Practice questions

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client whose urinary output was 100 mL for the past 12 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a urine output of less than 30 mL/hr due to the risk for fluid imbalance. Therefore, the nurse should see this client first.

A nurse is checking a newborn's vital signs. Which of the following methods of temperature measurement should the nurse use?

Axillary The nurse should obtain the newborn's temperature using the axillary method because this method is accurate and safe for newborns. Axillary temperatures are expected to range from 36.5º to 37.5º C (97.7º to 99.5º F) in newborns.

A nurse in a provider's office is reinforcing teaching with a client who is to follow a 2,000 mg sodium-restricted diet. Which of the following client food selections indicates an understanding of the teaching?

Canned peaches Canned peaches have a low sodium content. This choice indicates understanding of the dietary instructions provided by the nurse.

A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

Capillary refill of 5 seconds to the client's toes A capillary refill of 3 to 5 seconds to the client's toes is an expected finding and indicates adequate circulation in the casted extremity.

A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

Change the appliance two times each week. The nurse should change the appliance two times each week to maintain an effective seal around the stoma. The nurse should remove the appliance carefully and cleanse the client's stoma.

A nurse is caring for a client who has a prescription for famotidine 160 mg PO every 6 hr. Available is famotidine oral suspension 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20 mL

A nurse is assisting with the care of a school-age child immediately following surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider?

250 mL of sanguineous drainage over the last 3 hr The nurse should recognize that if more than 3 mL/kg/hr of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately.

A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion?

A client attempts to hit another client during group therapy. The nurse should request a prescription for seclusion for a client who is at risk for harming themselves or others, or who exhibits violent behavior.

A nurse is receiving change-of-shift report for four clients. The nurse should plan to collect data from which of the following clients first?

A client who has asthma and had frequent exacerbations on the previous shift When using the airway, breathing, circulation (ABC) approach to client care, the nurse should prioritize data collection from a client who has asthma. The client experienced several exacerbations of asthma on the previous shift, which can result in an obstruction of the client's airway.

A nurse is talking with a client who says the provider agreed to initiate a do-not-resuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first?

Check for documentation that the provider spoke with the client about the DNR. The first action the nurse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decision and that documentation meets legal requirements.

A nurse in a long-term care facility is reviewing standard precaution guidelines with an assistive personnel (AP). The nurse should instruct the AP to use which of the following to clean up a blood spill?

Chlorine bleach solution The nurse should instruct the AP to use a bleach solution to clean up a blood spill. A 1:10 bleach-to-water solution will destroy all bloodborne pathogens.

A nurse is reviewing the medical history of a client who is scheduled for a colonoscopy to establish a diagnosis of diverticulitis. Which of the following findings should the nurse identify as increasing the client's risk for developing diverticular disease?

Chronic constipation Diverticular disease is a disorder in which pouches or sac-like projections occur in the bowel mucosa through weakened areas of the muscular layer of the intestines. The nurse should identify chronic constipation as a risk factor for diverticular disease.

A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects?

Gastric ulcer formation The nurse should monitor the client for indications of a gastric ulcer formation, which is a common adverse effect of prednisone.

A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when which of the following PPE is removed first?

Gloves The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority action for the AP to take is to remove the gloves, which are considered the most contaminated of the PPE.

A nurse is evaluating the safe use of electrical equipment by a newly hired assistive personnel (AP). Which of the following actions by the AP demonstrates an understanding of the proper use of electrical equipment?

Grasps the plug of a device in the client's room to pull it straight out from the wall The nurse should recognize that by grasping the plug, rather than the cord, the AP is demonstrating an understanding of proper equipment use and preventing risk of injury from electronic equipment.

A nurse is reinforcing teaching with a client about how to replace their two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest?

Hold the skin taut while removing the barrier. Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin.

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Hypervigilance Common manifestations of PTSD include recurrent recollections of the precipitating trauma, hypervigilance, irritability, insomnia, and difficulty concentrating.

A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

INR 5 A client receiving warfarin to prevent clot formation related to atrial fibrillation should have an INR of 2 to 3. An INR of 5 or greater indicates that the client is at risk for bleeding. Therefore, the nurse should notify the provider about this laboratory value.

A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?

Moist mucous membranes The condition of mucous membranes is an indicator of hydration status. Moist mucous membranes indicate adequate hydration and a positive response to IV fluid therapy.

A nurse is caring for a client who is actively dying from cancer. Which of the following actions should the nurse take?

Moisten the client's conjunctiva with sterile normal saline. If the client's eyes are open, the nurse should moisten the conjunctiva with sterile normal saline, artificial tears, or an ophthalmic lubricating gel.

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse plan to take?

Monitor the client's intake and output. The nurse should ensure that intake and output measurements are accurately obtained to monitor for fluid overload.

A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following information?

Motor response The nurse should collect data about the client's motor response and assign the response a score of 1 to 6, according to the Glasgow Coma Scale.

A nurse is contributing to the plan of care for a client who has a prescription for range-of-motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyperextension?

Move the arm behind the body with the elbow straight. Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow straight.

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect?

Muscle weakness The nurse should expect a client who has hypokalemia to have bilateral muscle weakness. Other manifestations of hypokalemia include hyporeflexia, muscle stiffness, cramping, and paralysis.

A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Observe the client's facial expressions during communication. The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whether the client understands what the interpreter is saying.

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Obtaining a client's vital signs prior to discharge Obtaining vital signs does not require use of the nursing process and is within the range of function for an AP. Therefore, the nurse should delegate this task to the AP.

A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

Open sterile packages. When preparing to perform tracheostomy care, the greatest risk to the client is the transmission of micro-organisms. Therefore, the priority action is to open sterile packages. The nurse should have a sterile bowl in which to pour the sterile solution to prevent the contamination of the sterile gloves.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

Open the outer package flap of the catheterization kit away from their body. The nurse should open the outer package flap of the catheterization kit away from their body to prevent their arm from crossing over the sterile field when opening the remaining flaps.

A nurse is making assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

Perform postmortem care for a client who died 1 hr ago. Performing postmortem care is within the range of function for an AP. Therefore, the nurse should delegate this task to an AP.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place an abduction wedge between the client's legs when in bed. The nurse should place an abduction wedge between the client's legs while in bed to prevent adduction of the legs and hip dislocation following a total hip arthroplasty.

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

Place the client in a lateral position. Late decelerations occur due to utero-placental insufficiency. The nurse should assist the client into a lateral position to improve uterine perfusion and oxygen transfer to the fetus.

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider?

Platelet count 95,000/mm3 The nurse should recognize that this platelet count is below the expected reference range for a client who is pregnant and might be indicative of HELLP syndrome. Other manifestations of HELLP syndrome include malaise and epigastric pain. The nurse should immediately notify the provider of this result.

A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

Poor lighting in the learning setting The nurse should recognize that the physical learning setting is an external factor that can affect the participants' learning ability. Environmental factors that affect learning include lighting, comfort of seating, and the temperature of the room.

A nurse is contributing to an in-service for newly licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

The child was born at 34 weeks of gestation. The nurse should identify that children born prematurely are at an increased risk for physical maltreatment. This increased risk is due to a possible impairment of bonding during infancy and an increased need for care due to medical concerns as a result of their premature birth.

A nurse is documenting client care in the medical record. Which of the following entries should the nurse make?

"Client remains NPO until x-ray procedure is complete." The nurse should use documentation that is specific and uses accepted terminology. The nurse can use the abbreviation "NPO," which is an accepted abbreviation for "nothing by mouth."

A nurse in a provider's office is obtaining a health history from a client who is scheduled to undergo a cardiac catheterization in 2 days. Which of the following questions is the priority for the nurse to ask?

"Do you know if you're allergic to iodine?" The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. Therefore, the priority question is to identify the client's allergies.

A nurse is caring for a client who is recovering from a motor-vehicle crash. The client's employer calls to ask if the client's injuries will prevent them from returning to work. Which of the following responses should the nurse make?

"I cannot give you this information. You will need to speak with your employee." Sharing client information with an employer is a violation of client confidentiality. HIPAA ensures that client information is kept confidential once it is disclosed in a health care setting. The nurse should inform the employer they will need to speak with the client directly.

A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which of the following client statements should the nurse use as an example of rationalization?

"I didn't get a good grade because my teacher does not like me." The nurse should recognize this statement as the use of rationalization by a client. Rationalization is used as a means of justifying unreasonable feelings, thoughts, or actions.

A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, "I am very upset and I want to be alone for a little while." Which of the following responses should the nurse make?

"I see that you are feeling overwhelmed. I will come back when you are ready." This response by the nurse is therapeutic and uses the communication technique of sharing observations. This response meets the requirements of a trusting nurse-client relationship. It respects the client's right to privacy and allows them to have control over their personal space while encouraging the expression of feelings.

A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I should apply sterile saline to lubricate the suction catheter." The nurse should lubricate the suction catheter with sterile saline prior to suctioning.

A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

"I should use counterpressure for back pain during labor." Counterpressure is a cutaneous stimulation strategy to decrease pain resulting from pressure of the fetal occiput against the spinal nerves.

A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching?

"I should wear a soft scarf around my neck when I am outside." A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun exposure.

A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions?

"I will give our baby sponge baths until the cord falls off." Immersing the umbilical cord stump in water might delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions?

"I will receive the nutrients I need through my IV fluid." During initial treatment of acute diverticulitis, the client is often kept NPO and receives parenteral nutrition to promote bowel rest. As the client's condition improves, they can progress to a soft, low-fiber diet. A high-fiber diet is prescribed once the client is fully recovered from the acute inflammation.

A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will secure the car seat in the car by using the seatbelt." The nurse should instruct the guardian to secure the car seat in the car by using the seatbelt.

A nurse is reinforcing discharge teaching with the parents of a school-age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching?

"I will soak my child's toothbrush in warm water to soften it before my child uses it." The nurse should instruct the parents to soften their child's toothbrush in warm water before they use it or allow them to use a sponge-tipped disposable toothbrush. These actions will minimize trauma to the gums and prevent bleeding of the oral cavity.

A nurse is reinforcing teaching with a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

"I will use condoms in addition to birth control pills to decrease my risk of becoming pregnant." Rifampin can interact with and reduce the effectiveness of oral contraceptives. Therefore, the nurse should instruct the client to use a secondary method to prevent pregnancy.

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

"If I forget to take a dose, I can take it later on the same day." If the client misses a dose of medication, they can take it later the same day but should not double the dose the next day.

A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?

"Your oncologist might prescribe a cold cap to wear during treatment to reduce hair loss." The nurse should inform the client that cold caps cause vasoconstriction, which can help to decrease hair loss by reducing the ability of the chemotherapy medication to reach the hair follicles.

A nurse is assisting with a discussion about STIs with a group of adolescents at a health fair. Which of the following statements should the nurse make?

"An infection with gonorrhea can result in infertility." Gonorrhea can lead to pelvic inflammatory disease and tubal scarring, which can result in infertility.

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include?

"Apply a water-based lubricant around the nostrils to prevent irritation." The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy.

A nurse is collecting data from a 5-year-old child at a well-child visit. The parent reports that the child is having frequent nightmares. Which of the following statements by the parent indicates to the nurse that the child is experiencing sleep terrors rather than nightmares?

"My child goes back to sleep right away." The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who is experiencing nightmares has difficulty returning to sleep because of continued fear.

A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following responses should the nurse make?

"What is your current understanding about the purpose of AA?" The nurse should identify the client's understanding about the purpose of AA to provide further information about the program and meetings and to facilitate a referral if needed. For treatment to be successful, the nurse should involve the client in the care decision-making process. This ensures the treatment program meets the client's individual needs and demonstrates caring by the nurse.

A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

"You should depress the button on the handheld marker when you feel your baby move." The nurse should instruct the client to depress the button on the handheld marker when they feel fetal movement. The nurse will note the mark on the fetal monitor tracing and the provider can review it. This test monitors fetal well-being.

A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include?

"You should increase your fluid intake while receiving this medication through the PCA pump." The client should increase their fluid intake to prevent or relieve the adverse effect of constipation while receiving morphine through the PCA pump.

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasonography the following day. Which of the following statements should the nurse include in the teaching?

"You will need to have a full bladder for the procedure." A full bladder is necessary because it moves the uterus upward for optimal visualization of the fetus and stabilizes the uterus for optimal reflection of sound waves.

A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?

"You will need to schedule a bone density test." Long-term use of corticosteroids, such as prednisone, can induce osteoporosis. Therefore, the client should schedule a bone density test to establish a baseline evaluation.

A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching?

"You will need to take the medication for the rest of your life." Hypothyroidism is a chronic disorder that requires lifelong thyroid hormone replacement therapy.

A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching?

"Your HIV status will be shared with members of your health care team." The diagnosis of HIV or AIDS is shared with every member of the health care team who provides direct care for the client, just like any other diagnosis.

Exhibit 1 Progress Report Consumes a 2 g sodium diet Walks three ti Exhibit 2 Graphic Record Age: 45 years BMI: 33mes per week Exhibit 3 History and Physical Two episodes of cholecystitis in the past 12 months Knee arthroplasty 3 years ago

A nurse is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) BMI The client's BMI of 33 indicates obesity, which increases the client's risk for colorectal cancer. Risk factors for colorectal cancer include high consumption of alcohol, tobacco use, a diet high in saturated fat that includes a high intake of red meat, being over 50 years of age, a family history of colon cancer or polyps, and a history of gastrectomy or inflammatory bowel disease.

A nurse is caring for a client who is experiencing acetaminophen toxicity. Which of the following medications should the nurse plan to administer to the client?

Acetylcysteine Acetaminophen toxicity can result in liver damage or death and requires treatment with acetylcysteine as an antidote. The nurse should plan to mix the medication with water or juice and administer an oral dose every 4 hr for up to 72 hr.

A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the following instructions should the nurse include?

Administer by subcutaneous injection. The nurse should include that enoxaparin should be injected into the subcutaneous tissue.

A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include?

Apply capsaicin cream four times daily. The nurse should instruct the client to apply capsaicin cream topically to provide warmth and relieve joint pain. The client should apply the cream no more than four times daily to avoid skin irritation.

A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include?

Apply the prosthesis immediately upon waking each day. The nurse should reinforce with the client the importance of applying the prosthesis immediately upon waking to prevent swelling of the residual limb.

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

Applying the stockings before the client gets out of bed The AP should apply antiembolic stockings while the client is in a supine position and before the client gets out of bed. Antiembolic stockings provide pressure to the lower extremities, which promotes venous return and reduces the risk of deep vein thrombosis formation in clients who are immobilized. Allowing the client to ambulate before applying the antiembolic stockings might cause lower extremity edema, making the stockings more difficult to apply.

A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

As soon as the client awakens in the morning Sputum from the base of the lungs provides the best specimen for collection. The AP should obtain the specimen early in the morning because overnight fluid accumulates in the base of the lungs while the client is sleeping.

A nurse enters a client's room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse take first?

Assist the client to a nearby waiting area. The greatest risk to the client is injury from the fire. Therefore, the priority intervention is to remove the client from immediate danger. After removing the client from the room, the nurse should then activate the fire alarm system, confine the fire by closing doors and windows, and extinguish the fire, if possible, using a fire extinguisher.

A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

Avoid foods with a high sugar content. The nurse should instruct the client to avoid sweet foods, which often increase the manifestations of dumping syndrome. These manifestations include nausea, sweating, abdominal pain, diarrhea, and weakness.

A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?

Avoid lying on the affected side. The client should avoid lying on the affected side because this increases intraocular pressure.

The nurse is collecting data from the adolescent 4 hr following the fasciotomy. Exhibit 1 Data Collection​ 1400: Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in al

Click to highlight the findings below that indicate an improvement in the adolescent's condition. When evaluating outcomes, the nurse should identify the adolescent's extremity pulse, capillary refill, extremity warm to the touch, no numbness or tingling, and a decrease in pain are all findings that indicate the fasciotomy was effective.

A nurse is collecting data on a newborn who is 3 days old. Exhibit 1 History and Physical Newborn was delivered at 37 weeks gestation via cesarean section for fetal distress.Apgar scores 8 at 1 min and 9 at 5 min.Birthweight 2,892 g (6 lb 6 oz)The client who gave birth plans to breastfeed. Exhibit 2 Flow Sheet Day 2 of Life 0900: Temperature 36.7° C (98° F)Heart rate 140/minRespiratory rate 48/minWeight 2,718 g (6 lb), 6% weight lossDay 3 of Life 0800:​ Temperature 36.4° C (97.5° F)Heart r

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Temperature 36.4° C (97.5° F) Weight 2,545 g (5 lb 9 oz) 12% weight loss Mild tremors noted when awake. Breastfeeding every 3 to 5 hr for 5 to 10 min. Birth parent reports nipple discomfort throughout the feeding. When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.

A nurse is assisting with the care of an adolescent in the emergency department (ED). Exhibit 1 Nurses' Notes 0700: Adolescent admitted to ED with parents concerned about left leg injury that appears to be getting worse. Parents report adolescent has had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715: Adolescent is alert and oriented to person, place, time, and situation. Adolescent reports left lower leg

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Pain Temperature WBC Casual Blood Glucose Potassium After reviewing the information in the adolescent's EMR and recognizing cues, the nurse should identify that the adolescent has a potential skin infection, such as cellulitis. The skin findings reveal that the medial lateral aspect of the left leg is causing pain and has a 3x3 cm2 area of redness with small pustules, tenderness, and warmth, which can indicate infection. The adolescent's temperature and WBC count are above the expected reference range, which can indicate infection. The adolescent's casual blood glucose and potassium are above the expected reference range, which can indicate infection or a complication of type 1 diabetes mellitus. The nurse should immediately follow up by reporting these findings because they can indicate infection or other complications.

A nurse is assisting with the care of a client who has schizophrenia in an inpatient facility. Exhibit 1 Medication Administration Record Day 1 0630: Clozapine 100 mg PO dailyAripiprazole 5 mg PO dailyMultivitamin PO daily Exhibit 2 Laboratory Results Day 1 0630: Sodium 125 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5 mEq/L) Chloride 90 mEq/L (98 to 106 mEq/L) BUN 8 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Total calcium 10 mg/dL (9 to 10.5 mg/dL) Phosphate 4 mg/dL

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. When analyzing cues, the nurse should identify that the client is taking a second-generation antipsychotic medication, which can lead to manifestations of tardive dyskinesia, including involuntary tongue movement and foot tremors. Frequent urination and incontinence are adverse effects of aripiprazole and should be reported to the provider. An increase in agitation is a safety risk for the client, staff, and others on the unit and requires immediate de-escalation.

A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

Client reports burning with urination. When using the urgent vs. nonurgent approach to client care, the nurse should determine that dysuria is a manifestation of a urinary tract infection. Therefore, the nurse should identify this as the priority finding to report to the provider.

A home health nurse is caring for a client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

Determine the client's mobility status. The first action the nurse should take when using the nursing process is to determine the client's mobility status. The nurse should begin collecting data about the client's ability to move freely within their environment while preventing injury. The nurse should begin by placing the client in the position providing the most support, then moving in increments to positions requiring less support and higher levels of tolerance.

A nurse is assisting in the care of a client who is postoperative following administration of general anesthesia. Exhibit 1 Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair.Apical pulse 154/min and irregularClient reports dyspnea Exhibit 2 Diagnostic Results 0835: Arterial blood gases (ABGs):pH 7.30 (7.35 to 7.45)PCO2 64 mm Hg (35 to 45 mm Hg)HCO3- 26 mEq/L (21 to 28 mEq/L)PO2 80 mm Hg (80 to 100 mm Hg) Exhibit 3 Vital Signs 0830: Temperature 36.9° C (98.4° F)Hea

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Upon collecting data, the nurse should note the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm. The nurse should determine that this client is most likely experiencing malignant hyperthermia, and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should assist the RN with the administration of dantrolene and oxygen. The nurse should also assist the RN to monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.

The nurse is continuing to care for the adolescent. Exhibit 1 Vital Signs​ 1400: Temperature 37° C (98.6° F)Weight 54.5 kg (120 lb)Pulse 89/minRespiratory rate 20/minBlood pressure 124/82 mm HgOxygen saturation 98% on room air1630: Temperature 38° C (100.4° F)Heart rate 94/minRespiratory rate 20/minBlood pressure 126/84 mm HgOxygen saturation 98% on room air

Complete the following sentence by using the lists of options. The client is at greatest risk for developing compartment syndrome as evidenced by the client's severe pain. The nurse should determine that the priority hypothesis is that the adolescent is developing compartment syndrome as evidenced by severe pain following the administration of pain medication. When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is severe pain. This can indicate compartment syndrome, which requires immediate intervention. Therefore, this finding is the highest priority.

A nurse is assisting with the care of a client who is 1 day postoperative following a total thyroidectomy. Exhibit 1 Laboratory ResultsDay 2, 0700: Sodium 143 mEq/L (136 to 145 mEq/L)Potassium 3.5 mEq/L (3.5 to 5 mEq/L)Chloride 104 mEq/L (98 to 106 mEq/L)BUN 15 mg/dL (10 to 20 mg/dL)Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L)Total calcium 8 mg/dL (9 to 10.5 mg/dL)Phosphate 4.6 mg/dL (3 to 4.5 mg/dL)Glucose 95 mg/dL (74 to 106 mg/dL)WBC count 9,500/mm3 (5,000 to 10,000/mm3) Exhibit 2 Nurses' Notes​

Complete the following sentence by using the lists of options. The client is at highest risk for developing hypocalcemia as evidenced by the report of numbness around lips The nurse should recognize cues and determine that the client is at highest risk for developing hypocalcemia as evidenced by the client's report of muscle spasms, numbness around lips, and decreased calcium level. Hypocalcemia is more likely to occur in clients who have experienced a thyroidectomy, due to accidental damage to the parathyroid. Numbness around the lips is a clinical manifestation specific to hypocalcemia. Hypocalcemia presents as muscle spasms and can lead to cardiac dysrhythmias. Hypocalcemia is the highest priority, as it requires immediate treatment with calcium gluconate to avoid dysrhythmias and other complications.

A nurse on the medical-surgical unit is assisting with the care of a client who was admitted from the emergency department (ED). Exhibit 1 Vital Signs Vital signs upon admission to the ED: 1400: Temperature 38° C (100.4° F)Heart rate 110/minRespiratory rate 24/minBP 96/58 mm HgPulse oximetry 96% on room air Vital signs upon admission to the medical-surgical unit: 1500: Temperature 37.2° C (98.9° F)Heart rate 96/minRespiratory rate 20/minBP 100/70 mm HgPulse oximetry 97% on room air Exhibit 2

Complete the following sentence by using the lists of options. The client is at risk for developing confusion due to sodium level Upon analyzing cues, the nurse should identify that the client is at risk for confusion due to a sodium level that is greater than the expected reference range. Hypernatremia places the client at risk for a decreased level of consciousness, falls, and seizure activity. Therefore, the nurse should assist in monitoring the client's level of consciousness and place the client on fall and seizure precautions.

A nurse is assisting with care of a client who is on 24-hr observation. Exhibit 1 Laboratory Results ​0530: Sodium 150 mEq/L (136 to 145 mEq/L) Potassium 5.5 mEq/L (3.5 to 5 mEq/L) Chloride 105 mEq/L (98 to 106 mEq/L) BUN 17 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Total calcium 10.0 mg/dL (9 to 10.5 mg/dL) Phosphate 4.0 mg/dL (3 to 4.5 mg/dL) Glucose 135 mg/dL (74 to 106 mg/dL) Platelet count 99,500/mm3 (150,000 to 400,000/mm3) WBC count 9,500/mm3 (5,000 to 10,000/mm3) To

Complete the following sentence by using the lists of options. The client is at risk for developing hemorrhaging due to thrombocytopenia .

A nurse is reinforcing teaching with a client who is pregnant. Exhibit 1 Nurses' Notes Week 6 of gestation: Spoke with client over the phone. Client reports nausea and vomiting with a weight loss of 0.9 kg (2 lb) from their pre-pregnancy weight. Client reports no noted change in voiding pattern and denies dry mucus membranes. Reminded client to eat small frequent meals of non-greasy, dry, sweet, or salty foods such as dry toast, crackers, and pretzels. Encouraged client to call back if nausea an

Complete the following sentence by using the lists of options. The client is at risk for experiencing metabolic acidosis due to the client's weight loss When prioritizing hypotheses, the nurse should recognize that the client is at risk for developing metabolic acidosis due to excessive weight loss. The intake and retention of food is not meeting the client's nutritional requirements. Undernutrition can lead to the breakdown of fatty tissue, which increases the release of nonvolatile acids into the blood stream.

A nurse is collecting data from a client who reports recent methamphetamine use. Which of the following manifestations should the nurse expect?

Dilated pupils The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance.

A nurse manager is preparing to complete a performance analysis for a group of assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the following actions should the staff nurse take?

Discuss how each AP's actions measure against the job description. To provide objective information, the staff nurse should compare the behavior of each AP to the facility job description. The nurse can provide specific information about how each AP either meets the standard or demonstrates a need for improvement.

A nurse is caring for a client in an outpatient setting. Exhibit 1 Nurses' Notes 1500: Client reports a recent history dyspnea and fatigue with mild activity. Notes shortness of breath when lying flat. Lips and mucus membranes pale in color. Respirations easy and unlabored at rest. Apical pulse strong and regular with audible S3. Crackles auscultated in lower lobes bilaterally. Abdomen soft and nondistended. Extremities cool to touch. +1 pedal pulses palpated bilaterally. Exhibit 2 History and P

Complete the following sentence by using the lists of options. The client is exhibiting manifestations of heart failure as evidenced by the client's BNP level When analyzing cues, the nurse should determine that the client is exhibiting manifestations of heart failure as evidenced by the client's BNP level. The client is experiencing dyspnea and fatigue, which might be manifestations of decreased cardiac output. Auscultation of S3 is an early indication of heart failure. A BNP level greater than 400 pg/mL is associated with heart failure. Chronic hypertension leads to myocardial hypertrophy and decreased ability of the heart to fill during diastole and is a common cause of heart failure.

A nurse is assisting with the care of a 1-month-old infant. Exhibit 1 Nurses' Notes 1500: Infant admitted to the pediatric unit. Parent reports their baby has been irritable and has vomited after each feeding within the last 3 days.Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive in all four quadrants. Small 1x1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor

Complete the following sentence by using the lists of options. The infant is at highest risk for developing dehydration as evidenced by the infant's vomiting When prioritizing hypotheses and using the urgent vs. nonurgent priority framework, the nurse should identify that the infant is at greatest risk for developing dehydration due to a loss of gastric content from vomiting. An infant who has pyloric stenosis presents with projectile vomiting after feeding, a distended abdomen, and an olive-shaped mass in the epigastrium.

A nurse is assisting with the care of a client who has a new diagnosis of anorexia nervosa. Exhibit 1 Laboratory Results Day 1 2030: Sodium 146 mEq/L (136 to 145 mEq/L) Potassium 3.3 mEq/L (3.5 to 5 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 21 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Phosphate 2.8 mg/dL (3 to 4.5 mg/dL) Glucose (casual) 75 mg/dL (74 to 106 mg/dL) Total protein 5.8 g/dL (6.4 to 8.3 g/dL) Albumin 3 g/dL (3.5 to 5 g/dL)Day 2 0530: Sodium 150 mEq/L (136 to

Complete the following sentence by using the lists of options. The nurse should first address the client's electrolyte imbalance , followed by the client's fear of weight gain When analyzing cues, the nurse should first address the client's electrolyte imbalance. The client has hypokalemia, which increases the risk for cardiac arrhythmias. Once the client's medical concerns are addressed, the nurse should then focus on the underlying psychological issues behind the eating disorder, such as the client's fear of weight gain.

A nurse is assisting with the care of a preschooler. Exhibit 1 Nurses' Notes Day 1 0900: Child admitted to respiratory unit from pediatrician's office. Parents at bedside. Parents state child has been sick with a cold and fever for 3 days. Developed vomiting and diarrhea 1 day ago. Child alert and oriented. S1 and S2 sounds present. Child has productive cough. Rhonchi auscultated on left lower lung. Mild retractions. Child placed on 2 L nasal cannula. Abdomen soft and nontender. Bowel sounds dim

Complete the following sentence by using the lists of options. When using the stable vs. unstable priority setting framework, the nurse should plan to first address the child's urinary output, followed by the ABG results. Vomiting, diarrhea, acid and base imbalance along with electrolyte imbalance can lead to metabolic alkalosis. Promptly addressing these deficits can improve the child's condition.

A nurse is assisting with the care of a newborn. Exhibit 1 History and Physical 41 weeks of gestation Spontaneous vaginal delivery with meconium-stained amniotic fluid at 1350 Apgar 7 at 1 min and 9 at 5 min Birth weight 2,500 g (5 lb 5 oz) Maternal urine toxicology positive for marijuana use during pregnancy Maternal blood type A, Rh negative Group B streptococcus β-hemolytic: positive (expected value: negative) Client who gave birth received three doses of intravenous antibiotics while in lab

Complete the following sentence by using the lists of options. The nurse should plan to first collect data about the newborn's respiratory rate , followed by the newborn's heart rate When generating solutions, the nurse should identify that expiratory grunting and nasal flaring are unexpected findings in a newborn and indicate respiratory distress. The presence of meconium-stained amniotic fluid increases the risk that the newborn will develop meconium aspiration syndrome. Therefore, the first action the nurse should take is to collect data about the newborn's respiratory rate, followed by the heart rate. The nurse should perform noninvasive data collection techniques, such as observing the respiratory rate, before more invasive techniques that might stimulate the newborn, such as auscultating the heart rate, to avoid alteration of data.

A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?

Consumption of contaminated food The nurse should include that hepatitis A is spread via the fecal-oral route through direct contact with stool or consumption of contaminated food and water.

A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use?

Coronary artery disease Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension.

A nurse is caring for a client who is receiving continuous feedings via a gastrostomy tube. Which of the following actions should the nurse plan to take?

Flush the tube with 50 mL of water if it becomes clogged. The nurse should flush the feeding tube with 20 to 50 mL of warm water if the tube becomes clogged to re-establish the patency of the gastrostomy tube.

A nurse is assisting with the care of a client admitted with profuse vomiting and abdominal pain. Exhibit 1 Nurses' Notes 0700: Client reports abdominal pain as 8 on a scale of 0 to 10 for 4 days. Nausea and profuse vomiting for 3 days. Client reports last bowel movement was 5 days ago.Abdominal: upper epigastric distension noted. Bowel sounds absent. Abdominal tenderness and rigidity noted on palpation. Abdominal distension noted.Allergies: penicillin, meperidine0800: Client reports worsening p

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing anaphylactic reaction due to bowel obstruction Upon recognizing client cues, the nurse should identify the client's WBC level, temperature, and neutrophils are outside the expected reference range, which can indicate an infection as a result of a bowel obstruction. A bowel obstruction can occur for a variety of reasons, including constipation, bowel adhesions, and medication adverse effects. The other areas of concern have been addressed with pain medication and IV fluids. The nurse should anticipate continuation of medical interventions.

A nurse is assisting with the care of a client who has bulimia nervosa. Exhibit 1 Admission Assessment Day 1 0630: Client admitted to inpatient unit for evaluation and treatment following report of binge eating and vomiting for more than 1 year.Client reports feeling excessively tired and light-headed.Neurologic: Client alert and oriented x 3.Respiratory: Lungs clear and equal bilaterallyHeart rate 65/minGastrointestinal: Diminished bowel sounds noted x 4. Client reports vomiting three to four t

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing cardiovascular abnormalities and electrolyte imbalance When recognizing cues, the nurse should determine that the client is at the greatest risk of developing cardiovascular abnormalities and electrolyte imbalance due to chronic vomiting. When chronic vomiting occurs, abnormal electrolytes result in hypokalemia, hypochloremia, and hyponatremia. Cardiovascular abnormalities such as bradycardia, arrhythmias, and electrocardiograph changes can occur.

A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

Drink high-protein and high-calorie nutritional supplements. The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that can lead to hypermetabolism and wasting of the client's muscle mass.

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse include?

Eat a bedtime snack. The manifestations described by the client indicate hypoglycemia. Eating a snack at bedtime will help prevent hypoglycemic episodes during the night.

A nurse is monitoring a client who is receiving IV fluids. For which of the following findings should the nurse stop the infusion?

Edema above the catheter insertion site Edema above the catheter site indicates infiltration. The nurse should stop the IV infusion.

A nurse is assisting a client who is postoperative to sit on the side of the bed. Which of the following actions should the nurse take?

Elevate the head of the client's bed. The nurse should elevate the head of the client's bed to decrease the distance the client has to move to sit on the side of the bed.

A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

Ensure the injection produces a wheal on the skin. The nurse should ensure that the injection of the PPD produces a wheal, or bleb, on the skin. This indicates the medication has been injected into the dermis of the skin.

A nurse is reinforcing teaching with a client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Expose the glans of the penis is the first step. The client should expose the glans of the penis to prepare for cleansing of the urinary meatus. Cleanse the penis using an antiseptic swab is the second step. The client should cleanse the area to decrease the levels of bacteria that could contaminate the urine specimen. Begin urination is the third step. The client should begin urinating to eliminate any bacteria or other micro-organisms that have collected in the urethra. Pass the cup into the urine stream is the fourth step. The client should pass the cup into the urine stream and collect 30 to 60 mL of urine. Move the cup out of the urine stream is the fifth step. The client should move the cup out of the urine stream after 30 to 60 mL of urine have been collected and before releasing their hand from the penis. This prevents the contamination of the urine specimen with flora from the client's skin. Replace the foreskin is the sixth step. The client should replace the foreskin ov

A nurse is collecting data from a client who has a hip fracture. Which of the following findings should the nurse expect?

External rotation Clinical manifestations of a hip fracture include external rotation and shortening of the affected extremity.

A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. Upon auscultation, the nurse hears high-pitched popping sounds. The nurse should report which of the following to the provider after hearing this sound?

Fine crackles Fine crackles are high-pitched popping sounds often caused by pulmonary edema, which can be a complication of heart failure.

A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take?

Flush the feeding tube with water before and after administering the medication. To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administration.

A nurse on a mental health unit is caring for a client. Exhibit 1 Nurses' Notes Day 1: Client admitted due to manifestations of depression, feelings of guilt, and thoughts of self-harm.The client reports not sleeping well and feeling irritable. Flat affect noted. Client also reports poor appetite and difficulty concentrating.Day 2: Client slept for 4 hr the previous night, ate 25% of breakfast. Client did not participate in group therapy and spent most of the day in their room yesterday. Exhibit

For each nursing action, click to specify if the nursing action is anticipated or contraindicated for the client. While taking action for this client, the nurse should identify that initiating suicide precautions, encouraging the client to attend group therapy, and frequently offering high calorie snacks are anticipated. The client expresses feelings of guilt, exhibits a flat affect, and expresses thoughts of self-harm, which increase the risk for suicidal behavior. The client should be encouraged to attend individual and group therapy to promote participation in the treatment plan. Frequent high calorie and high protein snacks can increase the client's intake and might be better tolerated than larger meals. The nurse should identify that allowing the client to sleep with their hands out of view is contraindicated due to the risk of self-harm.

A nurse is assisting with the care of a client who was admitted to the emergency department (ED). Exhibit 1 Admission Assessment Day 1 1930: Client admitted to the ED by police after report of violent behavior in public. Client smashed a glass window with their hands. Client is stating, "I am Jesus." Client is attempting to hit staff. Client placed in restraints. Neuro: Client is alert and oriented x 0. Client is swinging their arms and shouting. Client is unable to answer questions and their sp

For each potential assessment finding, click to specify if the finding is consistent with schizophrenia or bipolar 1 disorder. Each finding may support more than 1 disease process. When analyzing cues, the nurse should distinguish between positive and negative manifestations of schizophrenia and bipolar 1 disorder. The client is displaying positive manifestations of schizophrenia, when compared to the assessment findings of a client who has bipolar 1 disorder.

A nurse is caring for a client who is postoperative following a perineal prostatectomy. Exhibit 1 Nurses' Notes Postoperative Day 1 0900: Client reports pain at the perineal surgical incision site as 5 on a scale of 0 to 10. Client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.Client reports hard, painful bowel movement.Client transferring out of bed to chair independently.Postoperative Day 2 1300: Client reports abdominal cramping and small, hard, painf

For each potential postoperative complication below, click to specify the nursing intervention that the nurse should implement. When taking actions for a client who is postoperative following a perineal prostatectomy, the nurse should assist the client with a sitz bath, encourage the client to drink prune juice, and instruct the client to perform calf pump and foot circle exercises. The nurse should offer the client a sitz bath to relieve pain and promote healing. The nurse should encourage the client to drink prune juice to relieve constipation. The nurse should instruct the client to perform calf pump and foot circle exercises to promote venous return and reduce the risk of a deep vein thrombosis.

The nurse is continuing to care for the adolescent. Exhibit 1 Data Collection 1400:Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower ex

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent. When generating solutions for an adolescent who has compartment syndrome, the nurse should anticipate that the adolescent will need a fasciotomy. A fasciotomy is needed to decrease atrial spasms and increase perfusion within the muscle compartments. The nurse should recognize that elevating the right leg above heart level and applying ice to the affected extremity are all contraindicated for an adolescent who has compartment syndrome. Elevating the right leg above heart level and applying ice to the affected extremity will further compromise blood flow. Removing the splint is part of the immediate treatment for a client experiencing compartment syndrome.

A nurse is assisting with the care of a 3-month-old infant. Exhibit 1 Nurses' Notes Admission Day (Day 1) Infant admitted for respiratory distress. 0800: Wheezing noted upon auscultation in bilateral lower lobes. Mild subcostal and substernal retractions noted. Mild nasal flaring present. Oxygen via nasal cannula at 1 L/min applied. Skin color is appropriate for genetic background. Mucus membranes are pink and moist. Infant is sleeping in parent's arms. 0900: Infant is breastfeeding. Respiratory

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the infant. When generating solutions for an infant who has cystic fibrosis, the nurse should anticipate prescriptions that address both the respiratory and gastrointestinal system. The nurse should anticipate a prescription to administer pancreatic enzymes PO within 30 min of breastfeeding to ensure that the digestive enzymes are mixed with breastmilk in the duodenum. The nurse should also anticipate a prescription to administer nebulized dornase alfa 2.5 mg per day to decrease the thickness of the infant's mucus. A prescription to use a flutter mucus clearance device every 2 hr and a prescription to administer nebulized hypertonic saline every 6 hr are both contraindicated for an infant because of their inability to properly use the devices. A prescription to perform airway clearance therapy (ACT) immediately after breastfeeding is contraindicated because

A nurse is assisting with the care of a client following a total hip replacement. Exhibit 1 Provider Prescriptions Postoperative Day 3 1400: Enoxaparin 30 mg subcutaneous every 12 hrMorphine 4 mg IV bolus every 3 to 4 hr for painOndansetron 4 mg PO as needed for nauseaAcetaminophen 500 mg PO every 4 to 6 hr for temperature greater than 38.4° C (101.1° F) Exhibit 2 Nurses' Notes Postoperative Day 3 1500: RN administered morphine for pain rating of 8 on a scale of 0 to 10. 1600: Client rates pai

For which of the following assessment findings should the nurse notify the provider? Select all that apply. When analyzing cues, the nurse should identify that a partial-thickness pressure injury over the sacral area, aching/cramping in the left calf, and a capillary refill of 4 seconds are unexpected findings 3 days postoperative for a total left hip replacement and can indicate complications of immobility, such as skin breakdown and deep vein thrombosis. These findings should be reported to the provider.

A nurse is caring for a client who is refusing a prescribed medication. Which of the following actions should the nurse take first?

Identify the client's concerns about receiving the medication. The first action the nurse should take when using the nursing process is to assess the client's concerns. By addressing these concerns using therapeutic communication, the nurse can establish if there are circumstances that make taking prescribed medication difficult, such as financial constraints, or if the client is experiencing adverse effects from the medication.

A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

Instruct the client not to get out of the bed. Lorazepam causes sedation, placing the client at risk for injury due to falling. Therefore, the nurse should instruct the client not to get out of bed.

A nurse is contributing to the plan of care for a client who is postoperative following a rhinoplasty. Which of the following interventions should the nurse recommend?

Instruct the client to avoid the Valsalva maneuver. The nurse should instruct the client to avoid the Valsalva maneuver and other activities that increase pressure at the operative site, resulting in an increased risk for bleeding.

A nurse is collecting data from a newly admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

Irritability An infant who has hypovolemia will experience irritability due to decreased perfusion. The nurse should report this finding to the provider.

A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

Lack of change in pupil size when the client looks from a far to a near object The nurse should expect the client's pupils to constrict when looking from a far to a near object. Lack of change in pupil size can indicate brain injury or increased intracranial pressure.

A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Lack of sleep The greatest risk for this client is exhaustion or death from lack of sleep; therefore, this is the priority finding. The nurse should encourage frequent periods of rest for the client throughout the day.

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

Maintain a sequential compression device. Sequential compression devices promote venous return by providing intermittent periods of compression on the legs.

A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider?

Metoprolol ER 50 mg per NG tube BID The nurse should clarify the prescription for metoprolol ER with the provider because it is an extended-release tablet. The nurse should not crush extended-release medication because parts of the medication dissolve at variable rates and the client can experience toxicity from the medication in a short period of time

A nurse is receiving change-of-shift report for a group of clients. The nurse should plan to implement which of the following time-management strategies?

Prepare a priority list of client needs for the shift. The nurse should prepare a client priority to-do list, which could include administering time-critical medications. This will allow the nurse to determine which clients should receive care first.

A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take?

Report the observations about the AP to the unit's nurse manager. The nurse should report their observations to the unit's nurse manager because they have a duty to report any behavior that poses a risk to client safety.

A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

Report the situation to the provider who obtained the informed consent. The provider is responsible for obtaining the informed consent and has the legal responsibility to answer any questions or concerns the client has. Therefore, the nurse should report the client's refusal of the procedure to the provider.

A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the guardian's stated cause. Which of the following actions should the nurse take?

Report the suspected child maltreatment to the appropriate agency. It is the nurse's legal and professional responsibility to immediately report suspected child maltreatment to the proper child protective service agency.

A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following client findings indicates a therapeutic effect of this medication?

Reports a decrease in the number of stools Pancrelipase is administered as replacement therapy for a deficiency in pancreatic enzymes, which results in steatorrhea, or fatty stools. The nurse should monitor for improved nutrition and a decrease in the number of bowel movements, which would indicate a therapeutic response to the medication.

A nurse is caring for a newborn who is 1 hr old. The client who gave birth received fentanyl 30 min before delivery. For which of the following adverse effects should the nurse monitor the newborn?

Respiratory depression Fentanyl, an opioid agonist, rapidly crosses the placenta, and it is present in fetal blood within 1 min. The nurse should monitor the newborn for respiratory depression, which is an adverse effect of fentanyl.

A nurse is preparing to perform venipuncture to obtain a blood sample from a client. Which of the following actions should the nurse take?

Select a site in the antecubital fossa. The nurse should select a vein in the antecubital fossa for blood draws.

A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

The AP reports client information to the oncoming AP in the hallway. The nurse should intervene when observing the AP reporting client information in the hallway because it is a breach of client confidentiality.

The nurse is assisting with preparing the adolescent for a fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?

The adolescent's parents have concerns regarding the surgery. When taking action for an adolescent who is scheduled for a fasciotomy, the nurse should notify the provider if the parents of the adolescent have questions or concerns regarding the procedure, which could indicate lack of understanding about the informed consent.

A nurse is caring for a client in an inpatient mental health facility. Exhibit 1 Medical HistoryClient is 44 years old, well-nourished, presenting with recurrence of labile behavior involving self-mutilation, recent arrest for reckless driving, stealing money from work for gambling debts, depressive episodes, and binge eating.Provider's skin assessment reveals multiple superficial self-inflicted lacerations to right arm. Client plays golf three mornings per week. Employed as salesperson at a car

Select the 2 findings from the client's medical record that are manifestations of borderline personality disorder. Behavior toward roommate Skin assessment When recognizing cues, the nurse should identify that the client's skin assessment and behavior toward roommate are indications of borderline personality disorder. Clients who have borderline personality disorder display unstable relationships, labile moods, and impulsivity, such as excessive spending, binging, substance abuse, and reckless driving. They also have recurrent episodes of self-harm and might engage in suicidal actions. They have difficulty controlling their anger and might have paranoid ideations. They have chronic feelings of emptiness and do not like to be alone.

A nurse is assisting in the care of an adolescent. Exhibit 1 Data Collection​1400:Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower

Select the 4 findings that require follow-up. Capillary refill Pedal pulse Skin temperature Pain When recognizing cues, the nurse should identify the findings that require follow-up in an adolescent who has an injury to the right leg include capillary refill, pedal pulse, skin temperature, and pain. The adolescent rates their pain as 10 on a scale of 0 to 10, which requires follow-up by the nurse. A capillary refill of 4 seconds is outside the expected reference range of less than 2 seconds. A pedal pulse of +1 is diminished and is outside the expected reference range. Skin temperature of the right extremity is cool to the touch, which is an unexpected finding. These findings are indicative of decreased perfusion to the extremity and require follow-up by the nurse.

A nurse is assisting in the care of a client who is 1 hr postpartum. Exhibit 1 Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous IV infusion 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Exhibit 2 Vital Signs 1200: Temperature 37.5° C (99.5° F)Heart rate 92/minRespiratory r

Select the 6 actions the nurse should take. Provide emotional support. Administer methylergonovine. Weigh the perineal pads. Insert an indwelling urinary catheter. Administer oxygen at 12 L/min via nonrebreather face mask. Firmly massage the uterine fundus.

A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?

Separate the child's used washcloth from those of others. Due to the contagious nature of the infection, it is necessary to separate the washcloth of a child who has conjunctivitis from those of others to prevent the spread of infection.

A nurse is caring for a client who adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the client's meal tray?

Spaghetti noodles with red sauce The nurse should identify that spaghetti noodles with red sauce is appropriate for a client who adheres to a kosher diet.

A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the teaching?

Strain the urine to collect stone fragments. The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation.

A nurse is collecting data from a school-age child who has hypoglycemia. Which of the following findings should the nurse expect?

Sweating The nurse should expect a school-age child who has hypoglycemia to have pale, sweaty skin. Other expected findings of hypoglycemia include irritability, tachycardia, tremors, and hunger.

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

Take up to three tablets during a single angina episode. The nurse should instruct the client to take up to three doses of the nitroglycerin, 5 min apart, if chest pain persists.

A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take?

Tell the client they should not experience any discomfort. The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort.

A nurse is caring for a client who is in the final stages of cancer. Which of the following client situations should the nurse identify as an ethical dilemma?

The client asks the nurse to help them die peacefully in their sleep. This situation presents an ethical issue for the nurse because the client is asking for a variation of active euthanasia, also known as assisted suicide, which is in violation of the Code of Ethics for Nurses. The nurse is legally and ethically unable to support this decision by the client and should ask for assistance with this dilemma.

A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect?

The client calls their partner to ask what they should wear each day. Clients who have dependent personality disorder have problems making everyday decisions without input from others.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which of the following findings should the nurse notify the provider?

The client has absent bowel sounds. Absence of bowel sounds can indicate absence of peristalsis, which is a manifestation of an ileus. The nurse should report this finding to the provider for reconsideration of the diet prescription.

A nurse is caring for a client who has a phobia of elevators. Which of the following should the nurse recognize as an indication that systematic desensitization has been effective for the client?

The client remains relaxed when thinking of the phobia. The purpose of desensitization therapy is to teach the client to use relaxation techniques to overcome the anxiety caused by the phobia. The nurse should recognize the client's lack of anxiety when thinking about the phobia as a positive response to the therapy.

A nurse is caring for a client who has asthma and has been taking montelukast for 1 month. Which of the following findings should indicate to the nurse that the client is complying with this medication regimen?

The client takes the medication once daily at bedtime. Montelukast, a leukotriene modifier, is taken once daily at bedtime for maintenance.

A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

The nurse administered insulin lispro to a client who has diabetes mellitus and is NPO. Lispro is a rapid-acting insulin given with or just after meals because the onset of action is 15 to 30 min after administration. A client who is NPO will not receive a meal and can have a potentially serious drop in blood glucose levels. Therefore, the nurse should complete an incident report after ensuring the safety of the client and notifying the client's provider.

A nurse is assisting with the care of a client in the emergency department (ED). Exhibit 1 Nurses' Notes 0600: Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke this morning on the living room floor trembling and flushed; remembers having intense dreams and was afraid they had a seizure so called a family member to bring them to the ED.Th

The nurse is contributing to the plan of care for the client. Select the 5 actions the nurse should implement. When generating solutions or planning care for a client who is experiencing alcohol withdrawal, the nurse should plan interventions that keep the client safe and treat the physical complications of alcohol withdrawal. The nurse should use the CIWA-Ar screening tool to determine the severity of withdrawal. Withdrawal seizures can occur 12 to 24 hr after cessation of alcohol use; therefore, the nurse should initiate seizure precautions to prevent client injury. The nurse should plan to administer chlordiazepoxide, a benzodiazepine, to decrease agitation, hallucination, and tremors. The nurse should place the client in a quiet environment with minimal stimuli to decrease agitation and the risk for seizures. The nurse should administer thiamine to prevent or treat Wernicke encephalopathy.

A nurse is assisting with the care of a client who is pregnant in the acute care setting. Exhibit 1 Nurses' Notes1400: Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied.1430: Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity. FHR: 150 to 155/min, moderate variability, adequate accelerations present, no decelerations noted. Pr

The nurse reviews the data at 1800. Which of the following actions should the nurse plan to take? Complete the following sentence by using the lists of options. The nurse should first address the client's respiratory rate , followed by the level of consciousness When prioritizing hypotheses, the nurse should recognize that magnesium sulfate is a central nervous system depressant that can affect respirations, consciousness, and reflexes when toxic blood levels occur. Using the ABC priority-setting framework, the nurse should plan to first take action to support respirations, followed by an action to increase the level of consciousness. The nurse should plan to discontinue the magnesium sulfate infusion and administer calcium gluconate as an antidote.

A nurse in a pediatric clinic is collecting data from a toddler. Which of the following findings should the nurse identify as a possible indication of physical neglect?

The toddler is inadequately dressed for the weather. Inappropriate dress is a suggestive finding of physical neglect. The nurse should collect further data for other indicators of physical neglect.

A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

Tomatoes The nurse should recommend tomatoes, which are a food source that is high in vitamin C.

A nurse is contributing to the plan of care for a client who has a continent urinary diversion. Which of the following interventions should the nurse plan to implement to facilitate urinary elimination?

Use intermittent urinary catheterization for the client at regular intervals. A continent urinary diversion contains valves that prevent urine from exiting the pouch. Therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client's pouch.

A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching?

Walk for 1 to 2 hr each day. The nurse should instruct the client to walk for at least 1 to 2 hr per day after surgery to promote venous return.

A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client?

Walking outside with a staff member During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse should include physical activity, such as walking, in the plan of care. Additionally, the one-on-one nature of the activity provides the client with a sense of security.

The nurse is reviewing the client's medical record. Exhibit 1 Data Collection​ 1400: Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lowe

Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply. When analyzing cues for a postoperative adolescent, actions the nurse should take include elevating the adolescent's affected limb at chest level, monitoring neurovascular status every hour, and removing the indwelling urinary catheter when it is no longer indicated. The nurse should elevate the affected limb at chest level to reduce edema. Neurovascular monitoring should be performed every hour for the first 24 hr post-surgery for immediate recognition of neurovascular compromise. For clients who have an indwelling urinary catheter, evidence-based practice indicates the catheter should be removed as soon as possible or within 24 hr if no longer indicated.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Wipe the drainage port with an antiseptic wipe after emptying urine from the bag. To prevent the spread of infection when emptying the drainage bag, the nurse should cleanse the client's drainage port with an antiseptic wipe to remove any residual urine prior to securing the spout back in place.

A nurse is performing a dressing change for a client who is 3 days postoperative. Which of the following findings should the nurse report to the provider?

Yellow-green drainage at the incision line Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse should report this finding to the provider.