

A client's IV pump delivers an inadequate dose of medication The nurse should complete an incident report to record occurrences which resulted in a medication error, such as a failure of the IV pump, as part of the quality improvement process. Other situations requiring an incident report includes significant complaints about care quality and visitor or client injury

A nurse is working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?

A middle adult client who has unstable vital signs

A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (SATA) A speech pathologist will be performing a swallowing study for you You should rest before eating a meal You should restrict foods that are high in vitamin D Reduce your intake of dietary fiber Thicken your beverages before drinking

A speech pathologist will be performing a swallowing study for you You should rest before eating a meal Thicken your beverages before drinking The nurse should instruct the client that a swallowing study will be performed to determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of MS. The nurse should encourage the client to rest before each meal. Clients who have MS often report weakness and are easily fatigued. The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of MS.

A nurse in a community center is providing an education session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?

Abdominal bloating

A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?

Acute confusion An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia.

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?

Administer high-dose antibiotic therapy Children who have CF metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?

Advocacy is a leadership role that helps others to self-actualize

A rural community health nurse is developing a plan to improve health care delivery for migrant farm workers. 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 goal of AHRG 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 caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding?

Albumin 2.8 g/dL The nurse should recognize that an albumin level of less than 3.5 indicates malnutrition and a need for additional nutritional supplementation. The expected reference range for albumin is 3.5-5

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 clients who have rheumatoid arthritis should balance rest with exercise to maintain muscle strength, joint function, and range of motion.

A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessment is the nurse's priority?

Amount of vaginal bleeding A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vaginal bleeding is the priority.

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? A client who is pregnant and has cytomegalovirus (CMV) An adolescent client who has foodborne botulism A child who has erythema infectiosum A young adult client who has herpes simplex virus type 1 (HSV-1)

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 caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information? An RN who is monitoring a client who started receiving a blood transfusion 5 min ago An assistive personnel (AP) who just began performing a bed bath A licensed practical nurse (LPN) who is reinforcing discharge instructions with a client An assistive personnel (AP)

An assistive personnel (AP) who is assisting a client to return to bed Performing a blood pressure check is within the range of function of an AP, and the AP should be available to obtain a blood pressure within the specified time

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

An older adult client who is anxious and attempting to pull out an IV line

A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider?

Apply a cold pack to the client's ankle for 30 min every hour

A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway? Withdraw the catheter if the client begins coughing Apply suction for 10 seconds Advance the catheter 2 cm after resistance is met Use medical asepsis when performing the procedure

Apply the suction for 10 seconds The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an 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

A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take? Ask the caller for verification of the identity Give the caller limited information about the client Transfer the phone call to the client's room Inform the caller that they should obtain permission from the client's provider

Ask the caller for verification of their identity According to HIPAA, if someone requests information about a client it is the nurse's duty to protect that information. Therefore, the nurse should inform the caller that nurses cannot release any client information over the phone without the permission of the client. The nurse should ask the verification of the caller's identity to determine if they have been authorized by the client to receive information

A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following should the nurse take first? Ask the client to rate their pain level Assist the client in changing positions Administer a PRN analgesic medication Explain the importance of early ambulation

Ask the client to rate their pain level Using the nursing process, the first action the nurse should take is to assess the client's level of pain. If indicated, the nurse should administer an analgesic, then wait 30 to 45 min to allow the analgesic to take effect before encouraging the client to ambulate. Management of the client'a pain is a priority for encouraging postoperative activity

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? Refer the nurse to the procedure manual Use a diagram to explain the procedure to the nurse Demonstrate the procedure to the nurse Ask the nurse about their knowledge of the procedure

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 charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

Ask the partner to list specific concerns

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 the contents from the tube and verify the pH level The nurse should verify that the pH level of the client's gastric aspirate is less than 5 to determine proper placement of a client's NG feeding tube prior to administering a bolus feeding.

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? Ask for help with a two-person assist transfer Assess the client for functional limitations Request a mechanical lift device Medicate the client for pain

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 caring for a client who has active tuberculosis. Which of the following actions should the nurse take?

Assign the client to a private room with negative air pressure

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assist with deep breathing and coughing

A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? Urine output 120 mL in 4 hr Systolic blood pressure 12 mm Hg lower than the preoperative level Audible stridor Normal sinus rhythm with an occasional premature ventricular contraction

Audible Stridor Audible stridor, or a high-pitched sound heard in the client's airway indicates edema, laryngeal spasm, secretions, or some type of airway obstruction that could become life-threatening. The nurse should report this finding to the provider

A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? Notify the provider if a thrill is palpated at the fistula Auscultate the affected extremity for a bruit Discourage range of motion exercises in the affected extremity Perform venipuncture in the affected extremity

Auscultate the affected extremity for a bruit The nurse should auscultate the AV fistula every 4 hr to ensure a bruit is present, which indicates patency

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Auscultate the apical pulse at least 1 min

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

Autonomy

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

Avoid including raw fruits in the client's diet

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 Restrict visitors to family members Limit oral fluid intake to between meals Prohibit fresh flowers in the client's room

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 assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? Slightly blue hands and feet Respiratory rate 40/min Axillary temperature 97.2 F Apical pulse 136/min

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

A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? Butterfly rash over the cheeks and nose Report of pain in the joints of the lower extremities Blanching of the fingers and toes Scaly patches over the knees and elbows

Blanching of the fingers and toes A client who has Raynaud's disease can have blanching of the fingers and toes in response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone

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 Potassium deficiency Infection Hyperbilirubinemia

Bleeding The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding

When caring for a child, a nurse plans to use nonpharmacologic interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? Coloring with crayons in a coloring book Deep breathing and "going limp as a rag doll" Blowing bubbles with liquid soap to "blow the hurt away" Taking a warm bath and playing with a bath toy

Blowing bubbles with liquid soap to "blow the hurt away" Having the child blow bubbles is a visualization technique that can help to decrease the child's discomfort. The child can visualize the pain as the bubble that they blow away from themself and into the air

A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

Blurred vision

A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? Intermittent cramping Moderate lochia rubra Boggy uterus Perineal edema

Boggy uterus When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is a boggy uterus which can indicate uterine hemorrhage. The nurse should immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes relaxed during the postpartum period the client will rapidly lose blood because no permanent thrombi have formed at the placenta

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

Borderline Clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation.

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make?

Broccoli Yogurt Cream cheese Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli, yogurt, and cream cheese do not contain tyramine.

A nurse is caring for a 2 month old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD?

C The nurse should assess the infant's abdomen for distention and visible peristalsis, which are manifestations of HD

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 birth?

Cervical laceration

A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first?

Change the position of the client

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

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? Teach the client reportable adverse effects from the medication Check the insulin dose with another licensed nurse Administer the insulin at a 90 degree angle Clean the insertion site

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 assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? "Big, bat, bop, the boat is bouncing back" Clang association Echolalia Neologisms Word Salad

Clang association Clang association is an alteration in speech in which the client uses words based on their sound, rather than their meaning. Clients who have neurological disorders can also have this alteration in speech

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? Keep the client resting in bed Ask the client to restate directions Clear objects from the client's walking area Evaluate the client's ability to swallow

Clear objects from the clients walking area The nurse should plan to clear objects from the clients 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 teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs with arthritis. The nurse should provide the client with which of the following information? Increase intake of fluids and fiber to prevent constipation Complete a serum pregnancy test before taking the medication This medication coats stomach ulcers so that they can heal Take a magnesium-containing antacid along with this medication

Complete a serum pregnancy test before taking the medication Misoprostol can induce uterine contractions. Clients of childbearing age must rule out pregnancy before taking misoprostol

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority? Lethargy Confusion Polyuria Fine hand tremors

Confusion When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is confusion because it is an early manifestation of lithium toxicity. The nurse should monitor the client for additional indications of lithium toxicity, including coarse hand tremors, incoordination, ECG changes, and sedation

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? Airborne Droplet Contact Protective environment

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 newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? Contact Droplet Airborne Protective environment

Contact The nurse should initiate contact precautions because clients transmit HSV by direct and indirect contact with others and the environment. The nurse should wear gloves when in close contact with the newborn

A nurse in an emergency department is assessing a school age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

Contact Child Protective Services

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 Assist the client to a knee-chest position Prepare the client for continuous internal monitoring Prepare for an emergency cesarean birth

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 teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

Cough

A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?

D abducting the hip joint by moving the leg away from the midline of the body.

A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Increased intraocular pressure Floating dark spots Decreased central vision Double vision

Decreased central vision The nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina

A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? Increased bowel sounds Dry, sticky mucous membranes Decreased deep tendon reflexes Numbness and tingling of the extremities

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

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

Decreased hallucinations Chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia

A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging? Decreased blood pressure Increased cardiac output Increased oral temperature Decreased lung expansion

Decreased lung expansion Older adult clients are more likely to have decreased lung expansion due to decreased mobility of the ribs

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?

Delegate non-nursing tasks to ancillary staff

A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? Assist the client with contacting individuals from the client's support system Give the client information about available community resources for shelter Suggest the client obtain mental health counseling Determine the client's perception of the personal impact of the crisis

Determine the client's perception of the personal impact of the crisis The first action the nurse should take using the nursing process is to assess the client. Therefore, the first action the nurse should take to determine the client's feelings and understanding of the natural disaster and its personal impact

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

Determine the client's reading skills

A nurse is an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? Offer a referral to the client for social services Develop a safety plan with the client Encourage the client to reach out to family and friends Provide the client with a list of support groups

Develop a safety plan with the client The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is to develop a safety plan with the client

A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect? Lethargy Diaphoresis Bradycardia Cough

Diaphoresis Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? Popcorn Diced steamed carrots Whole celery sticks Marshmallows

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 on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

Difficulty performing ADL's

A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following action should the nurse take? Document the client's refusal of the medication Administer the medication that the provider prescribed Request consent from the client's family to administer the medication Administer an oral dose of the medication

Document the client's refusal of the medication The client has the right to refuse medication. The nurse should document the refusal in the client's medical record

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? Apply an over the counter cream if the wound becomes infected Clean the wound twice a day with povidone-iodine Apply heat to the wound for 10 min, four times per day Double-bag soiled dressings in plastic bags for disposal

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 admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

Droplet The nurse should initiate droplet precautions for this client by placing the client in a private room and wearing a surgical mask when caring for the client.

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

Dry mouth Clonidine is an indirect-acting antiadrenergic agent used for HTN, severe pain, and attention deficit disorder. The nurse should inform the client that dry mouth, or xerostomia, is a common adverse effect of clonidine.

A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? Dry the newborn Assign the first Apgar score to the newborn Place an identification bracelet on the newborn Obtain the newborn's weight

Dry the newborn The greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take is to dry the newborn

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

Dyspnea Fluid overload can lead to the backup of fluid in the pulmonary system resulting in shortness of breath.

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 paresthesias from increased edema in the compartment involved

A home health 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 To prevent stool leakage and skin irritation

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care? Encourage the parents to bring toys from home Use a visual analog scale to rate the toddler's pain Inform the toddler about the procedure 1 week before hospitalization Stress to the parents the need for maintaining the hospital's daily routine

Encourage the parents to bring toys from home To help decrease the toddler's anxiety, the nurse should encourage the family to bring familiar objects from home, such as toys, blankets, and feeding utensils

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

A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the following actions should the nurse plan to take? Allow the plasma to warm for 30 min before transfusion Confirm the client's identification by checking the room number Enter the plasma product number into the client's medical record Administer each unit of plasma over 4 hr

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 mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship? Encourage the client's problem-solving abilities Discuss the client's previous experience with loss Promote the client's self-esteem Establish the termination date of therapy

Establish the termination date of therapy This task occurs in the orientation phase of a therapeutic relationship

A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? Tell the client to self-report to the state health department Require that the client speak with a public health nurse Explain to the client why this information will be shared Refer the client to a social worker for counseling

Explain to the client why this information will be shared It is the responsibility of the nurse to advocate for the client, provide confidential information, and explain legal requirements. Reporting communicable disease occurrences helps with identifying outbreaks and overall disease trends

A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?

Explore the client's reasons for refusing the treatment

A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (SATA) Nystagmus Facial flushing Diplopia Nasal congestion Headache

Facial flushing Nasal congestion Headache

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?

Facilitate an interdisciplinary conference at the new facility for the family

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According Nägele's rule, which of the following should the nurse document as the client's estimated date of birth (EDB)?

February 15 - Add 7 days to the first day of the client's LMP (8+7=15) and then subtract 3 months

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 Pain in weight bearing joints Decreased heart rate Peeling of the soles of the feet

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 To reduce diarrhea and inflammation

A nurse manager is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using?

Flight of ideas Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes.

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?

Floating dark spots

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 medication s should the nurse anticipate administering? Naloxone Flumazenil Acetylcysteine Atropine

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 nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? Flush the client's gastrostomy tube with 30 mL of water before administering the medication Crush the client's medication and mix them in with the tube feeding formula prior to administration Change the client's feeding bag every 72 hr Administer multiple prescribed medications at the same time

Flush the client's gastrostomy tube with 30 mL of water before administering the medication The nurse should flush the gastrostomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?

Form a committee of staff members to investigate current staffing issues

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? Ensure that the staff nurse changes the dressing Notify the nurse manager Complete an incident report Gather more information about the staff nurse's actions

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 is caring for a client who is in the manic-phase of bipolar disorder. Which of the following manifestations should the nurse expect? Hypersensitivity to criticism Fears of abandonment Grandiose delusions Reclusive behavior

Grandiose delusions Clients who are in the manic phase of bipolar disorder typically exhibit behaviors that appear to be euphoric. Clients can also have abrupt mood changes, expansiveness, unlimited energy, poor impulse control, and grandiose delusions

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 non-pharmacological 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? Spinal manipulation Acupuncture Therapeutic touch Guided imager

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