study this

A nurse is planning for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?

Auscultate for bruit in the left arm every 4 hours

A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?

Auscultate the client's left arm for a bruit every 4 hr

A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching?

Avoid foods that have high levels of oxalates.

A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take?

Begin prophylactic treatment with ciprofloxacin

*A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care?

Restrict protein intake to the RDA.

A nurse is caring for a client following insertion of a subclavian prescription to initiate an IV infusion of Ringer's lactate at 150 ml per hr. Prior to starting the infusion, which of the following actions should the nontunneled percutaneous central venous catheter (CVC). The provider writes a nurse take?

Review the chest x-ray report

*A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the following food selections indicates that client understands teaching?

Rice with black beans

A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

Schedule routine care tasks during hours when the client is awake

*A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following?

Schizophrenia

A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? a. A series of four hepatitis vaccines is recommended to prevent viral hepatitis. b. Hepatitis B is transmitted by contaminated food. c. Chronic hepatitis can lead to renal cell cancer. d. Clients who have a history of viral hepatitis are unable to donate blood

Series of four hepatitis vaccines is recommended to prevent viral hepatitis

A nurse is caring for a client who is requesting treatment for a gambling disorder. Which medication should the nurse expect to give?

Sertraline

*bathe four clients, distribute fresh water, and obtain the morning vital signs. At noon the nurse ask the AP to transport one client to physical therapy. The nurse delegate more effectively in the future?

Set a clear timeframe for the completion of each tasks

*The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority finding by the nurse?

Shortness of breath

*A nurse is teaching a client who has low-literacy level about home managements of diabetes mellitus. Which of the following action sis appropriate?

Show the client as educational video

*A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following actions in response take?

Sit at or below the clients eye level during feedings.

*A community health nurse is caring for a client who request a referral for family therapy. The nurse should include who from interdisciplinary team?

Social worker

*A nurse is caring for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS). Which of the following referrals is the nurse's priority?

Speech-language pathologist

A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge?

Start each meal with a protein source

The nurse should include which of the following dietary instructions when preparing the client for discharge?

Start each meal with a protein source

*A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate. Which of the following should the nurse identify as a contraindication to medication?

Glaucoma

A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?

Glycosylated hemoglobin - Ha1c

A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?

Graft-versus-host disease

A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?

Hallucinations

*A nurse on a mental health unit is admitting a client who has posttraumatic stress disorder. Which of the following findings should the nurse expect?

Has difficulty concentrating on a task

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?

Head compression

A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

Healthy weight

A nurse is assessing an adult male client who has BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

Healthy weight (normal BMI is 18.5 to 24.9)

A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?

Heart rate greater than 60/min

A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take?

Heat the skin one minute prior to placing the program

A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, "I don't know how much longer I can take this, but I'm afraid he'll really hurt me if I leave. "Which of the following is an appropriate nursing intervention?"

Help the client to recognize the signs of escalation of abuse behavior

*A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following?

Heroin intoxication

*Nurse managers preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions?

Herpes simplex

A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?

Hold the bottle of sterile solution with the palm over the label while pouring

A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?

Hospice care improves quality of life through palliative care

Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?

Hydromorphone

A nurse is caring for a client following an open colectomy. Which findings place the client at risk for delayed wound healing?

Hyperemesis

A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?

Hyperreflexia

Contraindication to methylergonovine?

Hypertension

*A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor?

Hypnosis promotes increased control of her pain perception during contractions

*A nurse is caring for a client who has hypertension and a new prescription for chlorthalidone. The nurse should monitor for which of the following adverse effects?

Hypokalemia

*Adolescent who has anorexia nervosa. What lab to check?

Hypokalemia

A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? Hypotension Tachycardia Muscle cramps Hyperreflexia

Hypotension

A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?

I should place a rolled blanket along each side of my baby's head in the car seat

*A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation?

I think that people just think you're just lazy and should earn money honestly

*A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan?

I understand I may experience difficulty sleeping on this medication

*A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone following client statements indicates need for further teaching?

I understand the methadone may cause me to have difficulty sleeping

A nurse is caring for a client who is receiving systematic therapy to treat agoraphobia. Which of the following client statements should indicate to the nurse that the treatment has ben effective?

I was able to sit on a park bench for 30 minutes

*A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?

I will avoid food and beverages that contain caffeine

*The nurses providing discharge instructions about engorgement for client has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction by the nurse?

I will manually express breastmilk

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching?

I will take this medication with 8 ounces of water

A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective?

I will use my cell phone on the ear opposite of my pacemaker

*A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response?

I'd like to know more about what's bothering you."

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

Immobilizing the affected extremity

A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

Improve joint functioning.

A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which statement should the nurse manager include in the teaching?

Include the complete name of the medication Morphine Sulfate

*receiving lasted Ringer's to treat fluid volume deficit. Indicates a therapeutic response to the treatment

Increased blood pressure

At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of client reports. Which should the nurse assess first?

Indigestion

At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Indigestion

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? Inform the client of available community resources. Assist the client in finding child care options. Agree upon short term goals for the client. Ask the client about their understanding of the diagnosis.

Inform the client of available resources

*A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take?

Inform the client of the risks involved if she leaves.

A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

Infuse 0.9% sodium chloride IV

*The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the following instructions is appropriate for the nurse to include in the plan of care?

Initiate droplet precautions for the client

A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?

Inject the medication in the lateral abdominal wall Version 2: "Insert the syringe halfway into the client's skin"

*A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleed. Which of the following actions should the nurse take?

Insert a large bore NG tube

A nurse delegates tasks to a LPN and AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Insert an indwelling catheter if the client has not voided in 3 hr (other ans: Measure the amount of gastric drainage every 2 hr)

*A nurse is caring for a client who has a femur fracture and is on bed rest with Buck's extension traction. Which of the following actions should the nurse take?

Inspect the client's skin under the device every 8 hours

A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan?

Iodine

A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed Which should the nurse recommend the client increase in their diet during lactation?

Iron !! (NOT calcium or Vit D apparently....)

*The nurse is completing an assessment for newborn who is 2 hrs old. Which of the following findings are indicative of cold stress?

Jitteriness of the hands

*A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take?

Keep a 3 foot distance from the radiation implant

*A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?

Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection)

*A nurse is assisting the provider with a paracentesis for a client who has ascites. Following collection of the specimen, which of the following actions should the nurse take next

Label the specimen.

A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview?

Lean in slightly when speaking to the client

A nurse is planning care for a client who has Alzheimers disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

Leave one side rail up on the clients bed.

*A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease. Which of the following positions should the nurse place the client to best promote optimal cardiac output?

Left lateral

*A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

Lipsmacking

The nurses assessing client with posttraumatic stress disorder. Which of the following findings to the nurse expect to find?

Loss of interest in usual activities

*A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV fusion. Which of the following should be reported to the provider

Mag levels 9mEq/L

A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients often agitated and frequently wanders the halls. Which of the following intervention should the nurse include in the plan of care?

Maintain Nutritional requirements by offering finger foods

*Child instillation of eye drops?

Maintain the child in sitting position 3 minutes after

A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care?

Maintain the head at a midline position

A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client

Maintains 3 to 4 finger width between the crutch pad and axilla

A nurse is reviewing the employee health program for new employees. Which assessment should the nurse recommend for all new employees to screen for the presence of TB?

Mantoux test (key word: screening)

A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

Massage the fundus.

*A nurse is completing a dietary assessment for a client who is Jewish and observe kosher dietary practices. Which of the following behaviors would the nurse expect to find?

Meat and dairy products are eaten separately

A nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of the following medications to the nurses instruct the client to discontinue 48 hrs prior to the procedure?

Metformin

*A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identify that which of the following medications is contraindicated?

Methylergonovine

A nurse is caring for a client who has cirrhosis of the liver. Which action should the nurse take?

Monitor for abdominal ascites

*A nurse is assessing a full term newborn who is 24 hr old. What should be reported to the provider?

Newborn neck is short and surrounded by skin folds (other ans: sclera has yellowish tiny - pathological within 24 hours)

*A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following?

Stroke

*A nurse is caring for a preschool-age child who has a short-leg plaster cast applied 1 hr ago. Which is an appropriate intervention?

Support the affected leg on a pillow

A nurse is monitoring the client during an IV urography procedure. Which of the following client reports is the priority finding?

Swollen lips

*CDC report (list 3)

Syphilis, Lyme Disease, and Hep A

*A nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears agitated and apprehensive. The nurse identifies that the client is in the alarm stage of general adaptation syndrome and should expect which of the following findings.

Tachycardia

Pancrealipase should be taken when?

Take with meals

*A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following should the nurse include in the assessment?

Tell me how often do you drink alcohol

*A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the clients name and discussing details of his diagnosis. Which of following actions should the nurse take first?

Tell the AP to discontinue their conversation

*A nurse is preparing to administer an enteral feeding via NG tube for a client the day after verifying placement of the tube using chest x-ray. Which method should the nurse use to confirm placement prior to initiating feeding?

Test pH level from client gastric aspirate

A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indications that the client is in the latent phase of labor?

The cervix is dilated 2 cm

A nurse is performing high frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective?

The child has increased sputum production

*A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include?

The client can administer a dose of medication every 6 to 8 min.

A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority?

The client has surgical hypoparathyroidism and positive Trousseau's sign

A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking the supplement?

The client takes aspirin daily

*A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox?

Rash in the mouth

*A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which of the following is a contraindication for administration?

Recent blood transfusion

*neutropenia about food safety to prevent food borne illness

Refrigerate leftover with 2 hrs

*A nurse is caring for a client who is postoperative following a hip arthroplasty and notes the dressing is saturated with sanguineous drainage. Which action should the nurse take?

Reinforce the dressing with sterile gauze

A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following actions should the nurse include in the plan of care?

Remind the client to place the cane on the unaffected side

A nurse is planning care for client to prevent complications of immobility. With the following actions should the nurse including the plan of care?

Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.

*A nurses is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

Remove elbow splints periodically to perform range of motion

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

Rephrase sentences the client does not understand

*A nurse is caring for a client who is racing a controlled epidural analgesia infusion. Which of the following nursing action is appropriate?

Replacing the infusion tubing every 72 hrs

A nurse is assessing a client who was brough to the ED by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

Report the incident to Adult Protective Services

A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take?

Report to the nurse manager

*Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

*A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescence client who was admitted for treatment of anorexia nervosa. Which of the following is an appropriate short-term goal the nurse should set?

The client will reach an appropriate body weight (other ans: The client will gain 2 to 3lbs weekly)

*A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately?

The clinic experiences coughing and wheezing after eating.

*A nurse is caring for a client who has fractured ribs, has developed thrombophlebitis and is being treated with a heparin drip. The client develops hematuria and has an aPTT of 100 seconds. Which action should the nurse take first?

Turn off the heparin drip

The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication?

Uric acid level

Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following findings requires further assessment by nurse?

Urinary output greater than fluid intake

*A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings indicate medication toxicity?

Urine output 20 ml/hr

*A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

Urine output of 20 mL per hour

A nurse is caring for a client who is at high risk for developing DI following a severe head injury. Which assessment finding indicate to the nurse that the client is developing DI?

Urine output of 250 mL/hr

A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

Urine specific gravity 1.001

A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? A wear an N95 B. Insert an in dwelling urinary catheter to monitor urinary output C. Monitor vital signs every 8 hours D . Use a dedicated stethoscope

Use a dedicated stethoscope for the client

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? Wear an N95 respiratory mask while caring for the toddler. Place the toddler in a room with negative air pressure. Use a designated stethoscope when caring for the toddler. Remove the disposable gown after leaving the toddler's room.

Use a designated stethoscope when caring for the toddler

A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder?

Uses others for personal gain

*A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI?

Using perfumed toilet paper

Safest intramuscular site in adults

Ventrogluteal site

A nurse discovers that the wrong dosage of medication was given to client. When determining what action to take you should recognize that which of the following ethical principles should be applied?

Veracity

A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Viewing the newborn's actions to be uncooperative

*Manifestations of food allergies

Vomiting

*The nurses is caring for a client recovering from an acute myocardial infarction. Which of the following laboratory values should nurse report to provider?

WBC 3,000/mm3

A nurse is planning care for client sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Wear a dosimeter film badge while in the client's room

A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should nurse monitor?

Weight

A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication? Decreased reflexes Weight gain of 1.4 kg (3 lb) Oyincreased urinary output Jugular vein distention

Weight gain of 1.4 kg (3 lb)

*A nurse caring for a client who is receiving total parental nutrition. Which of the following assessment findings required immediate intervention by the nurse?

Weight increase of two kg/day

A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective?

Weight loss

*A nurse is teaching a client about smoking cessation. Which of the following client statements should the nurse identify as an understanding of teaching?

Will use high carbohydrate snacks as a substitute for cigarette.

A nurse is caring for a male adolescent client who has heart failure. Based on the client's chart finds. Which of the following actions should the nurse plan to take?

Withhold digoxin (0.8-2.0)

*A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should nurse take?

Withhold heparin IV infusion

*A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following?

Works on several tasks simultaneously

*A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate?

You appear to be feeling overwhelmed"

*A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate?

You should receive Rh immune globulin within 72 hours of delivery."

A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter line. Which of the following information should the nurse include in the teaching?

Your PICC line will allow long-term access for antibiotic therapy

*A home health nurse is teaching the parents of a school age child who has legg-calve-perthes disease. Which of the following information should the nurse include

Your child should continue to attend school

*A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following client should the nurse assess first?

a client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago

A nurse is assessing a client wasn't following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure?

a) Systolic presssure subtracted by diastolic pressure (132 - 40) = 92

A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? Beef liver Egg whites Steamed clams Broiled lobster

Egg whites

*A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication?

Eggs

A nurse is caring for a client who is receiving total parenteral nutrition. For which of the following findings should the nurse monitor as a potential complication of TPN?

Electrolyte imbalance

*A nurse is administering medications to a client who has dysphagia and a new prescription for divalproex sodium extended release tablets. Which of the following actions should the nurse take?

Administer the medication with applesauce

*A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care?

Elevate the client's affected extremity when in bed

A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

Elevated pulmonary artery pressure (other ans: hepatosplenomegaly)

A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation?

Administers PO analgesia 20 minutes prior to irrigation

*A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP?

Administrative oral fluids to client with dysphasia

A home health nurse is teaching a guardian about administering tube feedings to their 3-month old infant. Which info should the nurse include in the teaching?

Allow the infant to suck on a pacifier during feedings

*bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemo.

Allow the sibling to wave at the client through the window of the door

Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation?

An older adults who has difficulty taking in fluids

*A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take?

"Apply the tourniquet 15 cm (6 in) above the insertion site

*A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching?

"Carbohydrates should be at least 45% of your caloric intake."

*A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take home. Which of thee following responses should the nurse make?

"I will call the pharmacist now to check on this medication"

*A nurse is providing discharge instructions for a client who has a new prescription for furosemide. Which of the following client statements indicates a need for further teaching?

"I will limit my intake of fish."

A nurse is caring for a client who has schizophrenia. The nurse should expect to exhibit which of the following manifestations?

- Repeats the word of others when speaking - Speaks in word salad - Has a blunt affect - Experiences delusions

*A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching?

"If I eat 500 fewer calories per day, I should lose 1 pound per week."

A nurse is giving discharge instruction to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states

"My stoma will drain liquid fluid continuously"

A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which findings should the nurse report to the provider?

"No bowel movement for 3 days"

Mastitis of the left breast

"No, you can continue to nurse from both your breast"

A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply

-Apply direct pressure to bleeding wounds-cover wounds with a sterile dressing-determine date of last tetanus toxoid vaccination

*A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task?

"Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic level less than 90."

A charge nurse overhears two AP in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

"Pease stop this discussion."

A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? A. The gastric residual volume is 250 mL following two hours of infusion. B. The client is lying in a supine position. C. The infusion pump for administering continuous feeding is turned off. D. Interior feeding bag and tubing are not dated.

"The infusion pump for administering continuous feeding is turned off"

*A nurse is teaching a client who is at 35 week of gestation about amniocentesis. Which of the following statements should the nurse include in the teaching?

"You should monitor for the onset of contractions after the test"

*A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? Select all that apply

-I have the right to refuse treatment -My health care proxy can make medical decisions for me

Insertion of indwelling catheter steps

1. Apply sterile gloves and place cleansing balls in antiseptic solution 2. Attach prefilled syringe to indwelling catheter inflation hub 3. Lubricate the catheter and place fenestrated drape over perineum 4. Cleanse the meatus with the dominant hand in a downward motion. 5. Insert the catheter until a flow of urine begins

*obtaining a culture

1. Assess the appearance of the wound 2. Obtain the specimen from granulation tissue of the wound 3. Place the swab in the culture tube. 4. Cleanse the would with 0.9% 5. Cover the wound with a sterile dressing

A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

1800

*A nurse is caring for a client who is post right-modified radial mastectomy. Which of the following should the nurse recognize as a priority finding?

Emesis of 110 mL of thick yellow fluid

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

1 cm of water present in the water seal

Informed consent

1. The client voluntarily give consent 2. The client should understand the treatment plan 3. The client who signs the informed consent form should be competent

A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? SATA

1. The nurse should pad the bony prominences 2. The nurse should remove the restraints every 2 hr. 3. The provider's prescription should include the (type of restraints?)

Making assignment for a float nurse from the medical unit to pediatric floor. What type of patient is appropriate?

10 year old who has pneumonia and is receiving respiratory treatment

*A nurse on an orthopedic floor is completing the morning assessments on several clients. Which client is more at risk for a fat embolism?

24 year old male who has a casted femur fracture

*A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurseplan for cardioversion?

Atrial fibrillation

*levels a depression in the skin 8 mm deep

4+edema

*A nurse is caring for client was GERD. Which of the following assessment findings the nurse expect to find?

Atypical chest pain

Four clients to an emergency department. The nurse should plan to see which of the following first?

50-year old client who has slurred speech, disoriented and reports a headache

Never assign this type of client to a person who is pregnant

60 year old client who is recovering from SHINGLES

*A nurse on a medical unit has received change of shift report. Which of the following clients should the nurse assess first?

A 68 year old client who had a MI 2 days ago and report chest pain on a scale of 4 out of 10.

A nurse manager at a public health clinic is concerned about the rising number of STI. The purpose of which of the following is to generate new ideas to address the public health concern?

A brainstorming session with nurses

An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first?

A child who has a forehead wound that is bleeding copiously

A nurses for Caring for four clients. Which of the following client should the nurse care for first?

A client is hypothyroidism and his stuporous

A nurse manager is reviewing medical records to recommend clients for discharge following a local mass casualty event. Which of the following clients should the nurse recommend for discharge?

A client is scheduled to have a colonoscopy in 12 hours

*A nurse receives report on a group of clients. Which of the following client should the nurse attend to first?

A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10

*A nurse receives change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse place to assess first?

A client who had a hip arthroplasty reports pain and erythema in their calf

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?

A client who had a stroke 2 days ago and needs help toileting

*A nurse in the post anesthesia care unit is caring for four postop clients. The nurse realizes that coughing poses a risk to which of the following clients?

A client who had a thyroidectomy

A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of MRSA. Which of the following information should the nurse include?

A client who has a history of MRSA can still transmit the infection

*A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?

A client who has a traumatic arm amputation

I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first?

A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL

A nurse is performing change of shift assessment for four clients. Which of the following findings should the nurse report to the provider first?

A client who has gastroenteritis and is lethargic and confused

A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? A. A client who uses a diaphragm for contraception and has lost 30lb in the past 6 months dieting B. A client who had an intrauterine device inserted yesterday and has cramping and bleeding C. A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday

A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding

A nurse in a postpartum unit is caring for several clients. After receiving a change of shift report, which of the following clients should the nurse assess first?

A client who is 3 days postpartum and has not had a bowel movement since prior to admission

A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first?

A client who is at 36 weeks of gestations and reports decreased fetal movement for 2 days

*A nurse is delegating task to an AP. Which can the nurse assign to the AP to measure vital signs?

A client who is requesting pain medication 2 days after surgery

*A nurse is planning care for four clients. Which of the following clients is the highest priority?

A client who is wearing an arm cast and reports numb fingers

*A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?

A client who reports tingling in the fingers following a thyroidectorny

*A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations requires completion of an incident report?

A client whose IV pump has malfunctioned

*A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client should the nurse identify as the priority?

A client with indications of hypovolemic shock

*A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?

A client's wrist restraints tied to the bed rails

*The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned?

A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident.

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? Exhibit

Administer pain medication to the client

A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?

Abdominal rigidity

A nurse is assessing an older adult client who had a stroke. Which of the following findings should the nurse recognize as an indication of dysphagia?

Abnormal movements of the mouth

*A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurse to facilities in the client grief process

Acknowledging the reality of the newborn's death

*A nurse is providing teaching to the parent of a 6 month old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include?

Administer acetaminophen drops to your child before bedtime

*The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate nursing action?

Administer oral rehydration solutions.

*A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following prescription is given by the provider should the nurse clarify?

Apply heat to affect extremity for 45 minutes on the 45 is off.

A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse?

Apply sterile gloves. 1296 in med surgical book

A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make?

Art therapist

*A provider has written a do not resuscitate order for a client who is comatose and does not have advance directives. A member of the clients family says to the nurse, "I wonder when the doctor will tell us what's going on" Which of the following actions should the nurse take first

Ask the family what the provider has discussed with them.

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

Assault

A nurse is admitting a client to a med-surg unit. What action should the nurse take first

Assess the clients level of mobility

*A nurse is caring for a female client who has bruises on her arms that she explains are result of physical abuse by her partner.

Assist the client to identify personal behaviors that trigger abusive behavior (IFFY ANSWER)

*A nurse is assessing the vital signs of a newborn who was born 8 hrs ago. Which of the following findings require interventions by the nurse?

Blood pressure of 72/45 mm Hg

*A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Bounding pulse (others: elevated urine specific gravity)

*Placenta previa. What client findings should the nurse include?

Bright red vaginal bleeding

A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make?

Bring the child to the funeral service before visitors arrive

A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication?

Burning

*Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate?

Give the client enalapril 2.5 mg PO twice daily

*A nurse is reviewing the lab report of a client who has a magnesium level of 1.0mEq/L. Which of the following should the nurse expect?

Cardiac dysrrhythmia

A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching?

Change clothes after working in the field

*A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take?

Check for an allergy to eggs

*A nurse is caring for a child who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action?

Check orthostatic blood pressure 1hr after administration

A nurse is caring for a client who is nuliparous and in the first stage of labor. The nurse observes a large gush of fluid coming out the client's perineal area. Which of the following is a priority action by the nurse?

Check the FHR

*A nurse is caring for a client who is who is receiving continuous feeding via NG tube. Which of the following actions would the nurse take?

Check the clients gastric residual every 4hrs

A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?

Chlorine Bleach

A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first?

Clarify the client's actual and perceived health needs

A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture?

Clear fluid drainage from the nares

A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first?

Client placed in restraints to the aggressive behavior

*A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first?

Client was having auditory hallucinations is becoming agitated

A nurse is performing an admission for a client who is to undergo a colonoscopy. Which medication is the priority to report?

Clopidogrel

*A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate?

Collecting urine sample

*A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

Come outside with me for a walk."

A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill?

Completed activities for one client before moving to the next client

*A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, "When the cat's away, the mice will play". The client response was, "The mice come out when the cat is not around". The nurse should document this finding which of the following in the client's chart?

Concrete thinking

A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?

Contractions occur every 90 seconds (it should be every 2-3 minutes)

The nurses reviewing clients admission laboratory results. Which of the findings required further evaluation?

Creatinine 1.8

A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include?

Educating the client how to cover nose and mouth with tissues when coughing

This is assessing clients as had a long arm cast. Which of the following findings of the dress moderate and when assessing for acute compartment syndrome?

Edema

*nurse is caring for a client who will be receiving a transfusion of platelets

Decrease in bleeding from puncture sites

*A charge nurse is discussing the use of applying ice to a client's injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?)

Decreased capillary permeability

A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process?

Decreased sense of taste

*A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take?

Determine if the AP is qualified to perform the test.

Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first?

Determine pain level

*A nurse is caring for a client who has heart failure and potassium level of 3 mEq/L. The nurse should obtain verification of which of the following rx from provider?

Digoxin 0.125 mg

A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which action should the nurse take?

Dim the lights in the room prior to examination

*A nurse is assessing a client who has non-Hodgkin's lymphoma. Which of the following finding should indicate to the nurse that the client might be experiencing syndrome of inappropriate antidiuretic hormone (SIADH)?

Diminished deep tendon reflexes

A nurse is caring for a client who is receiving continuous enteral feedings and report diarrhea. Which of the following actions should the nurse take?

Discard opened cans of formula after 24 hrs

*A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take?

Discontinue oxytocin infusion

A client was having suicidal thoughts tells the nurse "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses for the nurses appropriate?

Do you have a plan to end your life?

*A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?

Do you have any active lesions?

*A nurse is caring for a school age child who has a blood pressure of 68/50 mm Hg and develop sepsis shock. Which of the following medication should the nurse expect to be prescribed?

Dopamine

*A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?

Drink hot water with lemon juice each morning when you wake up

A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first?

Dry the newborn

A nurse is providing teaching to a client who is at 8 week gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include?

Eat a dry carbohydrate before getting out of bed

A nurse is providing teaching to a client who is at 8 weeks of gestations and experiencing episodes of N/V. Which of the following instructions should the nurse include?

Eat a dry carbohydrate before getting out of bed

A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome? Edema Shortness of breath Petechiae Change in mental status

Edema

A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?

Encourage client fluid intake of 2,500 mL daily (Other answer: apply a donut ring pillow) (iffy answer)

*A nurse is reviewing the medical records of four clients. Which of the following prescriptions correct documentation?

Enoxaparin 3 mg SC every 12 hr

*A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing action?

Ensure eye shield is covering the eyes.

*A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. What should the nurse include in the teaching?

Estrogen therapy increase the risk for thrombus formation

A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult?

Evidence-based practice data

During the immediate postoperative period following thoracic surgery, a nurse medicates a client for pain on a schedule. The rationale for this nursing action is which of the following?

Facilitates deep breathing

A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

Faint pedal pulse of left leg

A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?

Fever

A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is EFFECTIVE?

Flat anterior fontanel

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of pulmonary congestions?

Frothy, pink sputum

Concurrent use of gentamicin with what medication increases the risk for ototoxicity?

Furosemide

A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Generalized edema

A nurse is teaching the guardian of an infant who has development dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include?

Gently massage the skin under the straps once per day

*The nurses is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care?

Obtain a cardiac rehabilitation consult

A nurse is preparing to administer an IV bolus of albumin. Which should the nurse take?

Occlude the IV tubing above the injection port

*A nurse is preparing to discharge a newborn who has atrial septal defect. Who should the nurse expect the provider to recommend?

Occupational manager / Case manager

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the AP requires the nurse to intervene?

Offers oral fluids to the client

A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?

Oliguria

A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased BP. What is it?

Opioid intoxication

A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Ototoxicity

A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?

PaCO2 level of 55 mm Hg

A nurse is giving change of shift report about a client who is 36 hr postoperative to another nurse. Which of the following should the nurse include?

Pain relieved by position change

A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

Paradoxical pulse (other ans: substernal chest pain)

A nurse is planning care for a client who has a gambling disorder. Which of the following instructions should the nurse provide to the cilent?

Participate in a 12-step program

*The nurse is caring for a postpartum client who has urinary retention. Which of the following actions should the nurse take?

Perform bladder scan

*Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to

Perform weight bearing exercises

A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

Peripheral neuropathy

A nurse in a pediatric unit is caring for a group of clients. For which of the following disease should the nurse implement droplet precautions?

Pertussis

A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications place the fetus at risk for teratogenic effects?

Phenytoin for seizure disorder

A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings?

Pinna below the outer canthus of the eye

*Home health nurse is carefully planning for Alzheimer's disease. To the following action should the nurse include in the plan of care

Place a daily calendar in the kitchen

*Client who had a CVA. What to perform to prevent foot dropping?

Place positioning boots on the client's feet

A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which action should the nurse take?

Place the client in a low-Fowler's position

A nurse is caring for client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions is appropriate?

Place the client private room.

A nurse planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include? A. Plug the infusion pump in an outlet next to the bathroom B. Pull the cord when unplugging the infusion pump C. Clean the infusion pump when it is turned on D. Place the infusion pump cord against the baseboards

Place the infusion pump cord against the baseboards

A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? A. Clothe the newborn in light cotton. B. Check the newborn's temperature every 8 hr C. Administer 120 mL of water between feedings. D. Place the newborn 45 cm (18 in) from the light source.

Place the newborn 45 cm from the light source

*A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention?

Placing weights as a child's bed

*The nurse is assessing a client is receiving radiation therapy. Which of the following findings should the nurse expect?

Platelets 95,000 mm3

A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? A. Take the client to the bathroom to void B. Ask the client to verify the surgical site C. Review deep breathing and coughing exercises D. Raise the side rails on the bed

Raise the side rails on the bed

A charge nurse overhears two assistive personnel in the unit lobby discussing the HIV status of a client. Which of the following response is the priority for the nurse to make?

Please stop this discussion

A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?

Poor problem solving ability

A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation?

Premedicate the client with the prescribed analgesic

A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection?

Profuse milky white discharge

*A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal syndrome. Which of the following should the nurse include in the plan of care?

Provide frequent orientation to time and place.

A nurse is planning car for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

Provide high-calorie nutritional supplements

*A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention?

Provide standby by assist with the client from bed

A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

Pulse 54/min

A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? A. The infant's eyes turn toward the light B. The infant's head turns away from the light C. The infant's eyes remain focused toward the floor D. The infant closes their eyes

The infant closes their eyes

A community health nurse is preparing to collect a data to study the health of a local community. The nurse should plan to obtain the information about which of the following factors during a windshield survey?

The leading cause of death for the prior year (other ans: availability of religious facilities... IFFY ANSWER)

A nurse is talking with an adult child of a client who has involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make?

The provider can prescribed restrains if your parent tries to harm others

A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?

The tubing may be kinked

*The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestations are associated with this finding?

Thirst

*The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching?

This medication helps decrease swelling and mucus production

*A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?

This technique decreases the risk of subcutaneous infiltration

Prior to first administration of lithium carbonate, what lab is important to check?

Thyroid hormone

*Gentamicin toxicity

Tinnitus

A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

Transport a school-age child to x-ray

A nurse is providing teaching about preventing mastitis to a client who is postpartum. Which of the following instructions should the nurse include?

Try to have your baby empty your breasts with each feeding

An occupational health nurse at a group of health care is planning activities to prevent and control the spread of communicable disease. The nurse should identify that which of the following activities is a secondary level of prevention?

Tuberculosis screenings

*I Just came from client is receiving IV moderate (Conscious) sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?

administer flumenazil

*A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of DVT

apply venous plexus foot pumps

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is

asymmetric, with variegated coloring

*A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply)

b. Syncope d. Vertigo

*A client asks the nurse if it is safe for him to take a glucosamine supplement

shellfish allergy

*Client taking phenelzine

cheddar cheese

*A circulating nurse is implementing a "time-out" before moving a client who is having total hip arthroplasty to the surgical site. Which of the following actions should the nurse take.

confirm the provider has marked the surgical site

A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?

diaphoresis

*A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contraction of the head and neck muscles. Which of the following medications should the nurse administer

diphenhydramine

*2 hr postoperative following an ileal conduit procedure bladder cancer

dusky color stoma

*A nurse on a med-surg unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter

female who is prone to development of blood clots in the urine

*A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

heightened perceptual field

A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

hepatits C

*A nurse in a provider's office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client's history is a contraindication to use in combination oral contraceptives?

impaired liver function

*A nurse is caring for a client who is taking alprozolam. Which prescription needs clarifying with the provider

lorazepam

*A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching?

notify your provider if you experience muscle weakness

*A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding?

oatmeal

*A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention?

paresthesia of the distal extremity

*A nurse is planning care for a child who is unresponsive and has increased ICP. Which of the the following actions should the nurse take?

place the child in Trendelenburg position (other ans: pad the side rails of the bed)

*haloperidol for the treatment of schizophrenia

screen the client for tardive dyskinesia

*A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods?

spinach

mononucleosis . What findings

splenomegaly, malaise, sore throat

*A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest?

take a daily walk on the hospital grounds

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve.

top left site (your left on screen, but right on body)

*Run cats spin the rain throwing procedures mechanical paper lake

word salad