8-#2
A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? Client report of uterine cramping Boggy funds 3 fingerbreadths above the umbilicus Client report of burning with urination Saturation of perineal pad in 15 min
? uterine cramping
A nurse is contributing to the plan of care oraclient whois major depressive disorder. Which of the following recommendations should the nurse include in the plan of care? o Suggest The Client Exercise Before Going To Bed o Recommend The Client Spend Time Alone In His Room o Encourage The Client To Use Positive Self Talk o Offer The Client Low-protein snacks throughout the day
Encourage The Client To Use Positive Self Talk
A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching? "I will place used sharp items in an empty cereal box for disposal" "I will put soiled dressings in a tied plastic bag before placing them in the trash" "I will use animal skin condoms when having sex" "I will disinfect contaminated hard surfaces with mixture of one part peroxide to 10 parts water"
"I will put soiled dressings in a tied plastic bag before placing them in the trash"
A nurse is assisting with the care of a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following findings should the nurse immediately report to the provider? a. The client passes small clots in the drainage bag.(Wrong) b. The nurse observes continuous bright red urinary output c. The client suddenly develops bladder spasms d. The nurse note the drainage flow rate has slowed
-spasms
A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?
?
A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include? o "Cover the electrical outlets with wet towels." o "Turn on fans in the facility to circulate air." o "Open the fireplace dampers in the day room." o "Move clients to a room above ground with few windows."
?
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
?
a nurse is collecting a health history from a guardian of a four-year-old child. Which of the following statements should the nurse address?
?
A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics describe hyperactive bowel sounds? A. Sounds are soft and at a rate of 1/min B. Can be a result of paralytic ileus C. Can be the result of an early bowel obstruction D. Indicates decreased motility
? Can be the result of an early bowel obstruction
A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include? ''Cover the electrical outlets with wet towels.'' ''Open the fireplace dampers in the day room.'' ''Move clients to a room above ground with few windows.'' ''Turn on fans in the facility to circulate air.''
? move clients
a nurse is assisting in the care of a client who is 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations of the nurse make?
? pelvic rock
A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? SATA. A. Record the date and time of the telephone prescription B. Request that the provider confirm the read-back of the prescription C. Ask the provider to spell out the name of the prescription D. Withhold the medication Until the provider signs the prescription E. Instruct another nurse to record the prescription in the medical record
A, B, C
A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching? o Administer the medication when the toddler has an acute asthma attack o Mix the medication in juice prior to administration o Provide an additional dose of the medication prior to physical activity o Administer the medication to the toddler each evening
Administer the medication to the toddler each evening
A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral? o Social Worker o Advanced Practice Nurse o Patient Care Technician o psychologist
Advanced Practice Nurse
A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy? Provide privacy during client care procedures Allow the client to choose treatment times. Be honest with the client about the prognosis. Administer pain medication on a routine schedule.
Allow the client to choose treatment times
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first? Complete an incident report. Document the fall in the client's medical record. Notify the client's provider. Measure the client's vital signs.
Check vital signs
A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following instructions should the nurse include in the teaching? A. "Carry your newborn back to the nursery in your arms when you need to rest" B. "Request that the nurses show their nursing license prior to removing your newborn from the room" C. 'Leave your newborn in the bassinet in your room while you use the bathroom" D. "Alert the staff if any of your newborns identification bands are missing"
D
A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take? Check on the client every 10 min during the bath Add bath oil after the client gets into the tub( Wrong) Allow the client to remain the the bath for 30 min Drain the tub water before the client gets out
Drain the tub water
A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine? A. Cola soft drink B. Instant coffee C. Hot cocoa D. Brewed green tea
Hot coco?
A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address? "I have a difficult time getting my child to eat green vegetables." "I have noticed that my child is withdrawn since we switched day care providers." "*My child still wets the bed at least two times per week."
I choose another option and got it wrong I thing its the child is withdrawn because of daycare?
A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information? The website URL is listed as.com. The author cites references to statements made. The author's name is listed without credentials The website was last updated 3 years ago.
I choose author cites references to statements made
A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster.Which of the following instructions should the nurse include?
I got this wrong
A nurse is caring for a client who was delivered by cesarean birth 1 day ago. The client requests non-pharmacological interventions to manage pain. When changing positions. Which of the following responses should the nurse make? a. You should change positions as little as possible. b. You can apply counter pressure to your back with each position change c. You should splint the incision with a pillow when changing position. d. You should use pattern paced breathing technique when changing position.(Wrong)
I think C?
A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which commendations should the nurse make? Use the arms to pick up heavy items. Perform pelvic rocking exercises several times per day. Sit in a hot tub for 30 min every evening. Raise chairs to keep knees lower than hips.
I think I choose raise chairs to keep knees lower than hips. Perform pelvic rocking exercises*
A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to assistive personnel?
I think I selected perform ROM
A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?
I think bright red bleeding
A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan? Perform dressing changes every other day. Apply dressings with sterile gloves. Use hydrogen peroxide for wound cleaning. Cleanse the most contaminated wounds first.
I think cleanse the most contaminated wound first?
A nurse is caring for an adult client who reports having trouble getting sleep at night. Which of the following recommendations should the nurse make? o Establish Daily Exercise Routine o Keep the telephone volume low while trying to fall asleep o Remain in bed until you fall asleep(wrong) o Sleep Longer Hours On The Weekend
I think establish daily exercise routine
A nurse is collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia? Hyperactive reflexes(Wrong) Dry mucous membranes Irregular heart rate Trousseau's sign
I think irregular heart rate
A nurse is reinforcing teaching with the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include?
I think keep in rear facing carseat until 2 or keep shoulder harness and armpit level
A nurse is reinforcing teaching with a client about collecting a stool specimen to check for occult blood. Which of the following statements by the client indicates an understanding of the teaching? "Eating pasteurized dairy products will affect my test results." "Having urine mixed in with the stool will not affect the results." "I should collect a specimen once each week for 4 weeks."
I think something about not eating red meat for 3 days prior?
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
I think to start exercising or reducing salt intake(2g sodium)
A nurse is reinforcing discharge teaching with a client who is stable angina pectoris which of the following statements by the client indicates an Understanding of what to do when chest pain occurs
I think to stop activity and lay down
A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?
I think use two different syringes
A nurse is reinforcing teaching with the parents of a newborn about bathing. Which of the following instructions should the nurse include in the plan of care? a. Set the water heater to 125. Degrees fahrenheit , b. Hold your baby under running water when washing his hair , c. Check water temperature with your fingers D. use moist towelette
I think using a towel
A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?
Im glad I'm done having children or I don't want any kids anymore
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? o Measure The Duration Of The Seizure o Restrain The Clients Arms And Legs To Prevent Injury o Lower the side rails of the bed when the seizure begins o Insert an oral airway into the client's mouth
Measure The Duration Of The Seizure
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include? Physical assessment findings Medications taken prior to admission Medical health insurance claims Family medical history
Physical assessment
A nurse is assisting with preparing a client who has a central venous catheter inserted for the administration of total parenteral nutrition. TPN which of the following actions should the nurse take. Use clean technique when changing the catheter dressing. Verify the amount of ton solution the client is receiving every 4 hr. Place the client in sims positions for catheter insertion. Prepare the client for a chest Xray to verify catheter placement.
Verify placement
A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action but the nurse? place a pulse oximeter on the clients finger administer oxygen to the client establish a patent airway for the client check the client's pulse rate
administer O2
A nurse is reinforcing teaching with a client who had a total right hip arthroplasty. Which of the following instructions should the nurse include? A. "You should avoid sleeping on your right side"(Wrong) B. "You should avoid exercising for the next 6 weeks" C. "You should avoid putting a pillow between your legs in bed" D. "You should avoid crossing your legs for 3 months"
avoid crossing legs
A nurse is reinforcing teaching with a client who is to have their plaster cast applied to his right arm Which of the Following information should the nurse include in the teaching
elevate arm after
A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?
empty pouch first
A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?
fidelity?
A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously after injecting 10 units of Air into the NPH insulin vial. Which of the following actions should the nurse take next?
inject air into regular insulin
A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take? Provide the client with a glass of orange juice. Position the client on their left side. Instruct the client to take a brisk walk. Check the client's temperature.
left side
A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify which of the following client care issues requires reporting to the interprofessional team? The client requires reinforcement of teaching about the purpose of his medications. The client requests to perform ADLs later in the day. • The client tells the nurse he prefers a snack before bedtime.
missing answer choice I thought it was something about not being able to eat or swallow? not able to grab eating utensils
A home health nurse is conducting a home inspection for a client who is it was for falls which of the following instruction should the nurse provide for the client
move clients bed to main floor of house ?
A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client? Move the client's bed to the main floor of the house. Keep lighting in the home dim. Place the bedside table 2 feet away from the bed. Place area rugs on slick floor surfaces.
move the bed to the main floor?
A nurse is contributing to the plan of care oraclient whois major depressive disorder. Which of the following recommendations should the nurse include in the plan of care? o Suggest The Client Exercise Before Going To Bed o Recommend The Client Spend Time Alone In His Room o Encourage The Client To Use Positive Self Talk o Offer The Client Low-protein snacks throughout the day
o Encourage The Client To Use Positive Self Talk
A charge nurse is reinforcing teaching with newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? o Soiled dressings should be placed in a biohazard trash receptacle o Droplet precautions require that wear gown glove when providing care o Following a blood spill,I should use a bleach solution with ratio of 1 to 20 o For a client who is Clostridium difficile, i Will Clean Hands my with an alcohol-based rub
o Soiled dressings should be placed in a biohazard trash receptacle
A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching? o You Can Safely Take This Medication If Become Pregnant o You can skip a dose of this medication if you are nauseated o You might experiences swollen gums while taking this medication o You should expect have blood work every 6 months while taking this medication
o You might experiences swollen gums while taking this medication
A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicate that the medication is effective? - our child has lost some weight since his last appointment - our child has a better grasp of reality - our child has increased his daily caloric intake -our child is able to complete his homework on time
our child is able to complete his homework on time
A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?
overhead light
A nurse is reinforcing teaching with a client who has asthma and a new prescription for a beclomethasone inhaler. Which of the following instructions should the nurse include in the teaching? rinse your mouth after each use of the inhaler decrease your calcium intake while taking this medication allow at least 5 minutes between puffs use this inhaler prior to using your short acting inhaler
rinse out mouth
A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching? "I should not feed my baby anything for 2 hours prior to an Immunization. "My baby will receive the rotavirus immunization orally." "I should expect my baby to have a high fever for 24 hours after an immunization."(Think I choose this) "My baby will receive three doses of the meningococcal immunization before kindergarten."
should receive the RV orally
A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
shoulder harness?
A nurse is applying a belt restraint to a client who has become physically aggressive which of the following actions should the nurse take. Apply the restraint under the client's clothes. Place the client in a sitting position. Tie the restraint to the railing of the client bed. Ensure the restraint is placed across the client chest. Ensure the restraint is placed across the client chest.
sitting position
a nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray, which of the following methods should the nurse use to verify the placement? Inject air and listen for bubbling. Measure the gastric residual. Test the ph of the gastric aspirate. Add food coloring to the formula.
test the pH
A nurse is providing a change-of-shift report for a client. Which of the following information should the nurse include in the report? "The client's mother died 4 years ago from breast cancer." "The client received the prescribed antibiotic every 8 hours." "The client reports pain is reduced when he is positioned on his side "The client's partner visited earlier today for 2 hours."
the client reports pain is reduced
A nurse is caring for a client who is 2 days postoperative following an above the knee amputation which of the following actions should the nurse take to promote progression toward independence and mobility for the client
use trapeze
A nurse is caring for a client who is 2 days postoperative following an above the knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?
use trapeze
A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider? Fatigue when ambulating 152 m (500 ft) Weight loss of 1 kg (2.2 lb) in the past 24 hr Productive cough with pink, frothy sputum Pale, clammy skin
weight loss?
