One Last Hoorah

*NGN* A nurse is caring for a client who requires naso-tracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps) Apply suction while rotating the catheter. Rinse the catheter to remove secretions. Don sterile gloves. Insert the catheter during the client's inspiration. Turn on the suction and set the pressure.

1) Turn on the suction and set the pressure. 2) Don sterile gloves. 3) Insert the catheter during the client's inspiration. 4) Apply suction while rotating the catheter. 5) Rinse the catheter to remove secretions.

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make? A) "I can start the medication 30 minutes earlier" B) "I can adjust the time and schedule for when it's convenient for you" C) "I can infuse the medication at a faster rate" D) "I have up to 2 hours after the usual schedule time to give you the medication"

A) "I can start the medication 30 minutes earlier"

A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first? A) Determine the client's Glasgow Coma Scale score B) Insert an indwelling urinary catheter C) Administer mannitol IV bolus to the client D) Prepare the client for an MRI of the brain

A) Determine the client's Glasgow Coma Scale score

*CASE STUDY* A nurse is reviewing the client's medical record. Admission Assessment 0900 Client reports, "I'm bloated and my stomach hurts.". History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis. Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco. The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? A) Have a second nurse confirm the information on the blood label. B) Insert a large bore IV Catheter C) Witness the client signing a consent for transfusion D) Flush the transfusion tubing with dextrose 5% in water. E) Expla

A) Have a second nurse confirm the information on the blood label. B) Insert a large bore IV Catheter C) Witness the client signing a consent for transfusion

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching? A) How to operate the portable suction machine B) How to secure the tracheostomy tube with ties at the back of the neck C) How to change the non disposable tracheostomy tube daily D) How to change the tracheostomy dressing using clean technique

A) How to operate the portable suction machine

A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease? A) Sit in a chair next to the bed B) Stand at the side of the bed C) Sit on the bed next to the client D) Stand at the foot of the bed

A) Sit in a chair next to the bed

A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect? A) Spotting B) Nausea C) Polyhydramnios D) Uterine tenderness

A) Spotting

A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take? A) The nurse should use a filter needle to withdraw the medication B) The nurse should break the neck of the ampule toward their body C) The nurse should use the same needle to draw up and inject the client D) The nurse should dispose of the ampule in the trash can

A) The nurse should use a filter needle to withdraw the medication

A nurse is preparing to insert an IV catheter for a client. Which of thefollowing actions should the nurse take? A. Choose a vein that is palpable and straight B. Elevate the client's arm prior to insertion C. Apply a tourniquet below the venipuncture site D. Select a site on the client's dominant arm

A. Choose a vein that is palpable and straight

A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take? A. Compare new prescriptions with the list of medications the client reports B. Encourage the client to make his own list after he returns to his home C. Include any adverse effects of the medications the client might develop D. Exclude nutritional supplements from the list of medications the client reports

A. Compare new prescriptions with the list of medications the client reports

A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete? A. Digoxin 0.25mg PO daily B. Cimetidine PO twice daily C. Epoetin alfa 150 units/kg three times weekly D. Tetracycline 200mg PO

A. Digoxin 0.25mg PO daily

A charge nurse is observing a conflict between two nurses who bothinsist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use? A. Encourage collaboration between the two nurses whenmaking the assignments B. Arrange for the nurses to have as few shifts together as possible C. Tell the nurses that the assignments will be more equitable in the future D. Ask each nurse to take turns making the assignments

A. Encourage collaboration between the two nurses whenmaking the assignments

*CASE STUDY* A nurse is caring for a client who is admitted to the medical-surgical unit. Admission Assessment 0900 Client reports, "I'm bloated and my stomach hurts.". History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis. Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco. The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up. A. Heart rate B. Current medications. C. Blood pressure. D. Stool results. E. Respiratory rate F. WBC count. G. Temperature H. Hemoglobin and hematocrit.

A. Heart rate B. Current medications. C. Blood pressure. D. Stool results. H. Hemoglobin and hematocrit.

A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take? A. Limit oral feedings to 30 min in length B. Weigh the infant every other day. C. Place the infant in the prone position for naps. D. Check the infant's oxygen saturation every 6 hr.

A. Limit oral feedings to 30 min in length

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include? A. Participate in range-of-motion exercises B. Use an incentive spirometer every 4 hours C. Remain on bed rest 24 hours D. Place a pillow under your knee while in bed

A. Participate in range-of-motion exercises

*CASE STUDY* A nurse is caring for a client who has been admitted to the hospital. 0900: The client reports experiencing a loss of appetite and shortness of breath within the last month or so. The client reports experiencing weakness, abdominal pain, severe itching, and mood changes. The client has had alcohol use disorder for the past 10 years and sometimes drinks alcohol uncontrollably. Select the 5 actions the nurse should take. A. Provide frequent rest periods for the client. B. Instruct the client to avoid blowing their nose forcefully C. Assess the client s level of orientation. D. Place the client on a low-carbohydrate diet. E. Restrict the client's sodium intake. F. Advise the client to avoid the use of soap and alcohol-based lotions. G. Place the client under contact isolation.

A. Provide frequent rest periods for the client. B. Instruct the client to avoid blowing their nose forcefully C. Assess the client s level of orientation. E. Restrict the client's sodium intake. F. Advise the client to avoid the use of soap and alcohol-based lotions.

*NGN* A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate?

ANSWER: C

*CASE STUDY* A nurse is caring for a client who has been admitted to the antepartum unit. Day 1 0900 Nurses' Notes: Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Cervical exam indicates 2 cm, 50% effaced, 0 station. History: 30-year-old client at 33 weeks gestation, Gravida 4 Para 3. Maternal blood type: Rh+. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. NKA. For each potential provider's prescription, click to specify if the prescription is anticipated or unanticipated for the client. Provider's Prescriptions: Place client in supine position Limit fluid intake to 3,000 mL/day Administer Oxytocin Maintain bed rest with bathroom privilleges Administer bethamethasone Administer terbutaline

ANTICIPATED: Maintain bed rest with bathroom privilleges Administer bethamethasone Administer terbutaline UNANTICIPATED: Place client in supine position Limit fluid intake to 3,000 mL/day Administer Oxytocin

A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make? A) "We can initiate medical care until you get legal assistance in preparing your advance directives" B) "Advance Directives can be signed without legal representation" C) "Advance directives can be a verbal agreement between you and your provider until legal review can be obtained" D) "A social worker will assist you to find affordable legal representation"

B) "Advance Directives can be signed without legal representation"

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take? A) Send the unsigned informed consent form to the facility's risk manager B) Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. C) Ensure that the client's family supports the provider's decision for surgery. D) Determine if the procedure is medically necessary for the client.

B) Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.

A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take? A) Cross the client's arms across their chest B) Hold the client's eyes shut for a few seconds. C) Place the client in a high-fowler's position D) Remove the client's dentures from their mouth.

B) Hold the client's eyes shut for a few seconds.

A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include? A) Monitor for weight loss B) Increase dietary calcium C) Take on an empty stomach D) Schedule dosage at bedtime

B) Increase dietary calcium

A nurse is reviewing the laboratory data of a client who received 2 units of packed RBCs. Which of the following laboratory findings should the nurse expect following the transfusion? A) Increased platelets B) Increased Hct C) Decreased Hgb D) Decreased WBC count

B) Increased Hct

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take? A) Position the client on the affected side for 4 hr following the procedure B) Instruct the client to avoid coughing during the procedure C) Inform the client that he will be NPO for 6 hr prior to the procedure D) Place the client in the prone position during the procedure

B) Instruct the client to avoid coughing during the procedure

A nurse is caring for a client who is receiving penicillin G via intermittent IV piggyback. Which of the following actions should the nurse take? A) Infuse the medication over 10 min. B) Instruct the client to notify the provider if diarrhea develops C) Refrigerate the medication after reconstitution D) Check the client for a sulfa allergy

B) Instruct the client to notify the provider if diarrhea develops

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A) Drooling B) Malaise C) Tinnitus D) Rhinorrhea

B) Malaise

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis? A) Sacrum B) Palms of the hands C) Shoulders D) Area of trauma

B) Palms of the hands

A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism? A) Serpentine limb movement B) Shuffling gait C) Nonreactive pupils D) Smacking lips

B) Shuffling gait *MIMICS THE SAME MANIFESTATIONS OF PARKINSONS* I.E.: BRADYKINESIA, RIGIDITY, SHUFFLING GAIT, DROOLING, TREMORS*

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly? A) Use a face shield with a mask when providing care to the client B) Tell the client, "You seem to be very upset". C) Engage the panic alarm D) Initiate seclusion protocol

B) Tell the client, "You seem to be very upset".

*CASE STUDY* A nurse is caring for a client who has been admitted to the antepartum unit. Day 1 0900 Nurses' Notes: Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Cervical exam indicates 2 cm, 50% effaced, 0 station. History: 30-year-old client at 33 weeks gestation, Gravida 4 Para 3. Maternal blood type: Rh+. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. NKA. Which of the following actions should the nurse take? Select ALL that apply. A) Vaginal culture B) Urine Culture C) Obtain provider prescription for antibiotics D) Ibuprofen 600 mg every 6 hr for mild to moderate pain E) Obtain provider prescription for phenzaopyridne

B) Urine Culture C) Obtain provider prescription for antibiotics E) Obtain provider prescription for phenzaopyridne

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective? A) Increased blood pressure B) Weight Loss C) Decreased inflammation D) Decreased pain

B) Weight Loss

A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority forthe nurse to ask the client? A. "How do you get along with your peers at school?" B. "Do you have thoughts of harming yourself?" C. "How do you manage your behavior?" D. "Do you have a criminal record?"

B. "Do you have thoughts of harming yourself?"

*CASE STUDY* A nurse in an emergency department is caring for a client. 57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States he is nauseous and has had several episodes of vomiting. The nurse is providing teaching to the client about self-care. Select the 3 statements the nurse should include in the teaching. A. "You can drink beverages that contain caffeine." B. "You should eat foods that are low in fat.". C. "Notify your provider if you experience vomiting or diarrhea.". D. "Limit alcohol intake to no more than one drink per day.". E. "You should eat foods high in protein.".

B. "You should eat foods that are low in fat.". C. "Notify your provider if you experience vomiting or diarrhea.". E. "You should eat foods high in protein.".

A nurse is receiving change-of-shift report for a group of clients. Which ofthe following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8%

B. A client who has a hip fracture and a new onset of tachypnea

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who is receiving heparin for deep-vein thrombosis. B. A client who is 1 day postoperative following a vertebroplasty. C. A client who has cancer and a sealed implant for radiation therapy. D. A client who has COPD and a respiratory rate of 44/min.

B. A client who is 1 day postoperative following a vertebroplasty.

*CASE STUDY* A nurse in an emergency department is caring for a client. 1200: Nurses' Notes. Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm. The nurse is preparing to speak to the facility's Social Worker about the client's condition. Select the 5 findings the nurse should plan to include in the report. A. ECG results. B. Client's report of lack of food in home. C. client's report of lack of access to bank accounts. D. Clients avoidance of eye contact. E. Clients report of weight loss. F. Numerous bruises in various stages of healing.

B. Client's report of lack of food in home. C. client's report of lack of access to bank accounts. D. Clients avoidance of eye contact. E. Clients report of weight loss. F. Numerous bruises in various stages of healing. **EVERYTHING BUT THE EKG**

A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include? A. Assess the child for frequent swallowing. B. Continuously monitor the child's respiratory status. C. Carefully suction the child's oropharynx to remove secretions. D. Administer pancreatic enzymes with meals.

B. Continuously monitor the child's respiratory status.

A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? A. Offer fluids every 2hr. B. Document the client's behavior prior to being placed in seclusion. C. Discuss with the client his inappropriate behavior prior to seclusion. D. Assess the client's behavior once every hour.

B. Document the client's behavior prior to being placed in seclusion.

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? A. Remove the client's restraint every 4hr B. Document the client's condition every 15 min C. Attach the restrain to the bed's side rails D. Request a PRN restrain prescription for clients who are aggressive

B. Document the client's condition every 15 min

A nurse is assessing a client immediately following a cardiaccatheterization. The nurse should notify the provider for which of the following findings? A. Report of discomfort at the insertion site. B. Hematoma over the insertion site. D. Bounding pulses in the affected extremity. E. Heart rate 90/min

B. Hematoma over the insertion site.

A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the followingactions should the nurse include in the plan of care? A. Encourage a maximum fluid intake of 1,500 ml per day. B. Increase the amount of refined grains in the client's diet. C. Provide the client with a cold drink prior to defecation. D. Administer a cathartic suppository 30 minutes prior to scheduled defecation times.

B. Increase the amount of refined grains in the client's diet.

A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? A. Bisacodyl 10 mg rectal suppository. B. Magnesium hydroxide 30 ml PO. C. Famotidine 20 mg PO. D. Loperamide 4 mg PO.

B. Magnesium hydroxide 30 ml PO.

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect? A. Head circumference exceeds chest circumference. B. Nontender, protruding abdomen C. Natural loss of deciduous teeth. D. Palpable fontanels.

B. Nontender, protruding abdomen

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen? A. Unclamp the collection port below the bag. B. Obtain the specimen from the retention port. C. Disconnect the catheter from the collection tubing. D. Use the balloon port to obtain the sterile specimen.

B. Obtain the specimen from the retention port.

A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse? A. Complete a discharge teaching for a client who has a newdiagnosis of diabetes mellitus B. Perform a sterile dressing change for a client who has an abdominal wound C. Perform an admission assessment for a client who is scheduled for surgery D. Complete the Glasgow Coma Scale for a client who has an evolving stroke

B. Perform a sterile dressing change for a client who has an abdominal wound

A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse? A. Inserts the catheter without applying suction. B. Waits for 2 min between suctions. C. Applies suction for 15 seconds. D. Encourages the client to cough during suctioning

B. Waits for 2 min between suctions.

*CASE STUDY* A nurse in an emergency department is caring for a client. 57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States he is nauseous and has had several episodes of vomiting. For each finding, clicks to specify if the finding is consistent with peritonitis or pancreatitis. Peritonitis vs. Pancreatitis Bloody stools: Hyperbilirubenemia: Abdominal Pain: Elevated WBC Count:

Bloody stools: PERITONITIS Hyperbilirubenemia: PANCREATITIS Abdominal Pain: BOTH Elevated WBC Count: BOTH

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take? A) Act as a liaison between the facility and the media. B) Recommend to the provider specific acute care clients for discharge. C) Determine the medical needs of incoming clients through the emergency department. D) Call in additional medical-surgical unit nursing care staff.

C) Determine the medical needs of incoming clients through the emergency department.

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin? A) Fibrinogen level B) aPTT C) INR D) Platelet count

C) INR *WARFARIN - PT/INR - ANTIDOTE = VITAMIN K* *HEPARIN - PTT/aPTT - ANTIDOTE = PROTAMINE SULFATE*

A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? A) Speak slowly when talking to the interpreter B) Pause in the middle of sentences C) Speak directly to the client D) Use gestures to convey meaning

C) Speak directly to the client

A nurse is teaching a client who has rheumatoid arthritis about illness management. Which of the following instructions should the nurse include in the teaching? A) Apply cold packs directly on the skin of the affected joints. B) Administer biological response modifiers to prevent infection. C) Take a hot shower in the morning to decrease stiffness. D) Cluster physical activities during the day.

C) Take a hot shower in the morning to decrease stiffness.

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client? A) Deep tendon reflexes 2+ B) Pulse rate 100/min C) Urine output 20mL/hr D) 1+ proteinuria via urine dipstick

C) Urine output 20mL/hr

*CASE STUDY* A nurse in an emergency department is caring for a client. 57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States he is nauseous and has had several episodes of vomiting. The nurse is preparing to discharge the client. Which of the following statements by the client indicate an understanding of the discharge teaching? Select all that apply. A. "I will eat fish for dinner at least twice per week.". B. "I will limit my morning coffee to no more than two cups.". C. "I will eat small, frequent meals.". D. "I should expect my bowel movements to be pale in color". E. "I will notify my provider if my urine is dark.".

C. "I will eat small, frequent meals.". D. "I should expect my bowel movements to be pale in color". E. "I will notify my provider if my urine is dark.".

A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin? A. Naproxen sodium B. Ibuprofen C. Acetaminophen D. Aspirin

C. Acetaminophen *DO NOT TAKE ENOXAPRIN WITH NSAIDS -> CAN INCREASE RISK FOR BLEEDING*

A nurse is preparing an in-service for a group of nurses about malpracticeissues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice? A. Leaving a nasogastric tube clamped after administering oral medication B. Documenting communication with a provider in the progress notes of theclient's medical records C. Administering potassium via IV bolus D. Placing a yellow bracelet on a client who is at risk for falls

C. Administering potassium via IV bolus

A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? A. Release the tourniquet B. Retract the stylet C. Advance the catheter into the vein D. Flush the catheter with saline

C. Advance the catheter into the vein

A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take? A. Administer aspirin to the child for fever B. Use droplet precautions when caring for the child. C. Assign the child to a negative air pressure room. D. Assess the child for Koplik spots

C. Assign the child to a negative air pressure room.

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Epigastric pain B. Hypertension C. Contractions D. Vomiting

C. Contractions

A nurse is assessing a client who is experiencing hypovolemia. Which of the following manifestations should the nurse expect A. Epistaxis B. Headache C. Dizziness D. Shortness of breath

C. Dizziness

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select All That Apply) A. Allow the client to choose among a variety of activities each day. B. Refute the clients delusions using logic C. Establish eye contact when communicating with the client. D. Reinforce orientation to time, place, and person. E. Give the client one simple direction at a time.

C. Establish eye contact when communicating with the client. D. Reinforce orientation to time, place, and person. E. Give the client one simple direction at a time.

A nurse is teaching a client who has chronic pain about avoidingconstipation from opioid medications. Which of the followinginformation should the nurse include in the teaching? A. Drink 1.5 L of fluids each day. B. Take mineral oil at bedtime. C. Increase exercise activity. D. Decrease insoluble fiber intake.

C. Increase exercise activity.

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussions on the child. B. Perform the procedure twice each day. C. Perform the procedure prior to meals. D. Administer a bronchodilator after the procedure

C. Perform the procedure prior to meals.

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Bleeding gums B. Urinary frequency C. Swelling of the face D. Faintness upon rising

C. Swelling of the face ***OTHER BANK HAS PRE-ECLAMPSIA AS AN OPTION INSTEAD OF SWELLING OF THE FACE**

A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? A. Frequent nosebleeds B. Upper extremity hypotension C. Weak femoral pulses. D. Increased intracranial pressure

C. Weak femoral pulses.

*CASE STUDY* A nurse in an emergency department is caring for a client. 1200: Nurses' Notes. Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm. Click to highlight the findings the nurse should report to the provider. Vital Signs Temperature 36.7° C (98° F). Heart rate 96/min. Blood pressure 142/96 mm Hg. Respiratory rate 16/min. SpO2 97% on room air. Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on a

Click to highlight the findings the nurse should report to the provider. Vital Signs: Temperature 36.7° C (98° F). Heart rate 96/min. Blood pressure 142/96 mm Hg. Respiratory rate 16/min. SpO2 97% on room air. Assessment: Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.

*CASE STUDY* A nurse in an emergency department is caring for a client. 57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States he is nauseous and has had several episodes of vomiting. Click to highlight the findings that require follow-up. Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States pain began approximately 12 hr ago and is worse when he is supine or after he eats. Rates pain as a 7 on a 0 to 10 pain scale. Sclera noted to be yellow. Heart rate regular, lungs clear to auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday. Denies recent illnesses, takes no prescribed m

Client presents for evaluation of severe pain in upper abdomen that radiates into his back. States pain began approximately 12 hr ago and is worse when he is supine or after he eats. Rates pain as a 7 on a 0 to 10 pain scale. Sclera noted to be yellow. Heart rate regular, lungs clear to auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday. Denies recent illnesses, takes no prescribed medications. Client is alert and oriented x 4.

A nurse is teaching a new parent about breastfeeding her 2-week-old infant. Which of the following statements by the parent indicates an understanding of the teaching? A) "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast" B) "Manually expressing my milk will decrease my milk supply" C) "My baby should always start on the same breast when feeding" D) "The more my baby is at the breast sucking, the more milk I will produce"

D) "The more my baby is at the breast sucking, the more milk I will produce"

A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? A) "Most people who have this procedure feel better following the treatment" B) "Your doctor wouldn't have ordered this treatment unless it was necessary" C) It's okay to be nervous before this treatment" D) "You don't have to go through with the treatment"

D) "You don't have to go through with the treatment"

A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching? A) Apply petroleum jelly to soothe the mucous membranes B) Use synthetic fabrics for the client's bedding C) Clean the equipment with an alcohol-based cleaning product D) Avoid using nail polish remover around the client

D) Avoid using nail polish remover around the client

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating? A) Fidelity B) Veracity C) Autonomy D) Beneficience

D) Beneficience

A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching? A) Place tongue on the mouthpiece of the meter B) Maintain a semi-fowler's position on during testing C) Record the average of the readings D) Blow into the meter as hard and quickly as possible.

D) Blow into the meter as hard and quickly as possible.

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actionsshould the nurse perform first? A) Administer an antiemetic medication B) Replace the NG tube C) Provide functioning of the suction device D) Evaluate function of the suction device

D) Evaluate function of the suction device

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet? A) Cheese B) Red meat C) Canned black beans D) Fish

D) Fish

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communications among staff caring for the client? A) Posting swallowing precautions at the head of the client's bed B) Noting changes in the treatment plan in the client's medical record C) Recording the client's progress in the nurses's notes D) Having interdisciplinary team meetings for the client on a regular basis

D) Having interdisciplinary team meetings for the client on a regular basis

A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? A) Polyuria B) Hypotension C) Weight Loss D) Hematuria

D) Hematuria

A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider? A) Pink-tinged coloration on the incisional line B) Mild swelling under the sutures near the incisional line C) Crusting of exudate on the incisional line D) Partial separation of the upper part of the incisional line.

D) Partial separation of the upper part of the incisional line.

A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching? A. "I can apply heat for the first 24 hours to minimize the pain in my hand." B. "I should not use my affected hand for 4 to 6 weeks." C. "I should expect numbness and tingling in my hand." D. "I will need to keep my hand elevated above my heart for several days."

D. "I will need to keep my hand elevated above my heart for several days."

A nurse is assessing a client who is postoperative following abdominal surgery andhas an indwelling urinary catheter that is draining dark yellow urine at 25ml/hr. Which of the following interventions should the nurse anticipate? A. Clamp the catheter tubing for 30 min B. Initiate continuous bladder irrigation C. Obtain a urine specimen for culture and sensitivity D. Administer a fluid bolus

D. Administer a fluid bolus

A nurse is preparing to reposition a client who had a stroke. Which of thefollowing actions should the nurse take? A. Raise the side rails on both sides of the client's bed during repositioning. B. Reposition the client without assistive devices. C. Discuss the client's preferences for determining a reposition schedule. D. Evaluate the client's ability to help with repositioning.

D. Evaluate the client's ability to help with repositioning.

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal hypoglycemia. B. Maternal fever. C. Chorioamnionitis. D. Fetal anemia.

D. Fetal anemia.

A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles? A. Decrease socialization with extended relatives until roles are identified. B. Encourage authoritative communication from the adult child. C. Minimize open discussion regarding the changes to avoid embarrassment. D. Implement firm but flexible boundaries in their relationship.

D. Implement firm but flexible boundaries in their relationship

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Swaddle the newborn with his legs extended. B. Administer naloxone to the newborn C. Maintain eye contact with the newborn during feedings D. Minimize noise in the newborn's environment

D. Minimize noise in the newborn's environment

A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? A. Insert a pillow under the client's knees. B. Position the client in reverse Trendelenburg. C. Assist the client into the lithotomy position. D. Place a wedge under one of the client's hips.

D. Place a wedge under one of the client's hips.

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse when pouring the sterile solution? A. Hold the bottle in the center of the sterile field when pouring the solution. B. Hold the irrigation solution bottle with the label facing away from the palm of the hand. C. Place the sterile gauze over areas of spilled solution within the sterile field. D. Remove the cap and place it sterile-side up on a clean surface.

D. Remove the cap and place it sterile-side up on a clean surface.

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray? A. Ham sandwich with milk. B. Shrimp salad and tomato soup with milk C. Bacon and cheese quiche with milk D. Scrambled eggs and toast with milk

D. Scrambled eggs and toast with milk

A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? A. A nurse will draw blood from your baby's inner elbow B. Your baby will be given 2 ounces of water to drink prior to the test C. This test will be repeated when your baby is 2 months old D. This test should be performed after your baby is 24 hours old

D. This test should be performed after your baby is 24 hours old

*CASE STUDY* A nurse is caring for a client. 0900: Nurses' Notes: Client reports a 3-month history of intermittent diarrhea and abdominal pain. Reports unintentional weight loss of 5.5 kg (12 lb) in 3 months. 0930: Stool sample obtained for fecal occult blood test. Fatty appearance and foul odor noted. For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process. A. Weight loss B. Steatorrhea C. Anemia D. Diarrhea E. Fever

For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Crohn's Disease: A. Weight loss B. Steatorrhea C. Anemia D. Diarrhea E. Fever **ALL OF THEM** Diverticulitis: D. Diarrhea E. Fever Ulcerative Colitis: A. Weight loss C. Anemia D. Diarrhea E. Fever

*CASE STUDY* A nurse in an emergency department is caring for a client. 57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States he is nauseous and has had several episodes of vomiting. The nurse is preparing to notify the provider about the clients current condition. For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client. Anticipated vs Contraindicated Provider Prescription: Insert an indwelling urinary catheter. Insert a nasogastric tube and maintain low intermittent suction. Administer lactated Ringer's 1 L via IV bolus. Administer famotidine 20 mg via intermittent IV infusion twice daily.

For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client. ANTICIPATED: Insert a nasogastric tube and maintain low intermittent suction. Administer lactated Ringer's 1 L via IV bolus. Administer famotidine 20 mg via intermittent IV infusion twice daily. CONTRAINDICATED: Insert an indwelling urinary catheter.

*CASE STUDY* A nurse is caring for a client who is admitted to the medical-surgical unit. Admission Assessment 0900 Client reports, "I'm bloated and my stomach hurts.". History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis. Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco. Select the findings that indicate improvement.

Hemoglobin 12 g/dL (14 to 18 g/dL) Hematocrit 36% (40% to 52%) Blood Pressure 112/74 Hear Rate 95 General- No distress HEENT

*CASE STUDY* A nurse is caring for a client who has been admitted to the antepartum unit. Day 1 0900 Nurses' Notes: Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Cervical exam indicates 2 cm, 50% effaced, 0 station. History: 30-year-old client at 33 weeks gestation, Gravida 4 Para 3. Maternal blood type: Rh+. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. NKA. Highlight the findings that indicate improvement in the client's condition. Nurses Notes: Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. FHR baseline 138. minimal variability. No further reports of burning with urination Laboratory Results: WBC 12.000/mm3 (5.000 to 10,000/mm3) Platelet count 188,

Highlight the findings that indicate improvement in the client's condition. Nurses Notes: Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. FHR baseline 138. minimal variability. No further reports of burning with urination Laboratory Results: WBC 12.000/mm3 (5.000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm3) Vital Signs: Temperature 37.1° C (98.7° F) Blood pressure 120/78 mm Hg

*CASE STUDY* A nurse is reviewing the client's medical record. Admission Assessment 0900 Client reports, "I'm bloated and my stomach hurts.". History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis. Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco. The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client. Nursing Actions A. Start an IV bolus of lactated Ringer's solution. B. Stay with the client for the first 15 min of the transfusion. C. Obtain the first unit of packed RBCs from the blood bank. D. Document

INDICATED: B. Stay with the client for the first 15 min of the transfusion. C. Obtain the first unit of packed RBCs from the blood bank. D. Document the blood product transfusion in the client's medical record. NOT INDICATED: A. Start an IV bolus of lactated Ringer's solution. E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

*CASE STUDY* A nurse is caring for a client who has been admitted to the antepartum unit. Day 1 0900 Nurses' Notes: Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Cervical exam indicates 2 cm, 50% effaced, 0 station. History: 30-year-old client at 33 weeks gestation, Gravida 4 Para 3. Maternal blood type: Rh+. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. NKA. The client is at risk for developing which of the 2 complications? Disseminated Intravascular Coagulation Sepsis Pre-Eclampsia Seizures Placenta Previa Premature Rupture of Membranes

Sepsis Premature Rupture of Membranes

*CASE STUDY* A nurse is caring for a newborn. Vital Signs 0640: Temperature 36.7°C (98.1° F) axillary. Heart rate 154/min. Respiratory rate 68/min. BP 72/48 mm Hg. 0650:. Heart rate 156/min. Respiratory rate 72/min. Nurses' Notes 0640:. Weight 4200 gm (9 Ib 4 oz), head circumference 35.5 cm (14 in). Respiratory rate 68/min, with mild grunting. 0650:. Respiratory rate 72/min, with mild grunting. 0700:. Respiratory rate 76/min, with moderate grunting and mild. intercostal retractions. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing Target 1 and Target 2. A. Hypoglycemia B. Bronchopulmonary dysplasia. C. Transient tachypnea of the newborn. D. Tachycardia.

The client is at risk for developing Target 1 and Target 2. B. Bronchopulmonary dysplasia. C. Transient tachypnea of the newborn.

*CASE STUDY* A nurse is caring for a client who is admitted to the medical-surgical unit. Admission Assessment 0900 Client reports, "I'm bloated and my stomach hurts.". History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis. Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco. The nurse anticipates that the client will likely require a ______________ as evidenced by the client's ___________.

The nurse anticipates that the client will likely require a ENDOSCOPY as evidenced by the client's STOOL TEST RESULTS.

*CASE STUDY* A nurse in an emergency department is caring for a client. 57-year-old male client presents to the emergency department with severe abdominal and epigastric pain that began about 12 hr ago. Client rates pain as a 7 on a 0 to 10 pain scale. Client reports pain worsens after eating and radiates into his back. States he is nauseous and has had several episodes of vomiting. The nurse should first address the clients _________ followed by the clients ________.

The nurse should first address the clients PAIN followed by the clients TEMPERATURE.

*CASE STUDY* The nurse is obtaining vital signs prior to the client's endoscopy. 0900 Client reports, "I'm bloated and my stomach hurts.". History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis. Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco. The nurse should first anticipate the need to ____________ and then _______________.

The nurse should first anticipate the need to OBTAIN IV ACCESS and then ADMINISTER IV FLUIDS.

*CASE STUDY* A nurse is caring for a client who has been admitted to the antepartum unit. Day 1 0900 Nurses' Notes: Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Cervical exam indicates 2 cm, 50% effaced, 0 station. History: 30-year-old client at 33 weeks gestation, Gravida 4 Para 3. Maternal blood type: Rh+. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. NKA. The nurse should recognize the client is experiencing _______ due to ______.

The nurse should recognize the client is experiencing PRETERM LABOR due to PREVIOUS PRE-TERM BIRTH.

*CASE STUDY* A nurse is caring for a client who has been admitted to the antepartum unit. Vital Signs. Day 1, 0900 Nurses' Notes. Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. FHR baseline 145, minimal variability. Complete the following sentence by using the list of options. The nurse should recognize the client is experiencing Select from Options1. due to Select from Options2. - . Options1. preterm labor. Rh incompatibility. preeclampsia. abruptio placentae. Options2. BMI. previous preterm birth. blood type. blood pressure.

The nurse should recognize the client is experiencing PRETERM LAOBR due to PREVIOUS PRETERM BIRTH

A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. "If you don't eat, I'll put restraints on your wristsand feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a) Assault b) Battery c)Malpractice d) Negligence

a) Assault

A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? a. "Perform chest percussion and postural drainage at least twice daily." b. "Administer pancreatic enzymes on an empty stomach." c. "Restrict intake of foods that contain gluten." d. "Use a nebulizer to administer a bronchodilator following airway clearance therapy."

a. "Perform chest percussion and postural drainage at least twice daily."

A nurse is caring for a client who is receiving total parenteral nutrition(TPN). The bag has 20 mL remaining to infuse but the new bag is not readily available. Which of the following actions should the nurse take? a. Administer dextrose 10% in water b. Slow the TPN infusion rate c. Temporarily discontinue the infusion d. Give 500 mL of lactated Ringer's solution

a. Administer dextrose 10% in water

A nurse is caring for a school-age-child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions Should the nurse take? a. Apply continuous pressure 2.5 cm (1in) above the percutaneous skin site b. Apply intermittent pressure 2.5 cm (1in) below the percutaneous skin site c. Apply continuous pressure 2.5 cm (1in) below the percutaneous skin site d. Apply intermittent pressure 2.5 cm (1in) above the percutaneous skin site

a. Apply continuous pressure 2.5 cm (1in) above the percutaneous skin site

A nurse is caring for a school age child who is postoperative and received morphine IVbolus for pain 10 min ago. Which of the following findings is the nurse's priority? a. Bradypnea b. Sedation c. Euphoria d. Constipation

a. Bradypnea

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse taketo evaluate the effectiveness of the procedure? a. Compare the client's current weight with pre-procedure weight b. Confirm that the client is able to urinate c. Check the client's serum albumin levels d. Examine for leakage at the site of the procedure

a. Compare the client's current weight with preprocedure weight

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take? a. Ensure the state health department has been notified b. Administer antitoxin c. Assess for skin necrosis d. Educate the family to avoid sharing personal belongings

a. Ensure the state health department has been notified

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase? a. Hip arthroplasty 1 week ago b. Family history of malignant hypertension c. Acute renal failure 6 months ago d. Chronic obstructive pulmonary disease

a. Hip arthroplasty 1 week ago *RECENT EYE SURGERY IS A CONTRAINDICATION AS WELL*

A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure? a. Hypertension b. Primary glaucoma c. Osteoarthritis d. Amputation

a. Hypertension

A nurse is caring for an adolescent who has hyperthermia. Which of thefollowing is an appropriate action for the nurse to take? a. Initiate seizure precautions b. Cover the adolescent with a thermal blanket c. Submerge the adolescent's feet in ice water d. Administer oral acetaminophen

a. Initiate seizure precautions

A nurse is caring for a client who has generalized petechiae andecchymosis. The nurse should expect a prescription for which of the following laboratory test? a. Platelet count b. Potassium level c. Pre-albumin d. Creatinine clearance

a. Platelet count

A charge nurse is teaching new staff members about factors that increase aclient's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Previous violent behavior b. A history of being in prison c. Experiencing delusions d. Male gender

a. Previous violent behavior

A nurse in an emergency department is caring for a client following a motor vehicle crash. The client Glasgow Coma Scale is 15 which of the following findings should the nurse expect? a. The client is oriented times three b. The client open the eyes to sound c. The client is unable to be command d. The client with drawls from pain

a. The client is oriented times three

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurseinclude in the hand-off report? a. The estimated blood loss was 250 ml b. There was a total of 10 sponges used during the procedure c. The client is a member of the board of directors d. The client was intubated without complications

a. The estimated blood loss was 250 ml

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? a. Using an electronic massaging system to remind clients when to take medications b. Educating clients about contraindications to specific immunizations c. Helping clients understand health screenings covered by their insurance plans d. Providing clients with info about the benefits of exercise

a. Using an electronic massaging system to remind clients when to take medications

A case manager is meeting with a client who asks about using alternativetherapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? a. We can review some information to help you select a safe alternative practitioner b. Feel free to try whatever therapies that fit within your personal belief system c. I'm sure you can find alternative remedies through an online support group d. If there are therapies available to you, your provider will tell you about them.

a. We can review some information to help you select a safe alternative practitioner

A nurse is providing teaching about immunizations to a client who ispregnant. Which of the following statements should the nurse include in the teaching? a. You can receive the immunization for influenza at any time during your pregnancy b. The immunization for varicella should be given at least 1 month prior to delivery c. The hepatitis B immunization should not be obtained untilafter you finish breastfeeding d. You can receive the rubella immunization during the third trimester of pregnancy

a. You can receive the immunization for influenza at any time during your pregnancy

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. Your desire to be an organ donor must be documented in writing b. You must be at least 21 years of age to become an organ donor c. Your name cannot be removed once you are listed on the organ donor list d. I cannot be a witness for your consent to donate

a. Your desire to be an organ donor must be documented in writing

A nurse is teaching a prenatal class about infection prevention at a communitycenter. Which of the following statements by a client indicates an understanding of the teaching? a. "I should take antibiotics when I have the virus" b. "I can visit my nephew who has chickenpox 5 days after the sores have crusted" c. "I can clean my cat's litter box during my pregnancy" d. "I should wash my hands for 10 seconds with hot water after working in the garden"

b. "I can visit my nephew who has chickenpox 5 days after the sores have crusted"

A nurse is providing teaching to a client who has depressive disorder and a new prescription for amitriptyline. Whichof the following statements by the client indicators an understanding of the teaching? a. "I can continue to take St. John's wort while taking this medication." b. "I know it will be a couple of weeks before the medication helps me feel better." c. "I expect this medication to raise my blood pressure." d. "I should take this medication on an empty stomach."

b. "I know it will be a couple of weeks before the medication helps me feel better." *DEPRESSIVE DISORDER MEDICATIONS TAKE 2-3 WEEKS TO BECOME EFFECTIVE*

A nurse is teaching a client who has atrial fibrillation and is to starttaking dabigatran. Which of the following statements by the client indicates an understanding of the teaching? a. "I can store the medication in the refrigerator." b. "I should keep the medication in the original container." c. "I can crush the medication and mix with applesauce." d. "I should replace any unused medication every 6 months. "

b. "I should keep the medication in the original container."

A nurse has just received a change-of-shift report for four clients. Which of thefollowing clients Should the nurse assess first? a. A client who is scheduled for a procedure in 1 hr b. A client who was just given a glass of orange juice for a low blood glucose level c. A client who received a pain medication 30 min ago for postoperative pain d. A client who has 100 mL of fluid remaining in his IV bag

b. A client who was just given a glass of orange juice for a low blood glucose level

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should thenurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery b. Administer analgesics on a scheduled basis for the first 24 hr c. Give cromolyn nebulized solution every 8 hr d. Apply a warm compress to the operative site every 4 hr

b. Administer analgesics on a scheduled basis for the first 24 hr

A nurse is caring for a 2 year old toddler. Which of the following foodchoices should the nurse recommend to promote independence in eating? a. Grapes b. Banana slices c. Hot dogs d. Popcorn

b. Banana slices a. Grapes (choking hazard) c. Hot dogs (choking hazard) d. Popcorn (choking hazard) *POTENTIAL CHOKING HAZARDS: NUTS, GRAPES, HOT DOGS, PEANUT BUTTER, RAW CARROTS, DRIED BEANS, TOUGH MEATS, POPCORN*

A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. Hypertension b. Herpes zoster c. Obesity d. Hypothyroidism

b. Herpes zoster

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first? a. Schedule nursing staff training for infection control procedures b. Identify possible precipitating factors related to the infections c. Meet with providers to discuss measure to decrease the infections d. Revise the current policy for catheter care

b. Identify possible precipitating factors related to the infections

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? a. Moving both crutches with stronger leg forward first b. Positioning both hands on the grips with his elbows slightly flexed c. Supporting his body weight while leaning on the axillary crutch pads d. Stepping with his affected leg first when going up stairs

b. Positioning both hands on the grips with his elbows slightly flexed

Nurse is developing care plan for client on Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following should the nurse delegate to an Assistive Personnel? a. Observe the position of the suspended weight b. Remind the client to use the incentive spirometer c. Check the client's pedal pulse on the right leg d. Ask client to describe her pain

b. Remind the client to use the incentive spirometer

A nurse is preparing to feed a newly admitted client who has dysphagia. Which of thefollowing actions should the nurse plan to take? a. Instruct the client to lift her chin when swallowing b. Sit at or below the client's eye level during feedings c. Talk with the client during her feeding d. Discourage the client from coughing during feedings

b. Sit at or below the client's eye level during feedings

A nurse is caring for an infant who has gastroenteritis. Which ofthe following assessment findings should the nurse report to the provider? a. Decreased appetite and irritability b. Sunken fontanels and dry mucous membranes c. Temperature 38 C (100.4 F) and pulse rate 124/min d. Pale and a 24 hr fluid deficit of 30 ml

b. Sunken fontanels and dry mucous membranes

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices". Which of the following responses is the priority for the nurse to state? a. I realize the voices are real to you, but I don't hear anything b. What are the voices telling you? c. How long have you been hearing the voices? d. Have you taken your medication today?

b. What are the voices telling you? *YOU NEED TO MAKE SURE THEY ARE NOT COMMAND HALLUCINATIONS THAT CAN CAUSE HARM TO THE NURSE OR PATIENT*

A nurse is caring for a client who has an implanted venous access port. Which of thefollowing should the nurse use to assess the port? a. An angiocatheter b. A butterfly needle c. A noncoring needle d. A 25 gauge needle

c. A noncoring needle

A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actionsshould the nurse take? a. Reassures the child that no one will be told about the abuse b. Use leading statements to obtain information from the child c. Explain to the child what will happen when the abuse is reported Ensure that multiple nurses are present for the physical examination

c. Explain to the child what will happen when the abuse is reported

A nurse is assessing a client who is inactive labor. Which of the followingfindings should the nurse report to the provider? a. Contractions lasting 80 seconds b. Early decelerations in the FHR c. FHR baseline 170/min d. Temperature 37.4 C (99.3 F)

c. FHR baseline 170/min

A nurse is providing discharge teaching to a client who is postoperativefollowing the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks b. I can resume activities, such as sewing c. I can lift objects that are less than 10 pounds d. I should bend at the waist when putting on my shoes

c. I can lift objects that are less than 10 pounds

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take? a. Flush the NG tube with 30 mL of 0.9% sodium chloride before and after medication b. Maintain the head of the bed at a 20 degree c. Measure gastric residual volumes every 4 hrs d. Advance the rate of feeding every 2 hrs

c. Measure gastric residual volumes every 4 hrs

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks ofgestation. Which of the following actions should the nurse take? a. Measure the fundal height to determine the placement of the ultrasound stethoscope b. Perform Leopold maneuvers prior to auscultating the FHR c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR d. Place the client in a side-lying position prior to assessing the FHR

c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR

While performing a routine assessment, a nurse notices fraying on the electrical cord ofa client's CPM device. Which of the following actions should the nurse take first? a. Report the defect to the equipment maintenance staff. b. Ensure the device inspection sticker is current c. Remove the device from the room d. Initiate a requisition for a replacement CPM device

c. Remove the device from the room

A nurse in an acute mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the followingactions should the nurse expect from the leader during the session? a. The leader lectures about medication adverse effects to the group members b. The leader has group members vote on what they would like to learn about during the session c. The leader allows the group to discuss whatever they would like to regarding their medications d. The leader encourages group members to remain silent until questions are called for.

c. The leader allows the group to discuss whatever they would like to regarding their medications

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching? a. Round the edges of toenails when trimming. b. Use moisturizing lotion between the toes c. Wear clean cotton socks every day. d. Soak feet twice daily.

c. Wear clean cotton socks every day.

A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventionsshould the nurse include in the plan? a. Take a bubble bath after intercourse b. void every 5-6 hr during the day c. wear loose-fitting underwear d. drink four 240 mL (8oz) glasses of water each day

c. wear loose-fitting underwear

A nurse in a mental health clinic receives a request from a client who isundergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make? a. "Why are you interested in seeing your therapist notes?" b. "I don't think you'll benefit from receiving your therapist notes right now" c. "Are you not happy with your treatment?" d. "We can provide a copy of your records, but the therapist's notes are not included"

d. "We can provide a copy of your records, but the therapist's notes are not included"

A nurse is providing an in-service about client evacuation during a fire.Which of the following clients should the nurse instruct the staff to evacuate first? a. A client who has a fracture and is in balanced suspension traction b. A client who uses a wheelchair and is confused c. A client who is bedridden and wears a hearing aid d. A client who is ambulatory and receiving oxygen

d. A client who is ambulatory and receiving oxygen

A nurse is caring for a client who is immobile. Which of thefollowing interventions is appropriate to prevent contracture? a. Place a towel roll under the client's neck b. Position a pillow under the client's knees c. Align a trochanter wedge between the client's legs d. Apply an orthotic to the client's foot

d. Apply an orthotic to the client's foot

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? a. Client who is taking bumetanide and has a potassium level of 3.6 mEq/L b. Client who is taking warfarin and has an INR of 1.8 c. Client who received Mantoux test 48 hr. and has an induration d. Client who is scheduled for a colonoscopy and is taking sodium phosphate

d. Client who is scheduled for a colonoscopy and is taking sodium phosphate

A nurse is reviewing a client's cardiac rhythm strips and notes a constant PR interval of 0.35 sec. Which of the following dysrhythmias is the client displaying? a. Premature atrial complexes b. Complete heart block c. Atrial fibrillation d. First degree atrioventricular block

d. First degree atrioventricular block

A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? a. Fibrocystic breast disease b. Fibromyalgia c. Renal calculi d. Hypertension

d. Hypertension

A nurse is caring for a newborn whose mother was taking methadone during herpregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? a. Acrocyanosis b. Bulging fontanels c. Bradycardia d. Hypertonicity

d. Hypertonicity

A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following should the nurse plan to use during the group session? a. Encourage clients to establish a timeline for their grieving process b. Assist clients in identifying ways suicide could have been prevented c. Discourage clients from sharing negative aspects of their relationship with the deceased persons d. Initiate a discussion with clients about ways to cope with changes in family dynamics

d. Initiate a discussion with clients about ways to cope with changes in family dynamics

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Encourage rural residents to focus health spending on tertiary health interventions b. Have a nurse from outside the community provide health lectures at the county hospital c. Launch a media campaign to increase awareness about industrial pollution d. Provide anticipatory guidance classes to parents through public school

d. Provide anticipatory guidance classes to parents through public school

A nurse is caring for a client who report xerostomia following radiation therapyto themandible. Which of the following is an appropriate action by the nurse? a. Instruct the client on the use of esophageal speech b. Suggest rinsing his mouth with an alcohol-based mouth wash c. Offer the client saltine crackers between meals d. Provide humidification of the room air

d. Provide humidification of the room air