101 QUESTIONS

The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq, po, daily. The drug available is Potassium Chloride 10 mEq/15 ml. How many mL(s) should the nurse administer? Answer _____________

30 ml

The nurse is preparing a class for parents of children diagnosed with sickle cell anemia. The nurse should instruct the parents to have their children avoid. select all that apply. A.Exposure to hot water B.Other children with infections C.Medications containing aspirin D.Contact sports

A, B, D

The nurse is caring for a client who is ventilator dependent. The nurse is aware that the high pressure alarm can be sounded for various reasons. Select all reasons that could apply. A.increased bronchial secretions B.the presence of an air leak C.the presence of a kink in the tubing D.the client stops breathing spontaneously E.acute bronchospasm F.the client is biting the tube G.the ventilator tubing is disconnected

A, C, E, F

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? A.Notify the health care provider (HCP). B.Continue monitoring the fetal heart rate. C.Encourage the client to continue pushing with each contraction. D.Instruct the client's coach to continue to encourage breathing techniques.

A. Notify the HCP HR should be 110-160

The nurse is caring for a client who has bumetanide prescribed. The nurse should suggest that the client include which of the following foods in the diet? A.Apricots B.Organ meats C.Sardines D.Fish

A.Apricots

The nurse should intervene if a staff member is observed: A.Discussing a client's diagnosis with visiting family members B.Collaborating with another nurse to review a prescription for blood transfusion C.Interrupting other staff members discussing a client in the cafeteria D.Reviewing a clients lab values with the nutritionist

A.Discussing a client's diagnosis with visiting family members

A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? A.NPO (nothing by mouth) status B.Ambulation at least 4 times daily C.Cholinergic medications to reduce pain D.Coughing and deep breathing every 2 hours

A.NPO (nothing by mouth) status

The nurse should intervene if the nurse notes a staff member A.Obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam) B.Placing a client on the affected side following surgical repair of a retinal detachment C.Handling a wet cast with the palms of the hands D.Using a broad base of support while transferring a client

A.Obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam)

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. A.Breast-feeding needs to be stopped for 3 months. B.Pregnancy needs to be avoided for 1 to 3 months. C.The vaccine is administered by the subcutaneous route. D.Exposure to immunosuppressed individuals needs to be avoided. E.A hypersensitivity reaction can occur if the client has an allergy to eggs. F.The area of the injection needs to be covered with a sterile gauze for 1 week.

B, C, D, E

The nurse in a community health clinic is talking with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? A. "This weekend we are going to a seafood restaurant" B. "I can feed my child oatmeal and eggs for breakfast" C. "My child loves to eat rice and chicken for dinner" D. "Last night we ate fish with corn for dinner"

B. "I can feed my child oatmeal and eggs for breakfast"

It would be appropriate to assign which of these tasks to the CNA? A.Feeding a client who is experiencing dysphagia B.One-on-one client observation for safety C.Removal of an indwelling catheter D.Performing a simple dressing change

B.One-on-one client observation for safety

The nurse is preparing the pre-operative checklist for a patient. The nurse would need additional training if which of the following tasks were delegated to the UAP? A.Removing dentures, glasses, jewelry, and prosthesis B.Shave the operative area C.Assist to void D.Obtain vital signs

B.Shave the operative area

The nurse is admitting a 20-year-old client with anorexia nervosa. The nurse should assess the client for A.stained enamel of the teeth B.lanugo-type hair on body C.persistent ringing in the ears D.white patches on the tongue

B.lanugo-type hair on body

The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. A.reinforcing the dressing of a client who has a decubitus ulcer B.monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit C.administering a tap water enema to a client who will undergo a colonoscopy in two hours D.placing a client who had an above the knee amputation 24 hours ago in a prone position E.assisting a client who had a colon resection 36 hours ago to ambulate F.showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care

C, D, E

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. A.Diarrhea B.Black, tarry stools C.Hyperactive bowel sounds D.Gray-blue color at the flank E.Abdominal guarding and tenderness F.Left upper quadrant pain with radiation to the back

C, D, E Gray-blue color at flank=turners sign severe pain is a sign of pancreatitis

The nurse has attended a staff development conference on preparing clients for neurological diagnostic tests. Which of the following statements, if made by the nurse would require follow-up? A."The electromyogram (EMG) is performed by introducing small needle electrodes into muscles." B."After having a Positron Emission Tomography (PET) of the head the client can resume normal activities." C."The electroencephalogram (EEG) will require the client to be NPO for 12 hours before the test." D."After the lumbar puncture (LP) the client will need to lie flat for about 3 hours."

C."The electroencephalogram (EEG) will require the client to be NPO for 12 hours before the test."

The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the health care provider (HCP)? A.Serum electrolytes B.Urine specific gravity C.24-hour fluid intake and output without restricting food or fluid intake D.Postoperative magnetic resonance imaging to detect any damage to the hypothalamus or pituitary gland

C.24-hour fluid intake and output without restricting food or fluid intake

The nurse is reviewing laboratory data of the following clients. It would be a priority for the nurse to follow-up with the primary health care provider if a client with A. Coronary artery disease has a low density lipoprotein (LDL) level of 129mg/dl B. Primary hypertension has a sodium level of 144mEq/L C. Rhinosinusitis has a white blood count (WBC) of 11,500/ul D. Diabetes mellitus type 1 has a glycosylated hemoglobin (hbA1c) level of 12%

D. Diabetes mellitus type 1 has a glycosylated hemoglobin (hbA1c) level of 12%

A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication? A."You have everything to live for." B."Why do you feel like a failure?" C."Feeling like this is all part of being depressed." D."You've been feeling like a failure for a while?"

D."You've been feeling like a failure for a while?" ask if they have a plan!!!

A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should notify the primary health care provider that the client has a A.BUN of 60 mg/dl B.Creatinine 3.5 mg/dl C.Sodium 145 mEq/L D.Potassium 6.8 mEq/L

D.Potassium 6.8 mEq/L

The nurse has a new prescription for Dopamine at 6mcg/kg/min. The patient weights 65kg. Dopamine concentration is 400mg/250mL. What rate should the nurse infuse the Dopamine via an infusion pump? Answer ___________

14.6 ml/hr

The nurse is caring for a client who has been prescribed 1,000 mL of Ringer's Lactate to infuse over 8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute should the nurse set the intravenous controller to administer? Answer ______________

21 gtt/min

A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid A.Two hours after the client has eaten a meal B.At the same time as a prescribed iron preparation C.After briskly shaking the bottle of Maalox D.When assessing the client for the presence of gastric pain

B.At the same time as a prescribed iron preparation

A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. A.Hypotension B.Leukocytosis C.Hyperkalemia D.Hypercalcemia E.Hypernatremia

A & C; Addison's= add cortisol, everything is low except ca+ & k+

The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply. A.A 47-year-old mother of a child with cystic fibrosis B.A 54-year-old man scheduled for a routine diabetes check C.A 43-year-old factory worker with symptoms of influenza D.A 35-year-old registered nurse scheduled for an annual pelvic exam E.An 87-year-old woman from a nursing home scheduled for a surgical follow-up

A, B, E

The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply. A.Ask permission before touching the client B.Provide a warm, social approach to the client C.Eliminate all unnecessary physical contact with the client D.Defuse any anger or verbal attacks with a non-defensive stance E.Use simple and clear language when communicating with the client.

A, C, D, E the patient will have alot of anxiety. Borderline- self harmers, not likely to commit suicide

The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium. A.administer the heparin in the abdomen B.administer 0.5ml of heparin sodium C.aspirate after inserting the needle D.use a 1 inch 21 gauge needle E.refrain from massaging the site after administer heparin F.remember that protamine sulfate is the antidote for heparin

A, E, F

The nurse has provided health promotion teaching for a group of clients who were recently diagnosed with the Human immunodeficiency virus (HIV). Which statement, if made by one of the clients, would require further teaching? A."I am glad that I can still clean my parakeet's cage" B."I will not go to the parade this weekend" C."I will increase protein in my diet" D."I will miss not being able to work in my garden

A."I am glad that I can still clean my parakeet's cage"

The nurse at a health promotion fair has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate a correct understanding of the information given? A."I will place my newborn infant in a rear facing car seat in the middle of the rear seat." B."I will wear a lap seat belt high on my belly since I am 8 months pregnant." C."I can use a front-facing car seat once my baby weighs 15 pounds." D." I can allow my six-year-old to use a seat belt in the front passenger seat"

A."I will place my newborn infant in a rear facing car seat in the middle of the rear seat."

A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? A."We will be sure not to leave hot liquids unattended." B."I guess our children need to understand what the word hot means." C."I guess our children need to understand what the word hot means." D."We will install a safety gate as soon as we get home so the children cannot get into the kitchen."

A."We will be sure not to leave hot liquids unattended."

The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should first plan to assess the client who is A.2 years old, has a temperature of 100.8 F and a blood pressure of 68/44 B.4 years old with a history of asthma and has a peak expiratory flow rate (PERF) of 81% C.5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain) D.7 years old with ulcerative colitis and has had 15 bloody tinged stools today

A.2 years old, has a temperature of 100.8 F and a blood pressure of 68/44 BP should be 80-110 diastolic

The nurse at a health clinic is screening male clients for testicular cancer. It would be a priority for the nurse to teach testicular self examination to A.A 17-year-old college football player B.A 39-year-old who smokes a pack of cigarettes day C.A 55-year-old with benign prostatic hypertrophy D.A 69-year-old with a family history of testicular cancer

A.A 17-year-old college football player prime age for testicular cancer is 15-35 years

The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with A.A potassium of 4.5 mEq/L has Kayexalate (sodium polystyrene) prescribed B.Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions C.Sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) D.Sensitivity to Penicillin is prescribed Zithromax (azithromycin)

A.A potassium of 4.5 mEq/L has Kayexalate (sodium polystyrene) prescribed

The primary health care provider has prescribed ampicillin 0.5 GM PO Q6H to a 15 month old toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5 mL. The recommended dosage is 50 mg/kg/day divided over 3 doses. The nurse should A.Call the primary health care provider to report that the prescription exceeds the recommended dosage B.Determine if the toddler has previously had a penicillin or a cephalosporin prescribed C.Give the toddler the ampicillin mixed with applesauce D.Wait until the result of the throat culture obtained one hour ago is available

A.Call the primary health care provider to report that the prescription exceeds the recommended dosage

The nurse is caring for a client being treated for Vancomycin Resistant Enterococcus (VRE). The nurse should place the client on A.Contact precautions B.Droplet precautions C.Protective precautions D.Airborne precautions

A.Contact precautions

The nurse is preparing a dose of 10 units of regular insulin and 35 units of NPH insulin for a client with type 1 diabetes mellitus. The nurse obtains an insulin syringe, gently rotates the insulin solutions, cleans the tops of the vials of insulin, and injects an amount of air equal to the dose prescribed into each vial. What is the next nursing action? A.Draws up 10 units of regular insulin and checks the syringe content with another nurse before drawing up the NPH B.Draws up 10 units of regular insulin, draws up 35 units of NPH insulin, and the checks the syringe contents with another nurse C.Draws up 35 units of NPH and checks the syringe contents with another nurse before drawing up the regular D.Draws up 35 units of NPH, draws up 10 units regular, and checks the syringe contents with another nurse

A.Draws up 10 units of regular insulin and checks the syringe content with another nurse before drawing up the NPH NR>RN

The nurse is precepting a newly-hired nurse who is caring for a client receiving a prescribed continuous nasogastric feeding. The nurse should intervene immediately if the newly-hired nurse A.Instills 30ml of normal saline into the feeding tube while auscultating over the stomach for bowel sounds B.Checks the pH of the 60ml gastric aspirate removed from the feeding tube C.Maintains the client with the head of the bed elevated at 45 degrees D.Hangs four hours worth of prescribed feeding formula in an open delivery system

A.Instills 30ml of normal saline into the feeding tube while auscultating over the stomach for bowel sounds

The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The nurse should anticipate that the client will initially be prescribed A.Nonsteroidal anti-inflammatory drugs (NSAIDs) B.Disease-modifying rheumatic agents C.Biologic Response Modifiers D.Long-term corticosteroids

A.Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse is developing a nursing care plan for a client who is the manic phase of bipolar disorder. Which intervention should the nurse include in the plan of care? A.Provide the client with finger foods B.Engage the client in competitive games C.Encourage the client to avoid foods that contain tyramine D.Place the client on direct suicide observation

A.Provide the client with finger foods

The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples A.Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment B.Telling a client that you will put in a feeding tube if the client does not eat is an example of battery C.Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice D.Placing hands on a client who says "do not touch me" is an example of assault

A.Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment

The nurse is assessing a 5-month-old infant. The nurse should expect the infant to A.Roll from abdomen to back B.Sit without support C.Say 'mama' and 'dada' D.Prefer use of one hand over the other

A.Roll from abdomen to back

The nurse is caring for a client who has oxalate kidney stones. The nurse should teach the client to avoid A.Spinach and rhubarb B.Mushrooms and rice C.Shell fish and aged cheese D.Organ meats and wine

A.Spinach and rhubarb ^ca+

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? A.Taking medications as scheduled B.Eating large, well-balanced meals C.Doing muscle-strengthening exercises D.Doing all chores early in the day while less fatigued

A.Taking medications as scheduled

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A.This is a normal, expected event. B.The client is experiencing early signs of ischemic bowel. C.The client should not have the nasogastric tube removed. D.This indicates inadequate preoperative bowel preparation.

A.This is a normal, expected event.

The infection control nurse is making rounds on a Medical Surgical unit. The infection control nurse should immediately intervene if a nurse is observed A.wearing a disposable surgical face mask when entering the room of a client with active pulmonary tuberculosis B.keeping the door to the room closed of a client with disseminate varicella zoster C.leaving a dedicated stethoscope in the room of a client with respiratory syncytial virus D.wearing a gown, gloves, and mask while taking the blood pressure of a client with Ebola Virus

A.wearing a disposable surgical face mask when entering the room of a client with active pulmonary tuberculosis

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. A.The client with heart failure (HF) who has bilateral rhonchi B.The client who 24 hours earlier gave birth to her second child by caesarean delivery C.The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis D.The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102°F (38.9°C) E.The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker F.The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

B, C, E, F

The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching A.steatorrhea commonly occurs or excessive secretion of fecal lipids is common B.ulcerative colitis occurs most frequently in Jewish males 30-50 years of age C.a diet in high in residue and low in complex carbohydrates is helpful in controlling symptoms D.corticosteroids may be prescribed during an exacerbation E.metronidazole (flagyl) and ciprofloxacin (cipro) are antibiotics commonly used during acute exacerbations F.eating small frequent meals and lay down after eating promotes absorption of nutrients

B, D, E

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? A.Adding a dose of heparin sodium B.Holding the next dose of warfarin C.Increasing the next dose of warfarin D.Administering the next dose of warfarin

B. Holding the next dose of warfarin PT 11-12.5 INR 0.9-1.2 Heparin longer than 1 week-risk for HIT

The client seems very despondent, refusing to get out of bed. The evening nurse finds the client crying, "I've screwed everything up. It's hopeless. It's no use." The client states to the nurse that at times she wishes she were dead. Which is the best initial nursing intervention? A.Call the doctor about her suicidal ideations B.Assess further her suicide thoughts & plans C.Assign a 1:1 to stay with her D.Have her sign a "suicide contract"

B.Assess further her suicide thoughts & plans Always assess first!

The nurse is teaching a client about crutch walking. Which of the following statements if made by the client indicates a need for further teaching? A."My elbows should be flexed 20-30 degrees, while walking." B."When I climb stairs I advance my affected leg first, with my crutches." C."I do not apply pressure under my arm when I use my crutches." D."When I am going to sit in a chair I put both crutches in the hand on my unaffected side."

B."When I climb stairs I advance my affected leg first, with my crutches."

The community health nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is A.12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) B.16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13% C.52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier D.70 years old, has schizophrenia, lives alone and reports hearing non threatening voices.

B.16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13%

The nurse in a community health setting is assessing the following clients. It would be a priority for the nurse to utilize a multidisciplinary approach for the client who is A.12 years old, with chicken pox and cannot attend school B.21 years old, pregnant, unemployed and has active pulmonary tuberculosis C.32 years old, a grade school teacher and is recovering from a sickle cell crisis D.74 years old, with mild Alzheimer's disease and is in an assisted living residence

B.21 years old, pregnant, unemployed and has active pulmonary tuberculosis

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? A.Prothrombin time of 12.5 seconds B.Activated partial thromboplastin time of 60 seconds C.Activated partial thromboplastin time of 28 seconds D.Activated partial thromboplastin time longer than 120 seconds

B.Activated partial thromboplastin time of 60 seconds

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? A.Hypovolemia B.Acute Kidney Injury C.Glomerulonephritis D.Urinary Tract Infection

B.Acute Kidney Injury

An unlicensed assistive personnel (UAP) is caring for a client who has an indwelling urinary catheter. Which action by the UAP would indicate the need for further instruction in the care of the client? A.Used soap and water to cleanse the perineal area B.Allowed the drainage tubing to rest under the leg C.Kept the drainage bag below the level of the bladder D.Used the drainage tubing port to obtain urine samples

B.Allowed the drainage tubing to rest under the leg

The nurse is admitting a client with major depression. It would be a priority for the nurse to A.Determine if the client was voluntarily admitted B.Ask the client if suicide has been contemplated C.Have the client's possessions searched for sharps D.Administer to the client the prescribed antidepressant

B.Ask the client if suicide has been contemplated

The staff members of an out patient clinic have successfully assisted the clients to safety during a fire in the waiting area. Which action should the nurse perform next? A.Close all open doors B.Call for additional help C.Attempt to extinguish the fire D.Assess the clients' vital signs

B.Call for additional help R-RESCUE A-ALARM C-CONFINE E-EXTINGUISH

The home health care nurse is assigned to see four clients who all live within three miles of each other. The nurse should first see the client who has A. Gastroesophageal reflux disease (GERD) and is reporting a burning abdominal pain that is relieved by walking B.Cancer of the esophagus who has given away a favorite shirt since the last visit C.Regional enteritis (Crohn's disease) who has an elevated temperature and is vomiting D.A gastrostomy tube who will begin self-feeding for the first time

B.Cancer of the esophagus who has given away a favorite shirt since the last visit SI?

A nurse is observing a newly-hired nurse provide care for assigned clients. The nurse should follow up if the newly-hired nurse is observed A.Wearing gloves when taking the blood pressure of a client with disseminated varicella zoster B.Cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi-drug resistant organism C.Washing the hands with the fingertips pointed downward before providing care for a client on protective precautions D.Removing the gloves before removing the gown when leaving a room of a client who is on contact precautions

B.Cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi-drug resistant organism should clean inner to outer

The nurse is admitting a client to the emergency department who is reporting visual impairment and loss of peripheral vision. The nurse should recognize that these symptoms are consistent with the medical diagnosis of A.Macular degeneration B.Closed angle glaucoma C.Senile cataract D.Retinal detachment

B.Closed angle glaucoma

The nurse is reviewing a client's ABG results, which reveal the following: pH 7.35; PaO2 75mmHg; PaCO2 55 mmHg; HCO3 30 mEq/L. The nurse should recognize that this result is suggestive of which acid base imbalance? A.Compensated metabolic acidosis B.Compensated respiratory acidosis C.Compensated metabolic alkalosis D.Compensated respiratory alkalosis

B.Compensated respiratory acidosis

The nurse is caring for a 72-year-old client who was recently diagnosed with metastatic breast cancer. The client is expressing feelings of depression and is asking the nurse, "Why me"? According to Erikson, which developmental stage is the client experiencing? A.Industry vs. inferiority B.Ego integrity vs. despair C.Generativity vs. stagnation D.Intimacy vs. isolation

B.Ego integrity vs. despair

The nurse working in the labor and delivery room has become aware of the following client situations. The nurse should first assess the client who is A.In the first phase of labor and the fetal heart rate ranges from 128 to 140 between contractions B.In the second phase of labor and the fetal heart rate is consistently beating at 132 beats per minute C.In the third phase of labor and the fetal heart rate has decelerated to its lowest point at the acme of the contraction D.In the third phase of labor and the contractions are lasting 60-70 seconds

B.In the second phase of labor and the fetal heart rate is consistently beating at 132 beats per minute

The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client A.Scheduled for an EEG is washing the hair B.Is being transported to have a magnetic resonance image (MRI) test and is attached to a pulse oximeter C.Is being taught to hold the breath at intervals during a computerized tomography (CT Scan) D.On protective precautions is eating soup brought in by a visitor

B.Is being transported to have a magnetic resonance image (MRI) test and is attached to a pulse oximeter

The nurse has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who A.Had a total knee replacement 24 hours ago is using continuous passive motion (CPM) exerciser while in a supine position B.Is scheduled for a myelogram in 4 hours and states "I can not drink any liquids until 12 hours after the procedure is finished." C.Had a total hip replacement 12 hours ago and has an abduction pillow in place D.Had a pin inserted 4 hours ago for a fractured femur has a small amount of bright red bleeding at the pin site

B.Is scheduled for a myelogram in 4 hours and states "I can not drink any liquids until 12 hours after the procedure is finished."

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? A.Anterior chest pain B.Pericardial friction rub C.Weakness and irritability D.Chest pain that worsens on inspiration

B.Pericardial friction rub

Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? A.Taking off the gloves first before removing the gown B.Removing the gown without rolling it from inside out C.Washing the hands after the entire procedure has been completed D.Removing the gloves and then removing the gown using the neck ties

B.Removing the gown without rolling it from inside out

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? A.Metabolic acidosis, compensated B.Respiratory alkalosis, compensated C.Metabolic alkalosis, uncompensated D.Respiratory acidosis, uncompensated

B.Respiratory alkalosis, compensated PH- Normal PACO2-abnormal HCO3-abnormal compensated

The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three-year- old should A.Discriminate between fantasy and reality B.Ride a tricycle independently C.Have a vocabulary of 7,000 words D.Play in a group of two or three with one being the leader

B.Ride a tricycle independently

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? A.Beclomethasone first and then the salmeterol B.Salmeterol first and then the beclomethasone C.Alternating a singe puff of each, beginning with the salmenterol D.Alternating a single puff of each, beginning with the beclomethasone

B.Salmeterol first and then the beclomethasone rescue ends in -rol, therefore its always first sit pt up, shake canister 10-15 seconds, all use spacer, slowly breathe in, hold breath 10 seconds, 1-2 minutes between each puff, rinse mouth

The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? A.The client who lacks knowledge regarding postoperative home care B.The client with problems clearing the airway related to abdominal incision pain C.The client with tissue perfusion alterations related to postoperative venous stasis D.The client who is at risk for infection related to a history of smoking for 20 years

B.The client with problems clearing the airway related to abdominal incision pain ABC's

The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client A.who had a cervical radium implant inserted sixteen hours ago is placed on bed rest B.who had transsphenoidal hypophysectomy twelve hours ago is drinking fluids through a straw C.who has received prescribed lithium for the past three days is observed eating a pickle brought in by a family member D.who had retinal detachment repaired using a gas bubble four hours ago is lying on the operative side postoperatively

B.who had transsphenoidal hypophysectomy twelve hours ago is drinking fluids through a straw increased ICP

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. A.Excessive bubbling in the water seal chamber B.Vigorous bubbling in the suction control chamber C.Drainage system maintained below the client's chest D.50 mL of drainage in the drainage collection chamber E.Occlusive dressing in place over the chest tube insertion site F.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

C, D, E, F Should not have vigorous bubbling in suction control chamber, should be gentle bubbling

The nurse has attended a staff development conference on Meniere's Disease. Which of the following statements, if made by the nurse would require follow-up? A."Meniere's Disease symptoms result from excess endolymphatic fluid in the inner ear." B."Clients with Meniere's Disease are encouraged to have a low salt diet." C."Assistive listening devices are required for clients with Meniere's Disease." "Stress is suspected to have a role in Meniere's Disease

C."Assistive listening devices are required for clients with Meniere's Disease."

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction? A."I need to bring a hat to wear during the trip." B."I should wear long-sleeved tops and long pants." C."I should not use insect repellents because it will attract the ticks." D."I need to wear closed shoes and socks that can be pulled up over my pants."

C."I should not use insect repellents because it will attract the ticks."

The nurse has provided discharge instructions for a client who has been prescribed digoxin. It would require follow up by the nurse if the client says A."I will consult my primary health care provider before taking medications that contain aspirin." B."I will not take any antacids within two hours of taking the digoxin." C."I will avoid fruits such as avocados, grapefruit and cantaloupe." D."I will remember that any visual disturbance can be a sign of digitalis toxicity."

C."I will avoid fruits such as avocados, grapefruit and cantaloupe."

The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? A.Finger paints and paper B.A rubber ball and bat C.A board game D.A stuffed toy

C.A board game the stuffed animal can carry bacteria, the finger painting can cause paper cuts and the ball and bat are a risk for injury

The nurse has received her client assignment for the day. Which client should the nurse check first? A.A client experiencing severe pain B.A client who is hearing voices in his head C.A client who has just returned from surgery D.A client who is in 4-point leather restraints

C.A client who has just returned from surgery always post-op first!

The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How should the nurse interpret this rhythm? A.Bradycardia B.Tachycardia C.Atrial fibrillation D.Normal sinus rhythm (NSR)

C.Atrial fibrillation

The nurse has received report on four clients. The nurse should first assess the client who has: A.Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% B.Parkinson's Disease and is demanding to leave the hospital against medical advice (AMA) C.Been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis therapy D.Heart Failure (CHF) whose pitting edema has increased to 2(+)

C.Been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis therapy

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? A.Induce vomiting. B.Call an ambulance. C.Call the Poison Control Center. D.Bring the child to the emergency department.

C.Call the Poison Control Center.

While performing an assessment of a 3-year-old client, the nurse notices bruises in various stages of healing on the concealed surfaces of the body. Which action should the nurse take next? A.Document the locations of the bruises in the medical record B.Notify the primary health care provider C.Contact the local reporting agency for suspected child abuse D.Ask the parent to explain the injuries

C.Contact the local reporting agency for suspected child abuse

The nurse is caring for a client with a diagnosis of fluid volume overload. The nurse reviews the laboratory test results and would expect to note which finding about the hematocrit level? A.Normal B.Increased C.Decreased D.Insignificant related to the condition

C.Decreased

Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL and a hematocrit level of 30%. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6°F orally. Which action should the nurse take? A.Begin the transfusion as prescribed. B.Administer an antihistamine and begin the transfusion. C.Delay hanging the blood and notify the health care provider (HCP). D.Administer 2 tablets of acetaminophen and begin the transfusion.

C.Delay hanging the blood and notify the health care provider (HCP). fever is 100.5 or ^

The nurse is caring for a client who has a new colostomy. The colostomy stoma is red, moist and slightly raised. The nurse should A.Determine if the client is allergic to the skin barrier B.Apply petroleum jelly gauze around the stoma C.Document the condition of the stoma D.Assess the client's temperature

C.Document the condition of the stoma

The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN: A.Assesses a client's apical pulse before administering Digoxin B.Elevates the client's stump on a pillow eight hours after amputation C.Dons a clean glove on the dominant hand before tracheal suctioning D.Positions a client on the operative side following a pneumonectomy

C.Dons a clean glove on the dominant hand before tracheal suctioning Needs to be a sterile glove

The nurse has become aware of the following client situations. The nurse should first assess the client who A.Had received a unit of packed red blood cells four hours ago and is requesting a bedpan B.Had an abdominal hysterectomy yesterday and is reporting calf pain C.Has history of multiple sclerosis and is reporting diplopia D.Had a tonsillectomy three hours ago and is reporting a sore throat

C.Has history of multiple sclerosis and is reporting diplopia

The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It would be most appropriate to assign that nurse to the client who A.Reports epigastric pain that "feels like indigestion" B.Has back pain and a pulsating abdominal mass C.Is HIV+ reporting vomiting and diarrhea D.Presents with lower abdominal pain and is six weeks pregnant

C.Is HIV+ reporting vomiting and diarrhea

The nurse is teaching a class on infant nutrition. The nurse should instruct parents to introduce A.Fruit juices at 3 months B.Honey sweetened water at 6 months C.Pureed chicken at 7 months D.Whole milk at 9 months

C.Pureed chicken at 7 months

The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse should anticipate the infant should A.Roll from prone to back B.Have no head lag C.Smile socially D.Have no tonic neck reflex

C.Smile socially this should happen by 3 months

The nurse is caring for a client with disseminated intravascular coagulation (DIC) who is receiving a unit of packed red cells. Thirty minutes after the start of the transfusion , the client reports chills and flank pain. The nurse should first A.Flush the intravenous tubing with normal saline B.Assess the client's vital signs C.Stop the transfusion D.Notify the primary health care provider

C.Stop the transfusion

The nurse is assessing a 3-year-old during a well-child visit. During the visit the boy says to his mother, "Mommy, I love you. I'm going to marry you". The nurse should A.Suggest to the mother not to encourage these types of statements B.Explain to the child that he will not be able to marry his mother even though he loves her C.Tell the mother that this statement is appropriate for his stage of development D.Recommend that the mother provide more opportunities for her son to play with other 3-year-old boys

C.Tell the mother that this statement is appropriate for his stage of development

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? A.The client is not experiencing dyspnea. B.The client is not experiencing nausea or vomiting. C.The pain has not been relieved by rest and nitroglycerin tablets. D.The client says the pain began while she was trying to open a stuck dresser drawer.

C.The pain has not been relieved by rest and nitroglycerin tablets. MI=MONA; Morphine, O2, Nitro, Aspirin. MI=Inverted T waves women- back pain & n/v & indigestion men- L jaw pain & chest pain

The nurse is caring for a client with bipolar disorder who has lithium prescribed. The nurse should suggest that the client have which of the following snacks? A.A fresh fruit cup B.Coffee and oatmeal cookies C.Tuna fish salad on saltine crackers D.Raw vegetables

C.Tuna fish salad on saltine crackers lithium- consistent na+

The nurse is caring for a mechanically ventilated client who was declared brain dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the A.client's primary care provider B.client's nurse manager C.closest living family member D.hospital's ethics committee

C.closest living family member

The nurse from the postpartum unit has been temporarily assigned to the medical surgical unit. It would be most appropriate to assign this nurse to the client who A.has returned from right total hip replacement surgery four hours ago B.is being observed for increased intracranial pressure C.had surgery two hours ago to remove the appendix D.is two weeks post partum being maintained on a mechanical ventilator for respiratory failure

C.had surgery two hours ago to remove the appendix

A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions should the nurse take? A.wear a gown and gloves when taking the client's health history B.place the client on droplet precautions C.keep the door to the client's room closed D.use sterile gloves when taking the client's blood pressure

C.keep the door to the client's room closed

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? A.Total loss of vision B.Pain in the affected eye C.A yellow discoloration of the sclera D.A sense of a curtain falling across the field of vision

D. A sense of a curtain falling across the field of vision pain in the affected eye is usually closed angle glaucoma, loss of central vision is macular degeneration know that iv abx dont work on eyes, must use drops or shots

The nurse has attended a staff development conference on sexually transmitted diseases. Which of the following statements, if made by the nurse would require follow-up? A."During the primary stage of syphilis a lesion occurs at the site of infection called a chancre" B."A client with HIV who has a reading of 5 or more on the mantoux test is considered to have a positive finding for pulmonary tuberculosis" C."Gonorrhea is often asymptomatic in women but causes urinary frequency and dysuria in males" D."Chlamydial infections are strongly linked with cervical cancer in women

D."Chlamydial infections are strongly linked with cervical cancer in women HPV

The nurse is providing teaching for a client prescribed ciprofloxacin for a urinary tract infection. Which statement made by the client indicates that there is a need for further teaching? A."I can take the ciprofloxacin with or without food." B."I'll need to wear sunscreen and protective clothing while taking ciprofloxacin." C."I'll need to contact my health care provider if I develop any white patches in my mouth." D."If I develop any tendon pain while taking ciprofloxacin, exercise should help to decrease the pain."

D."If I develop any tendon pain while taking ciprofloxacin, exercise should help to decrease the pain." If tendon pain- call MD immediately!

The nurse in a well baby clinic has assessed several children today. It would be a priority for the nurse to suggest follow up for the child who is A.2 months old with a positive babinski reflex B.5 months old and does not hold their own bottle C.10 months old who cries around strangers D.18 months old who needs support while ambulating

D.18 months old who needs support while ambulating

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? A.A primigravida client in the active stage of labor B.A multigravida client who was admitted for induction of labor C.A client who is not contracting but has suspected premature rupture of the membranes D.A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

D.A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? A.A postoperative client preparing for discharge with a new medication B.A client requiring daily dressing changes of a recent surgical incision C.A client scheduled for a chest x-ray after insertion of a nasogastric tube D.A client with asthma who requested a breathing treatment during the previous shift

D.A client with asthma who requested a breathing treatment during the previous shift

A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication should the nurse look for during the client's postprocedure assessment? A.Bradycardia B.Nausea and vomiting C.Numbness in the legs D.A rigid, board like abdomen

D.A rigid, board like abdomen

The nurse is caring for a client with a soft tissue injury. The client reports using a herbal remedy for 3 weeks prior to seeking health care but can not remember what was taken. The nurse should recognize that which of the following herbal remedies can be utilized effectively for soft tissue injuries? A.Saint John's Wort B.Kava Kava C.Dong-Quai D.Aloe Vera

D.Aloe Vera

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? A.Monitoring the temperature B.Monitoring complaints of heartburn C.Giving warm gargles for a sore throat D.Assessing for the return of the gag reflex

D.Assessing for the return of the gag reflex

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? A.Hypercalcemia B.Hypernatremia C.Frothy, fatty stools D.Decreased hemoglobin

D.Decreased hemoglobin

The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment? A.Apply ice to the stoma site. B.Apply pressure to the stoma site. C.Notify the health care provider (HCP). D.Document the amount and characteristics of the drainage.

D.Document the amount and characteristics of the drainage. expected for up to 2 days post surgery stoma gray>call MD

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A.Gloves and gown B.Gloves and goggles C.Gloves, gown, and shoe protectors D.Gloves, gown, goggles, and a mask or face shield

D.Gloves, gown, goggles, and a mask or face shield could splash

The nurse is made aware of the following situations. The nurse should first check the client who A.Had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed B.Has cervical traction and is moving the legs by flexing and extending the feet C.Has Alzheimer's disease (stage 1) and was returned to the room after being found wandering in the hallway D.Has a history of partial seizures and is sitting in the bed picking at the clothing and smacking the lips

D.Has a history of partial seizures and is sitting in the bed picking at the clothing and smacking the lips

The nurse in the emergency department is caring for clients admitted following a rescue from a burning bus. The nurse should first see the client who A.Has the tibia bone protruding through the skin and is in severe pain B.Has third degree burns of the left foot and is crying C.Is unconscious, pulseless, and has dilated pupils D.Has soot on the face and the nares and is coughing

D.Has soot on the face and the nares and is coughing

Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients: A.Reports blood tinged sputum following a bronchoscopy B.Has decreased abdominal girth following paracentesis C.Reports a headache following a lumbar puncture D.Is observed flexing and extending the legs two hours after cardiac catheterization

D.Is observed flexing and extending the legs two hours after cardiac catheterization

A client diagnosed with depression is prescribed amitriptyline hydrochloride. During the initial phases of treatment, the client's care plan should include which nursing intervention A.Obtain daily drug blood levels. B.Provide the client a tyramine-free diet. C.Assess the client for anticholinergic effects. D.Obtain postural blood pressure prior to each medication administration.

D.Obtain postural blood pressure prior to each medication administration.

The nurse on a psychiatric unit is caring for a client with paranoid schizophrenia who has lost 15 pounds within the past 3 weeks. The client accuses the staff of trying to poison all of the clients on the unit. Which of the following nursing interventions would be a priority for the nurse to include in the client's plan of care? A.Determine the client's favorite foods B.Offer the client small quantities of food at frequent intervals C.Sit with the client during meals D.Provide the client with pre-packaged foods that the client likes

D.Provide the client with pre-packaged foods that the client likes

The mother of an infant tells the nurse that the baby has not been tolerating feedings lately and she noticed an olive-shaped mass in the infant's abdomen. The nurse recognizes that this could be an expected finding if the infant has A.Intussusception B.Hirschsprung's disease C.Umbilical hernia D.Pyloric stenosis

D.Pyloric stenosis

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation? A.Serum chloride level of 98 mEq/L (98 mmol/L) B.Serum sodium level of 145 mEq/L (145 mmol/L) C.Serum calcium level of 10.5 mg/dL (2.75 mmol/L) D.Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

D.Serum potassium level of 2.8 mEq/L (2.8 mmol/L) run IV k+ at 10ml/hr with normal saline 3PVCs-VTach?

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? A.Ask the client to leave the group for this session only. B.Refer the client to another group that includes other manic clients. C.Tell the client to stop monopolizing in a firm but compassionate manner. D.Thank the client for the input, but inform the client that others now need a chance to contribute.

D.Thank the client for the input, but inform the client that others now need a chance to contribute. if manipulative or narcissistic- set firm limits lithium level:0.5-1.5

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. How should the nurse describe this test to the client? A.The test may be painful B.The test will take approximately 2 hours C.Fluids will be restricted following the test D.The dye injected may cause a warm, flushing sensation

D.The dye injected may cause a warm, flushing sensation -be sure to check for shellfish or iodine allergy no metformin 48hrs before and after contrast

The nurse has attended a staff development conference on cultural considerations for clients receiving hospice care. Which of the following statements if made by the nurse would require follow-up A.The family of a client of the Buddhist faith may ask for a priest to be present at the time of death B.The family of a client of the Jewish faith may request to have mirrors covered after the death of the client C.The family of a client of the Muslim faith may request that the body of the client be turned to face the East at the time of the client's death D.The family of a client of the Hindu faith may request that the client body be bathed after the client's death

D.The family of a client of the Hindu faith may request that the client body be bathed after the client's death Only the family may touch the body

The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? A.Wear a particulate respirator mask when providing wound care B.Instruct visitors not to bring flowers into the client's room C.Place the client in a private room with negative air pressure D.Wear a disposable gown when changing the client's dressing

D.Wear a disposable gown when changing the client's dressing

The nurse is caring for a client who has left ventricular failure. Which of the following should the nurse recognize as being consistent with this diagnosis? A.3+ pedal edema B.Jugular vein distention C.Oxygen saturation of 96% D.Wheezing during expiration

D.Wheezing during expiration

The nurse should initiate protective precautions for a client who has a A.Red Blood Cell Count (RBC) of 3,900/mm3 B.Platelet count of 400,000μ/L C.Hemoglobin (Hgb) 9.0 g/dl D.White Blood Cell Count (WBC) 2,500/mm3

D.White Blood Cell Count (WBC) 2,500/mm3

The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse's priority action would be to A.notify the nursing supervisor B.asking the nurse about recent alcohol consumption C.complete an incident report D.relieve the nurse of assigned clients

D.relieve the nurse of assigned clients