RN Comprehensive Online Practice 2019 A with NGN

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

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

A nurse is caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging?

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

A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first?

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

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

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

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect?

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

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

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

A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching?

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

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

"I will bend at my knees when picking an object up off the floor." Rationale: The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object.

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

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

A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching?

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

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?

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

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

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

A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?

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

A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching?

"Set your hot water heater temperature at or below 120 degrees Fahrenheit." Rationale: The nurse should instruct the client to set the maximum hot water temperature to no more than 49° C (120° F). The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn.

A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I am not tired." Which of the following statements by the parents indicates an understanding of the teaching?

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

A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make?

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

A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter without a pressure-sensitive valve. Which of the following information should the nurse include in the teaching?

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

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

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

A nurse is preparing to administer heparin 5,000 units subcutaneously. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5

A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.6

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference?

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

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?

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

A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first?

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

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

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

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

Administer epinephrine IM. Administer 0.9% sodium chloride IV. Discontinue the IV medication. Monitor vital signs frequently. Rationale: When taking actions for a preschooler who is experiencing an anaphylactic reaction, the nurse should discontinue the IV medication, administer 0.9% sodium chloride IV, administer epinephrine IM, and monitor vital signs frequently. Because the nurse administered ceftriaxone, the nurse should discontinue the cause of the reaction; in this case, it is the IV medication. Administering 0.9% sodium chloride IV will help restore fluids, as fluid shifts can occur quickly during a reaction. Administering epinephrine IM is the first line of therapy for anaphylactic reactions because it constricts blood vessels and dilates bronchioles. Monitoring vital signs frequently will allow the nurse to monitor for signs of shock.

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

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

A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for pain control, and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information?

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

A nurse working on a medical-surgical unit receives a telephone call requesting the status of a client from an individual who identifies themself as the client's parent. Which of the following actions should the nurse take?

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

A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first?

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

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

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

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

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

A nurse is caring for a client who is receiving a transfusion of packed red blood cells (RBCs). The nurse should suspect a transfusion reaction based on which of the following assessment findings? Select all that apply.

Back pain Headache Anxiety Rationale:When analyzing cues, the nurse should identify that the assessment findings of back pain, headache, and anxiety can be indications of a possible hemolytic transfusion reaction. Other manifestations of a hemolytic transfusion reaction include fever, chills, chest pain, tachycardia, dyspnea, and hypotension.

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

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

When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort?

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

A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse?

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

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

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

A nurse is caring for a child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

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

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?

Place the skin barrier over the stoma and hold it for 30 seconds.

A nurse is caring for a client who has schizophrenia in an inpatient facility. Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Client has involuntary tongue movement and foot tremor. Client reports an increase in urination and had one episode of incontinence. Family noticed increased agitation and delusions. Rationale: 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 side 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 in a provider's office is caring for a client. Which of the following provider prescriptions should the nurse anticipate for this client? Select the 4 prescriptions the nurse should anticipate.

Collect urine specimen for urinalysis. Collect urine specimen for urine culture. Educate client on new prescription for sulfamethoxazole/trimethoprim. Educate client on new prescription for phenazopyridine. Rationale: When analyzing cues, the nurse should anticipate provider prescriptions to collect urine specimens for urinalysis and urine culture and to educate the client on new prescriptions for sulfamethoxazole/trimethoprim and phenazopyridine. The nurse should identify that the client is most likely experiencing a urinary tract infection (UTI). UTIs are diagnosed through urinalysis and urine culture. Clients experiencing a UTI should be prescribed an antibiotic and an analgesic for urinary pain relief and frequency.

A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information?

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

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

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

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

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

A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate?

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

A nurse is preparing to perform an intermittent urinary catheterization for a client who has urinary retention. Which of the following images indicates the catheter the nurse should use?

D Rationale: This is a straight urinary catheter, which should be used to perform an intermittent catheterization for a client who has urinary retention.

A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?

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

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

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

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

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

A nurse on a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take?

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

A nurse is caring for a 1-month-old infant. Complete the following sentence by using the lists of options.

Dropdown 1: Dehydration Dropdown 2: Vomiting Rationale: When prioritizing hypotheses and using the urgent vs. nonurgent priority framework, the nurse should identify that the infant is at the greatest risk for developing dehydration due to a loss of gastric content from vomiting. An infant with pyloric stenosis presents with projectile vomiting after feeding, distended abdomen, and olive-shaped mass in the epigastrium.

A nurse is caring for a client who has a new diagnosis of anorexia nervosa. Complete the following sentence by using the lists of options.

Dropdown 1: Electrolyte imbalance Dropdown 2: Fear of weight gain Rationale: 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 in a provider's office is caring for a client. Complete the following sentence by using the lists of options.

Dropdown 1: Pyelonephritis Dropdown 2: Urinalysis results Rationale: The nurse should determine that the priority hypothesis is the client is at the highest risk for developing pyelonephritis as evidenced by the client's urinalysis results. The urinalysis indicates dark cloudy urine, increased specific gravity, increased pH, increased red and white blood cells, positive nitrites, positive leukocytes, and trace amounts of blood, which indicate a urinary tract infection (UTI). If left untreated, a UTI can lead to pyelonephritis.

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care?

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

A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take?

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

A nurse in a provider's office is caring for a client. The nurse is assessing the client. Which of the following assessment findings should the nurse report to the provider?

Frequency Dysuria Urgency Rationale: When recognizing cues, the nurse should identify that the client's report of frequency, dysuria, and urgency are manifestations of a UTI and should be reported to the provider. These manifestations occur due to bacteria invading the urinary tract through the urethra.

A nurse in a provider's office is caring for a client. The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instructions should the nurse plan to include?

Gently cleanse the perineum before intercourse. Rationale: When generating solutions, the nurse should educate the client on how to prevent future UTIs by cleansing the perineum prior to intercourse. During intercourse, bacteria from the skin can enter the urinary tract, causing infection.

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

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

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

Hemorrhage thrombocytopenia Rationale: When analyzing cues, the nurse should recognize that the client is experiencing thrombocytopenia and is at risk for hemorrhage due to low platelet count. The client is experiencing bleeding from their nose that is not resolving with pressure being applied. Petechiae of the arms is a manifestation of thrombocytopenia. Chronic alcohol use disorder increases the risk for hemorrhaging due to the inability of the liver to assist with platelet formation.

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor?

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

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

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

A nurse is caring for a 5-year-old child. Complete the diagram by dragging from the choices below to specify what condition the child is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the child's progress.

Initiate droplet precautions. Request a prescription for IV antibiotics. Epiglottitis Temperature Breath sounds Rationale: The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottitis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds.

An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN?

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

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

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

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take?

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

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Keeps the head of the bed elevated to 45 degrees for 1 hr after feedings Rationale: The nurse should keep the client's head elevated to 30° to 45° for 1 to 2 hr after feedings to decrease the risk for aspiration.

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

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

A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first?

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

A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first?

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

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

Monitor the client's physical manifestations. Assess the client for a secondary gain from illness. Somatic symptom disorder Vital signs Pain Rationale: Upon recognizing and analyzing the client's assessment findings, such as joint pain and physical inactivity, the nurse's priority hypothesis should be that the client is most likely experiencing somatic symptom disorder. It is essential to generate solutions and take actions by monitoring the client's physical manifestations and assess for the presence of secondary gains from their illness. Somatic symptom disorders are characterized by the presence of many real physical manifestations like dizziness, nausea, back pain, and joint pain. The nurse should evaluate and monitor the client's vital signs and pain.

A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take?

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

A nurse is assessing a client who is 2 hr postoperative following a cardiac catheterization. Which of the following information should the nurse report to the provider?

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

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

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

A nurse is caring for a client in the inpatient psychiatric unit. Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

Observe the client swallowing all prescribed medications. Provide one-on-one observation. Assess the client's method of lethality. Ensure the client does not have access to sharp objects. Rationale: When taking actions, the nurse's primary concern should be the client's safety. The nurse should observe the client swallowing all prescribed medications to confirm they are not hoarding pills; provide one-on-one observation; assess the client's method of lethality by discussing the client's suicide plan; ensure the client does not have access to sharp objects, including silverware; and also ensuring that all windows and exit doors are locked.

A nurse is caring for a client in the emergency department (ED). The nurse is planning care for the client. Select the 5 actions the nurse should plan to take.

Perform a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Initiate seizure precautions. Administer chlordiazepoxide. Maintain a low-stimulation environment. Administer thiamine. Rationale: When generating solutions and planning care for a client who is experiencing alcohol withdrawal, the nurse should plan interventions that keep the client safe and treat the physical manifestations 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, hallucinations, 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 Wernicke syndrome.

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan?

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

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

Platelet count Hemoglobin Rationale: The nurse should determine that the priority findings are the decreased platelet count and decreased hemoglobin, which should be reported immediately to the provider. Using the urgent vs. nonurgent framework, the nurse should determine that a platelet count of less than 20,000/mm3 and a hemoglobin of less than 7 g/dL are critical values and indicate the client is at increased risk for spontaneous hemorrhage and anemia.

A nurse is caring for a client who is on the spinal cord injury (SCI) unit. Drag words from the choices below to fill in each blank in the following sentence.

Pneumonia Autonomic dysreflexia Rationale: The nurse should analyze cues from the client's manifestations and determine that the client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who has a cervical SCI is at risk for respiratory complications because spinal innervation to the respiratory muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally and a decrease in oxygen saturation to less than 92% can indicate pneumonia. The client's sudden increase in blood pressure, bradycardia, flushing of the skin above the area of the injury, headache, and blurred vision are manifestations of autonomic dysreflexia, which can be a life-threatening condition.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump?

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

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first?

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

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect?

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

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

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

A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Remove the inner cannula. Remove the soiled dressing. Clean the stoma with 0.9% sodium chloride irrigation. Change the tracheostomy collar. Rationale:When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the soiled dressing and then clean the stoma with 0.9% sodium chloride irrigation. Finally, the nurse should instruct the parent to change the tracheostomy collar.

A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first?

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

A nurse is caring for a newborn. Complete the following sentence by using the lists of options.

Respiratory rate Heart rate Rationale: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 assess the newborn's respiratory rate, followed by the heart rate. The nurse should perform noninvasive assessments, such as observing the respiratory rate, before more invasive assessments that might stimulate the newborn, such as auscultating the heart rate, to avoid alteration of data.

A nurse is caring for a client who is pregnant in the acute care setting. The nurse reviews the assessment data at 1800. Which of the following actions should the nurse plan to take? Complete the following sentence by using the lists of options.

Respiratory rate Level of consciousness Rationale: 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 airway, breathing, circulation priority framework, the nurse should plan to first take action to support respirations, followed by action to increase the client's level of consciousness. The nurse should plan to discontinue the magnesium sulfate infusion and administer calcium gluconate as an antidote.

A nurse is caring for an adolescent in the emergency department (ED). The nurse is reviewing the adolescent's electronic medical record (EMR). Which of the following findings requires immediate follow-up by the nurse? Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Skin assessment Temperature WBC count Casual blood glucose Potassium Rationale: 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 assessment reveals that the medial lateral aspect of the left leg has a 3 x 3 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 also 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 on these findings because they can indicate infection or other complications.

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

Skin breakdown An infection Rationale: When recognizing cues, the nurse should identify that the child is at risk for developing skin breakdown and infection due to the gastrostomy tube site. The gastrostomy tube site is red and there is drainage from the site, which could lead to skin breakdown. The child has also developed a fever, which could indicate infection.

The client returns to the provider's office 3 days later. Click to highlight the findings that indicate the client's urinary tract infection is improving. To deselect a finding, click on the finding again.

Specific gravity pH WBC Rationale: When evaluating outcomes, the nurse should identify that the client's urinary tract infection (UTI) is improving as evidenced by the client's urine specific gravity, pH, and WBC results. These findings are within the expected reference ranges and indicate that the medication has been effective in treating the UTI.

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

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

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

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

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

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

A nurse is assessing a newborn who is 3 days old. Click on the findings that require follow-up. To deselect a finding, click on the finding again.

Temperature 36.4C (97.5F) 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. Client reports nipple discomfort throughout the feeding. Rationale: 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.

The client returns to the provider's office 3 days later. Which of the following assessment findings should the nurse report to the provider as unexpected? For each Assessment Finding, click to specify if the finding is expected or unexpected.

Temperature, skin, and bowel elimination - Unexpected Urine color, voiding pattern, oxygen saturation, and blood pressure - Expected Rationale: When taking action, the nurse should identify that the client's urine color, voiding pattern, oxygen saturation, and blood pressure are expected findings and do not need to be report to the provider. The client's report of orange urine is an expected finding due to the prescribed medication phenazopyridine, which can cause reddish-orange discoloration of urine. The client's voiding pattern is an expected finding due to increased fluid intake of 3 L daily. The client's oxygen saturation is an expected finding due to the client's history of COPD. The client's blood pressure is an expected finding due to the client's history of hypertension. The nurse should identify that the client's temperature, skin, and bowel elimination are unexpected findings and should be reported to the provider. The client's temperature is above the expected reference range, which can be an indication of Clostridium difficile. The client's diarrhea can also be an indication of C. difficile. The client's unexpected bruising can be an indication of Stevens-Johnson syndrome. C. difficile and Stevens-Johnson syndrome are potential side effects of trimethoprim/sulfamethoxazole.

A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority?

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

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

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

A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene?

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

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

Use 0.9% sodium chloride for irrigation of the NG tube. Rationale: The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube.

A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include?

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

A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine?

WBC count 2,800/mm3 Rationale: Clozapine can cause agranulocytosis, which can be life-threatening. Therefore, a WBC count of less than 3,000/mm3 is a contraindication for the client to receive clozapine. The nurse should withhold the medication and notify the provider of the client's WBC count.

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan?

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