RN Comprehensive Online Practice 2023 A

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."

A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give?

"There's a protocol for reviewing your medical record, and I can initiate the process."

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.

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

Ensure that the client understands the medication regimen.

A nurse is preparing to administer 2 units of fresh frozen plasma to a client. Which of the following should the nurse plan to take?

Enter the plasma product number into the client's medical record.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?

Fever unresponsive to antipyretics

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

Fiber

A nurse is caring for a client who is 1 hr postpartum. Select the 6 actions the nurse should take.

Firmly massage the uterine fundus. Administer methylergonovine. Weigh the perineal pads. Provide emotional support. Insert indwelling urinary catheter. Administer oxygen.

A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering?

Flumazenil

A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first?

Gather more information about the staff nurse's actions.

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

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

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.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?

Making a list of activities to complete

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

Monitor the client's mouth every 8 hr.

A nurse is caring for a client. 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

A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. which of the following findings should the nurse include in the teaching?

Nausea

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.

A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect?

Partial-thickness skin loss

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.

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

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

Platelet count Hemoglobin

A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan?

Provide a staff member to stay with the client continuously.

A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging?

Rapid decrease in blood pressure

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

Rapid speech

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication?

Reduce environmental stimuli.

A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Seizures Blood pressure

A nurse working on an inpatient mental health unit is caring for a client who is experiencing active suicidal ideations. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?

Serve meals with plastic utensils.

A nurse is providing teaching to a client who is scheduled for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?

Short-term memory loss

A nurse is 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

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?

The time of the client's last dose of pain medication

A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?

"Tell me more about your understanding of the options."

A 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."

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."

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

"I will provide you with information about medical treatment to include in your living will."

A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make?

"It seems like you feel your visits are a waste of time."

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?

"My child has only a small amount of mucus after percussion therapy."

A nurse is providing 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."

A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make?

"When crusts have formed on every lesion."

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."

A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain

A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism?

A client who channels their energy into a new hobby following the loss of their job

A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include?

Empty the appliance when it is one-third to one-half full.

A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant?

Absence of symptoms

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer high-dose antibiotic therapy.

A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?

Agency for Healthcare Research and Quality

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

Allow for frequent rest periods throughout the day.

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

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider?

Axillary temperature 36.2C (97.2F)

A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?

Check the insulin dose with another licensed nurse.

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Arrange the lunch tray for a client who has a hip fracture.

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

Ask another nurse to witness the disposal of the new patch.

A 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.

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?

Aspirate contents from the tube and verify the pH level.

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.

A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care?

Avoid venipunctures when possible.

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

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted births?

Cervical laceration

A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?

Check the client's oxygen saturation level.

A nurse is 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

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?

Continue observing the fetal heart rate.

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

Decreased central vision

A nurse is caring for a client who has potassium level of 3 mEq/L (3.5 to 5 mEq/L). For which of the following manifestations should the nurse monitor?

Decreased deep tendon reflexes

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend?

Diced steamed carrots

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.

Discontinue the IV medication. Administer 0.9% sodium chloride IV. Administer epinephrine IM. Monitor vital signs frequently.

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend?

Double-bag soiled dressings in plastic bags for disposal.

A nurse in a provider's office is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Complete the following sentence by using the lists of options.

Dropdown 1: Delayed wound healing Dropdown 2: Glucose level

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

Dropdown 1: Hemorrhage Dropdown 2: Thrombocytopenia

A nurse is providing phone advice for a client who is pregnant. Complete the following sentence by using the lists of options.

Dropdown 1: Metabolic acidosis Dropdown 2: Weight loss

A nurse is caring for a client who is in the spinal cord injury (SCI) unit. Complete the following sentence by using the list of options.

Dropdown 1: Oxygen saturation Dropdown 2: Urinary output

A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?

Edema

A nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Elevate the affected leg.

A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis?

Hematuria

A nurse is assessing a client who is scheduled for surgery. Click to highlight the assessment findings that the nurse should notify the provider about prior to the procedure.

Hemoglobin level Allergies Family history

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

Implement fall precautions for the client.

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Increase the client's dietary iron intake.

A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?

Increased opacity of the lens

A nurse on a mental health unit is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Initiate suicide precautions - Anticipated Potassium 40 mEq PO daily - Anticipated Low-sodium diet - Contraindicated Fluoxetine 20 mg PO daily - Contraindicated

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

Insert a lubricated gloved finger and advance along the rectal wall.

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.

A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Strict adherence to routines

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

Stroke the infant's cheek.

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Support the client's left arm on a pillow while sitting.

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

Take the medication 15 min before playing sports.

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.

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

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. For each assessment finding, click to specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis. Each finding may support more than one disease process.

Temperature - Crohn's disease, Ulcerative colitis, and Peritonitis. Weight - Crohn's disease, and Ulcerative colitis. Bowel pattern - Crohn's disease. WBC - Crohn's disease, Ulcerative colitis, and Peritonitis. Heart rate - Peritonitis. Albumin level - Crohn's disease, and Ulcerative colitis. Abdominal pain - Crohn's disease.

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

Tension pneumothorax

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene?

The LPN and the AP grasp the client under their arms to lift him up in bed.

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

The client is pacing around the chair in which their partner is sitting.

A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse?

The client needs assistance when transferring from the bed to a wheelchair.

A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and 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.

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

Time the medication was given

A nurse is 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.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?

Use a reward system to modify the child's behavior.

A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

Wheezing

A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take?

Withhold the heparin infusion.

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

aPTT