vati retake
A nurse is caring for a client who is receiving a blood transfusion at 125ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Infuse 0.9% sodium chloride IV Administer an antipyretic Decrease the infusion rate to 75ml/h Place the client in a left lateral position
Infuse 0.9% sodium chloride IV
A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? Insert an indwelling catheter if the client has not voided in 3 hr. Obtain the abdominal girth now and every 4 hr. Assess and document the level of consciousness every hour. Measure the amount of gastric drainage every 2 hr.
Insert an indwelling catheter if the client has not voided in 3 hr.
A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan? Eggs Latex Peanuts Iodine
Iodine
A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating? Justice Autonomy Nonmaleficence Veracity
Justice
A nurse from the State Health Department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention? Herpes simplex virus 2 Candida albicans Staphylococcus aureus Lyme disease
Lyme disease
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? Encourage the client to gain 2.3 kg (5 lb) per week. Weigh the client once per week throughout hospitalization. Monitor the client for 1 hr after meals. Allow the client to choose meal times.
Monitor the client for 1 hr after meals.
A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider? No bowel movement for 3 days Report of dry mouth Respiratory rate 14/min Potassium level 4.8 mEq/L
No bowel movement for 3 days
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? Notify the facility operator. Close the fire doors on the unit .Turn of oxygen sources. Put out the fire with the appropriate extinguisher.
Notify the facility operator.
A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? Oliguria Constricted pupils Shivering Bradypnea
Oliguria
A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include? Daily bath given at 1000 Vomited a large amount of emesis immediately after surgery Flushed IV with 0.9% sodium chloride Pain relieved by position change
Pain relieved by position change
A nurse is assessing a client who has pericarditis. Which of the following findings is the priority? Dependent edema Pericardial friction rub Paradoxical pulse Substernal chest pain
Paradoxical pulse
A nurse is planning care for a client who has a gambling disorder. Which of following instructions should the nurse provide to the client? Participate in a 12-step program. Plan to take clozapine for the next 6 months .Use systematic desensitization to decrease gambling behaviors. Learn to use projection to adapt to stressful experiences.
Participate in a 12-step program.
A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings? Head circumference 1 cm greater than chest Positive Babinski reflex on bilateral feet Passage of meconium stool Pinna below the outer canthus of the eye
Pinna below the outer canthus of the eye
A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? Provide the client with a walker. Premedicate the client with the prescribed analgesic. Obtain the client's vital signs and oximetry prior to ambulation. Reinforce the client's surgical dressing.
Premedicate the client with the prescribed analgesic.
A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks' gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? Rupture the amniotic sac Medicate the client for pain Prepare the client for a cesarean section. Perform a vaginal exam.
Prepare the client for a cesarean section.
A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plain of care? Provide a flexible activity schedule. Provide high-calorie nutritional supplements. Allow the client to eat meals alone in her room. Allow the client to choose her clothes independently.
Provide high-calorie nutritional supplements.
A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care? Provide a flexible activity schedule. Provide high-calorie nutritional supplements. Allow the client to eat meals alone in her room. Allow the client to choose her clothes independently
Provide high-calorie nutritional supplements.
A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? Portable suction Cervical collar Hemodialyzer Pulse oximeter
Pulse oximeter
A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? Speak directly into one of the client's ears. Rephrase sentences the client does not understand. Drop voice volume at the end of sentences .Exaggerate lip movements.
Rephrase sentences the client does not understand.
A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints? The client follows the nurse's simple instructions .The client apologizes for their aggressive behavior. The client requests that the restraints be removed. The client maintains eye contact while talking with the nurse.
The client follows the nurse's simple instructions
A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration? The client tucks his chin while swallowing food. The client sits upright in bed during meals. The client pockets food on one side of his mouth. The client has a cough reflex.
The client pockets food on one side of his mouth.
A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following? An air leak noted at the insertion site. The tubing may be kinked Water needs to be added to the suction-control chamber. The suction is set too low.
The tubing may be kinked
A nurse in the telemetry unit is reviewing the laboratory results of an adult client who is being treated for myocardial infarction. Which of the following is an expected finding for this client? Brain natriuretic peptide (BNP) 10 ng/L High-density lipoprotein (HDL) 75 mg/dL Alanine aminotransferase (ALT) 30 unit/L Troponin I (TNI) 0.8 ng/mL
Troponin I (TNI) 0.8 ng/mL
A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include? A client who has a history of MRSA will need antibiotics .A client who has a history of MRSA can develop immunity to the infection. A client who has a history of MRSA requires a protective environment .A client who has a history of MRSA can still transmit the infection
.A client who has a history of MRSA can still transmit the infection
A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? Urine specific gravity of 1.028 Urine output of 250 mL/hr Serum sodium of 115 mEq/L Blood glucose of 198 mg/dL
Urine output of 250 mL/hr
A nurse is caring for a client who has manifestations of increasing intracranial pressure (ICP) following a stroke. Which of the following actions should the nurse take? Maintain systolic blood pressure between 140 to 150 mm Hg. Lay the client _in bed .Provide oxygen for a saturation of less than 92% .Cluster nursing care procedures.
.Provide oxygen for a saturation of less than 92%
A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? Urine specific gravity of 1.028 Urine output of 250 mL/hr Serum sodium of 115 mEq/L Blood glucose of 198 mg/dL
Urine output of 250 mL/hr
A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia? Serum calcium 10 mg/dL Urine specific gravity 1.001 Serum sodium 138 mEq/L Urine pH 6
Urine specific gravity 1.001
A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate? Have the client tilt her head slightly so that the medication enters the nasolacrimal duct. Gently wash away any exudate along the eyelid margin from the outside towards the inner canthus. Drop prescribed number of drops onto the cornea. Use aseptic technique and drop the medication into the conjunctival sac.
Use aseptic technique and drop the medication into the conjunctival sac.
A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use? Ventrogluteal Dorsogluteal Vastus lateralis Rectus femoris
Ventrogluteal
A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene? Holding the newborn in an en face position Asking the father to change the newborn's diaper Viewing the newborn's actions to be uncooperative Requesting the nurse take the newborn to the nursery so she can rest
Viewing the newborn's actions to be uncooperative
A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? Limit each of the client's visitors to 1 hr per day. Remove dirty linens from the room after double bagging. Wear a dosimeter film badge while in the client's room. Ensure family members remain at least 1 m (3.2 feet) from the client.
Wear a dosimeter film badge while in the client's room.
A nurse is caring for a group of clients. Which of the following clients should the nurse assess first? A client who has heart failure and reports shortness of breath while ambulating A client who has benign prostatic hyperplasia and is unable to urinate A client who had an open cholecystectomy and has green drainage from the T-tube a client who has abdominal pain and is vomiting coffee-ground emesis
a client who has abdominal pain and is vomiting coffee-ground emesis
A nurse is receiving report on four clients. Which of the following clients should the nurse assess first? A client who has an ileal conduit and mucus in the pouch A client who has an arteriovenous fistula that vibrates when palpated A client who had a transurethral resection of the prostate with red-tinged urine in the bag a client who has chronic kidney disease with cloudy dialysate outflow
a client who has chronic kidney disease with cloudy dialysate outflow
A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is asymmetric, with variegated coloring. scaly and red ].brown, with a wart-like texture. firm and rubbery.
asymmetric, with variegated coloring.
A nurse is planning care for a client who is comatose and has a stage II decubitus ulcer on the coccyx. Which of the following interventions is appropriate to include in the plan of care? a. Massage the area to improve circulation b. Provide the client with an alternating pressure mattress c. Apply a sterile dry gauze dressing over the client's wound d. Place the client in a chair four times a day
b. Provide the client with an alternating pressure mattress
A nurse is teaching a newly licensed nurse about advance directives for clients who have schizophrenia. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "Clients will need their provider's approval before signing advance directives." "Clients should contact the court if they wish to change their living will." "Clients must designate a guardian to initiate their advance directives." clients can appoint a health care surrogate for when they are unable to make decisions."
clients can appoint a health care surrogate for when they are unable to make decisions."
A nurse is assessing a client who is having an exacerbation of lupus erythematosus. After reviewing the findings and the client's medical record, which of the following prescriptions should the nurse expect? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Progress Report Headache pain of 5 on a scale from 0 to 10 Report of loss of vision New onset of nystagmus Photophobia Begin etanercept therapy. Decrease the dosage of prednisone Replace the acetaminophen with ibuprofen. Discontinue the hydroxychloroquine therapy.
Discontinue the hydroxychloroquine therapy.
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following is an expected finding? Dry, raised facial rash Subcutaneous pulse Hyperuricemia polycythemia
Dry, raised facial rash
A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome? Edema Shortness of breath Petechiae Change in mental status
Edema
A nurse is teaching a client who has left-leg weakness how to use a standard walker. Which of the following actions by the client indicates a need for further teaching? -places the walker 2 feet forward with each step (12 inc) -moves the left leg and the walker ahead together -holds the walker 6 inches below waist level with elbows flexed -lifts the walker when moving it forward (rolling)
-moves the left leg and the walker ahead together
A nurse is providing teaching to the parent of a child who has pediculosis capitis. Which of the following information should be included in the teaching? -spray car seat covers with an antimicrobial solution -use a stiff bristled brush to clean furniture -store nonwashable items in plastic bag for 14 days -us an anthelmintic medication for 7 days
-store nonwashable items in plastic bag for 14 days
A nurse is discussing the Z-track administration of hydroxyzine hydrochloride with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? this technique prevents injury to the sciatic nerve -this technique decreases the risk of subcutaneous infiltration -this technique allows a larger amount of medication to be injected -this technique increases the absorption rate of the drug
-this technique decreases the risk of subcutaneous infiltration
A community health nurse is teaching a group of restaurant workers about hepatitis A. Which of the following statements should the nurse make?" Manifestations first appear 6 months after exposure to the virus." "With immunization, your risk of contracting hepatitis A is reduced by half." "You can get hepatitis A by eating undercooked pork products." "Hepatitis A can be spread by fecal-oral contact
"Hepatitis A can be spread by fecal-oral contact
A nurse is admitting a client who requests a do-not-resuscitate order. Which of the following statements indicates to the nurse that the client understands advance directives?" I will need to have my partner present if I don't want to be resuscitated." "I will not qualify for organ donation if I am not resuscitated." "I will not receive CPR if my heart stops beating. ""I will need to have an attorney prepare my advance directives.
"I will not receive CPR if my heart stops beating.
A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make? "Do you understand HIPAA regulations?" "This discussion is only appropriate in a private area." "Please stop this discussion." "Did you know you can be liable if you breach confidentiality?"
"Please stop this discussion."
A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge? "Limit your meals to three times per day." "Consume at least 25 grams of fiber daily." "Start each meal with a protein source." "Check your blood glucose level before each meal."
"Start each meal with a protein source."
A nurse is teaching a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching? "ECT should cure you of your depressive disorder." You will receive ECT treatments every day for the next 2 weeks." "You might experience confusion when first waking up after the procedure." "ECT often causes a permanent loss of long-term memory."
"You might experience confusion when first waking up after the procedure."
A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter (PICC) line. Which of the following information should the nurse include in the teaching? "Your PICC line will allow long-term access for antibiotic therapy." "You should use a 5-milliliter barrel syringe to flush your PICC line at home." "Your PICC line must be placed in your nondominant arm." "You should immobilize the arm with the PICC line using a sling."
"Your PICC line will allow long-term access for antibiotic therapy."
A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make? "The provider will notify your parent's employer about admission to the facility." "Your parent will have to take the medication that the doctor prescribes." "Your parent might have electroconvulsive therapy without providing consent." "the provider can prescribe restrains if your parent tries to harm others
"the provider can prescribe restrains if your parent tries to harm others
A nurse on a medical unit has just received change of shift report. Which of the following clients should the nurse assess first? -a 48 year old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (101F) -68 year old client who is 2 days post myocardial infarction (MI) and reports chest pain at a4 on a 0 to 10 scale
-68 year old client who is 2 days post myocardial infarction (MI) and reports chest pain at a4 on a 0 to 10 scale
A nurse is planning care for a client who has a new diagnosis of HIV. Which of the following client statements should the nurse address first? -I'm lonely because I don't have anyone to talk to -I can't seem to gain any weight -I lost my job last week and now I don't have health insurance -ive been living in a homeless shelter for the last week
-I can't seem to gain any weight
A nurse is taking care of a client who has a diagnosis of HIV. Which of the following client statements should the nurse address first? -I'm lonely because I don't have anyone to talk to -I can't seem to gain any weight -I lost my job last week and now I don't have health insurance -I have been living in a homeless shelter for the last week
-I'm lonely because I don't have anyone to talk to
A nurse is performing disaster triage following a natural disaster. Which of the following should the nurse identify as the highest priority to receive care? -A client who has agonal respirations -a client who has an open skull fracture and is unresponsive -a client who has a traumatic arm amputation -a client who has a fracture of the femur
-a client who has a traumatic arm amputation
A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI) . Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure?-jugular vein distention -weight gain -peripheral edema -bilateral lung crackles
-bilateral lung crackles
A nurse is assessing a client who is 8hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognize as the priority finding? -urinary output of 100ml in 4 hr -coughing frothy, pink secretions -emesis of 110ml of thick yellow fluid -red drainage on the dressing
-coughing frothy, pink secretions
A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?Encourage client fluid intake of 2,500 mL daily. Moisturize dry skin areas on the client every other day . Place a dehumidifier in the client's room .Apply a donut ring pillow under the client's sacral area.
Encourage client fluid intake of 2,500 mL daily.
A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? Failure to engraft Veno-occlusive disease Graft-versus-host disease Pancytopenia
Graft-versus-host disease
A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply.) 1-"By witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave consent." 2-A client who signs an informed consent form should understand the treatment plan." 3-"A client who signs an informed consent form should be competent." 4-"The nurse should disclose the purpose of the treatment before the client signs the consent form." 5-"Signing the informed consent form indicates that the family agrees to the treatment options."
1, 2, 3
A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect? Blood pressure 94/68 mm Hg Urinary output 30 mL/hr Respiratory rate 24/min Heart rate 152/min
Heart rate 152/min
. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? Herpes simplex virus (HSV) type 1 Hepatitis A Human papillomavirus (HPV) Pediculosis capitis
Hepatitis A
A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?Hepatitis C Crohn's disease Peptic ulcer disease Bronchitis
Hepatitis C
A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? 0900 1800 1300 2100
1800
A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?" "I should place my baby's car seat rear-facing until 6 months of age." "I should put the car seat retainer clip at the level of my baby's belly button." "I should position my baby's car seat at a 90-degree angle in the car." I should place. rolled blanked along each side of my baby's head in the car seat
I should place. rolled blanked along each side of my baby's head in the car seat
A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.) 1-Expresses interest in ADLs 2-repeats the words of others when speaking 3-Speaks in word salad 4-Has a blunt affect 5-Experiences delusions
2, 3, 4, 5
A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.) 1-The provider should renew the prescription for restraints every 48 hr 2-The nurse should pad the bony prominences. 3-The nurse should tie the restraints using a square knot.. 4- the nurse should remove the restrains every 2hr 5- the provider's prescription should include the type of restrains to use
2, 4, 5
A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first? Explain to the client the consequences of refusal. Identify the reason for the client's refusal. Document the client's refusal in the medical record. Inform the provider of the client's refusal.
Identify the reason for the client's refusal.
A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? Monitoring the insertion site for infection Checking for orthostatic hypotension Forcing fluids Immobilizing the affected extremity
Immobilizing the affected extremity
A nurse is caring for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.) 1-Changing a dressing for a client who has a stage 3 pressure injury 2-Obtaining signed consent from a client for a screening colonoscopy 3-Measuring I&O for a client who is receiving parenteral nutrition 4-Transferring a client from a bed to a chair with a mechanical lift 5-Providing postmortem care for a client who experienced cardiac arrest
3, 4, 5
A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? Treat mild to moderate depression. Enhance the immune system .Prevent and treat prostate enlargement. Improve joint functioning.
Improve joint functioning.
A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan? Auscultate the client's left arm for a bruit every 4 hr. Compare blood pressure in both arms every 2 hr .Instruct the client to keep the left arm in a dependent position. Encourage the client to restrict movement of the left arm.
Auscultate the client's left arm for a bruit every 4 hr.
A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take? Administer an antitoxin. Quarantine the client. Monitor the client for a productive cough. Begin prophylactic treatment with ciprofloxacin
Begin prophylactic treatment with ciprofloxacin
A home health nurse is performing an in-home fall assessment for a client. Which of the following findings should the nurse identify as a potential hazard for the client? Electrical cords secured to the baseboards A computer chair with wheels that lock A standard toilet seat in the bathroom Carpeted floors in the kitchen
Carpeted floors in the kitchen
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? Constipation Indigestion Swollen ankles Urinary frequency
Indigestion
A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first? Confirm schedule for delivery of supplies. Coordinate interdisciplinary health care services. Demonstrate how to perform the procedure. Clarify the client's actual and perceived health needs.
Clarify the client's actual and perceived health needs.
A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? Clear fluid drainage from the nares Report of pain around the eyes Dried blood in the mouth Mandibular asymmetry
Clear fluid drainage from the nares
A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? Client fell out of bed because an assistive personnel left the rails of the bed down. Client's roommate thinks the client is confused and fell when getting out of bed .Client appears to have slipped in water but reports no injuries. Client found lying on the floor near the bedside table.
Client found lying on the floor near the bedside table.
A nurse is admitting a client who has new diagnosis of acute gout. The nurse should anticipate which of the following prescriptions from the provider?Methotrexate Etanercept Adalimumab Colchicine
Colchicine
A nurse is reviewing the laboratory reports for a newborn who is breastfed and has a hemoglobin level of 14 g/dL. Which of the following actions should the nurse take? Give the newborn an iron-fortified formula. Continue with the current feeding regimen. Supplement feedings with an oral rehydration solution. Administer an iron supplement to the newborn
Continue with the current feeding regimen.
A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first? Determine the client's pain level. Irrigate the wound with 0.9% sodium chloride irrigation. Apply skin preparation to wound edges .Don sterile gloves.
Determine the client's pain level.
A nurse is providing teaching for the client who has a new prescription for lithium carbonate. Which of the following should the nurse include the teaching? Diarrhea is an indication of toxicity. Take medication w/ milk You should take this medication on an empty stomach
Diarrhea is an indication of toxicity.
A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take? Position the examination light toward the client's face. Stand on the right side of the client when examining the left eye. Dim the lights in the room prior to the examination. Place the ophthalmoscope directly against the client's forehead
Dim the lights in the room prior to the examination.
A nurse is teaching a client who has osteoporosis about how to increase calcium in their diet. The nurse should instruct the client that which of the following foods is the best source of calcium? 1/2 cup raw carrots 3 oz canned tuna 6 oz low-fat yogurt 1 slice whole-wheat bread
6 oz low-fat yogurt
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A 4-year-old client who has a Wilms tumor and is receiving chemotherapy An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod A 10-year-old client who has pneumonia and is receiving respiratory treatments
A 10-year-old client who has pneumonia and is receiving respiratory treatments
A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry A client who had a myocardial infarction 3 days ago and reports chest discomfort A client who had a stroke 2 days ago and needs help toileting A client who has awoken following a bronchoscopy and requests a drink
A client who had a stroke 2 days ago and needs help toileting
A nurse is performing change-of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first? A client who has gastroenteritis and is lethargic and confused A client who has cystic fibrosis, has a thick, productive cough, and reports thirst A client who has sickle cell anemia and reports pain 15 min after receiving oral analgesic A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL
A client who has gastroenteritis and is lethargic and confused
A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first? A client who is at 38 weeks of gestation and reports irregular uterine contractions A client who is at 39 weeks of gestation and is scheduled for a weekly nonstress test (NST) A client who is at 40 weeks of gestation and is scheduled for an induction of labor A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days
A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days
A nurse is reviewing morning values of several clients. Which of the following findings is the highest priority for the nurse to report to the provider? A client who has syndrome of inappropriate antidiuretic hormone and has a sodium level of 128 mEq/L A client who has chronic emphysema and a PCO2 of 50 mm Hg. A client who has sepsis and a WBC of 15/mm3 A client who is prescribed digoxin and furosemide and has a potassium level of 3.1 mEq/L
A client who is prescribed digoxin and furosemide and has a potassium level of 3.1 mEq/L
A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? A client who had an intrauterine device (IUD) inserted yesterday and has cramping and bleeding A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding• A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting
A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting
A nurse is caring for a client who is 2 hr postoperative following an ileal conduit procedure for bladder cancer. For which of the following finding should the nurse notify the provider? A dusky-colored stoma absence of bowel sounds serosanguineous drainage urinary output 40ml/hr
A dusky-colored stoma
A nurse is performing a dressing change for a child who has a grafted burn wound. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Administer an analgesic .Cleanse the wound. Apply a thin layer of topical medication. Apply the dressing to cover the area. Splint the grafted extremity.
Administer an analgesic .Cleanse the wound. Apply a thin layer of topical medication. Apply the dressing to cover the area. Splint the grafted extremity.
A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching? Add the contents of the capsules to food. Dissolve the capsules in a glass of chocolate milk. Administer the medication with a glass of orange juice. Administer the medication at bedtime.
Administer the medication with a glass of orange juice.
A nurse is assessing a client who has schizophrenia. The nurse should identify that which of the following manifestations indicates a risk for self-harm? Anergia Auditory hallucinations Avolition Visual hallucinations
Auditory hallucinations
A nurse is providing teaching for the parents of a school-age boy who has hemophilia. The parents tell the nurse that the child loves soccer. The child is adamant about playing with his peers on the school team next year, and the parents state that, "We are unable to say anything to convince him that ___ is impossible." Which of the following is an appropriate suggestion? -allow the child to try out for the team as long as he wears protective gear at all times. -suggest that the parents purchase a soccer video game for the their child -try to persuade the child to become involved with the swimming or tennis team insteaad encourage the child to be involved with the soccer team as the coach's assistant or team manger
encourage the child to be involved with the soccer team as the coach's assistant or team manger
A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?Blurred vision Dry mouth Fever Constipation
fever
A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder (OCD). Which of the following is appropriate for the nurse to include in the plan of care? Work with the client to create a flexible daily schedule. Offer solutions to assist in problem solving Teach the client to meditate about obsessive thoughts. gradually decrease the time allowed for ritualistic behavior
gradually decrease the time allowed for ritualistic behavior
A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document? it expresses my wishes about distribution of my belongings after death it designates a family member to make my health care decisionsit is required for anyone undergoing surgery it communicates my wishes for end-of-life care
it communicates my wishes for end-of-life care
A community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house. Which of the following is a priority intervention? Plan for a follow-up visit to the home Instruct family members who are smoking to go outside. Suggest smoking cessation strategies to family member review the effects of second hand smoke with family members
review the effects of second hand smoke with family members
At the beginning of the ____ shift, a team leader delegates the following tasks to the assistive personnel (AP) have four clients, distribute fresh water and obtain the morning vital signs. At noon, the nurse asks the AP to transport one client to physical therapy. The AP reports two clients still need bed baths. Which of the following is an appropriate strategy for the nurse to delegate more effectively in the future? plan a more reasonable job assignment co assignee a more qualified individual to assist the AP. set a clear time for the completion of each task volunteer to give the baths for the AP
set a clear time for the completion of each task
A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first? • Take the client outdoors. Wrap blankets around the client. Loosen the client's clothing. Open the client's windows.
• Take the client outdoors.
