COMP review

a nurse manager is updating protocols for the use of belt restraints. which of the following guidelines should the nurse manager include

document the clients condition every 15 mind

a nurse is preparing to feed a newly admitted client who has dysphagia. which of the following actions should the nurse plan to take

sit at or below the client's eye level during feedings

a nurse is preparing to obtain a health history from a client who is on bedrest. which of the following positions should the nurse take to place the client as ease

sit in a chair next to the bed

a nurse is caring for a client who has a placenta previa. which of the following findings should the nurse expect

spotting

a nurse is caring for an infant who had gastroenteritis. which of the following assessment findings should the nurse report to the provider

sunken fontanels and dry mucous membranes

a nurse is teaching a client who has RA about illness management. which of the following instructions should the nurse include in the teaching

take a hot shower in the morning to decrease stiffness

a nurse is providing discharge teaching about home care for a surgical incision to a client who speaks a different language from the nurse. the nurse is communicating with the client using an interpreter. which of the following actions should the nurse take

talk directly to the client

a nurse is teaching a new nurse about caring for clients in the ER. which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly

tell the client "you seem to be very upset"

a nurse in an emergency department is caring for a client following a MVA. the client GCS is 15 which of the following findings should the nurse expect

the client is oriented x3

a nurse in an acute mental health facility is participating in a medication education group. the leader of the group uses a laissez-faire leadership style. which of the following actions should the nurse expect from the leader During session

the leader allows the group to discuss whatever they would like to regarding their medications

a nurse is preparing to administer a medication that is available in a glass ampule. which of the following actions should the nurse plan to take

the nurse should use a filtered need to withdrawal the medication

a newly license nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. which of the following tasks should the nurse identify as a tertiary prevention

using an electronic messaging system to remind clients when to the medication

a case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. which of the following statements should the nurse make

we can review some information to help you select a safe alternative practitioner"

a nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care, which of the following instructions should the nurse include in the teaching

wear clean cotton socks every day

a nurse is creating a plan of care for a female client who has recurrent urinary tract infections. which of the following interventions should the nurse include in the plan

wear loose-fitting underwear

a nurse administering furosemide IV bolus to a client who has fluid volume excess. the nurse should recognize which of the following findings as an indications that the medication has been effective

weight loss

a nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. which of the following statements by the client indicates an understanding of the teaching

"I can lift objects that are less than 10 pounds"

a nurse is preparing to administer vancomycin IV too an adult client, the client asks the nurse if the medication can be given 2 hr earlier. which of following statements should the nurse make

"I can start the medication 30 minutes earlier"

a nurse is teaching a prenatal class about infection prevention at a community center. which of the following statements by a client indicates an understanding of the teaching

"I can visit my nephew who has chickenpox 5 days after the sores have crusted"

a nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. which of the following statements by the client indicates an understanding of the teaching

"I know it will be a couple of weeks before the medication helps me feel better"

a nurse is teaching a client who has afib and is to start taking dabigatran. which of the following statements by the client indicates an understanding of the teaching

"I should keep the medication in the original container"

a client is hesitant to create advanced directives due to concern about affording legal representation, which of the following statements should the nurse make

"advanced directive can be a verbal agreement between you and your provider until legal review can be obtained"

a nurse is an ED is assessing an adolescent who has conduct disorder. which of the following questions is the priority for the nurse the ask the client

"do you have thoughts of harming yourself?"

a nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. which of the following instructions should the nurse include

"participate in range-of-motion exercises"

a nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. which of the following instructions should the nurse include

"perform chest percussion and postural drainage at least twice daily"

a nurse is a PACU is transferring care of a client to a nurse on the med-surg unit. which of the following statements should the nurse include in hand-off report

"the estimated blood loss was 250 milliliters"

a nurse is teaching a new parent about breastfeeding her 2-week-old infant. which of the following statements by the parent indicates an understanding of the teaching

"the more my baby is at the breast sucking, the more milk i will produce"

a nurse in a mental health clinic receives a request from a client who i undergoing psychotherapy to obtain a copy of therapist's notes. which of the following responses should the nurse make

"we can provide a copy of your records, but the therapist's notes are not included"

a nurse is admitting a client who has schizophrenia. the client states "im hearing voices". which of the following responses is the priority for the nurse to state?

"what are the voices telling you?"

a nurse is providing teaching about immunizations to a client who is pregnant. which of the following statements should nurse include in the teaching

"you can receive the immunization for influenza at any time during your pregnancy"

a nurse is caring for a client who has given informed consent for electroconvulsive therapy. just before the procedure the client tells the nurse she is considering not going forward with the treatment. which of the following statements by the nurse is appropriate

"you dont have to go through with the treatment"

a nurse is caring for a client who asks for information regarding organ donation. which of the following responses should he nurse make

"your desire to be an organ donor must be documented in writing"

a nurse is planning care for an older adult client who has dementia. which of the following interventions should the nurse include in the plan of care? (SATA)

-give the client one simple direction at a time -reinforce orientation to time, place, and person -establish eye contact when communicating with the client q

a nurse is caring for a client who requires nasotracheal suctioning. identify the sequence the nurse should follow to perform the suctioning

1. turn on the suction, set the pressure 2. don sterile gloves 3. insert catheter during inspiration 4. apply suction while rotating catheter 5, rinse the catheter to remove secretion

a nurse is providing teaching to a client who has a new prescription for enoxaparin. which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin

Acetaminophen

a quality control nurse is reviewing medication prescriptions for a group of clients. which of the following medication prescriptions should the nurse identify as being complete.

Digoxin 0.25mg PO daily

a nurse is assessing a client who is in active labor. which of the following findings should the nurse report to the provider

FHR baseline 170/min

a nurse is reporting a client's lab tests to the provider to obtain a prescription for the clients daily warfarin. which of the following lab tests should the nurse plan to report to obtain the prescription for warfarin

INR

a nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal leceration. the client reports not having a bowel movement for 4 days. which of the following medications should the nurse administer

Magnesium hydroxide 30 ml PO

a nurse is receiving change-of-shift report for a group of clients. which of the following clients should the nurse plan to assess first

a client who has a hip fracture and a new onset of tachypnea

a nurse is providing an in-service about client evacuation during a fire. which of the following clients should the nurse instruct the staff to evacuate first

a client who is ambulatory and receiving oxygen

a nurse is reviewing the medical records of four clients. the nurse should identify that which of the following client findings requires follow-up care

a client who is taking warfarin and has in INR of 1.8

a nurse just received change of shift report for four client. which of the following clients should the nurse assess first

a client who was just given a glass of orang juice for a low blood glucose level

a nurse is caring for a client who has implanted venous access port, which of the following should the nurse use to access the port

a noncoring needle

a nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. which of the following actions should the include in the plan of care

administer a cathartic suppository 30 mins prior to scheduled defecation times

a nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. which of the following actions should the nurse include

administer analgesics on a scheduled basis for the first 24 hrs

a nurse is caring for a client who is receiving TPN. the bag is 20 ml remaining to infuse, but the new bag is not readily available. which of the following actions should the nurse take

administer dextrose 10% in water

a nurse is preparing an in-service fro a group of nurses about malpractice issues in nursing. which of the following examples should the nurse include as an example of malpractice

administering potassium via IV bolus

a nurse is caring for a client who has a prescription for a peripheral IV catheter. after puncturing the skin with the access device and noting blood return in the flashback chamber, which of the following actions should the nurse perform next

advance the catheter into the vein

a nurse is caring for a client who is immobile. which of the following interventions is appropriate to prevent contracture?

align a trochanter wedge between the client's legs

a nurse is caring for a client who is repeatedly refusing meals. the nurse overhears an AP telling the client "if you dont eat, ill put restraints on your wrists and feed you". the nurse should intervene and explain to the AP that this statement consists of which following tort?

assault

a nurse is planning teaching for a client and their family about home oxygen therapy. which of the following information should the nurse plan to include in the teaching

avoid using nail polish remover around the client

a nurse is caring for a 2 year old toddler. which of the following food choices should the nurse recommend to promote independence in eating

banana slices

a nurse is caring for a client whose partner recently died. the nurse sits with the client to provide comfort. which of the following ethical principles is the nurse demonstrating

beneficence

a nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. which of the following instructions should the nurse include in the teaching

blow into the meter as hard and quickly as possible

a nurse is caring for a school-aged child who is postoperative and received morphine IV bolus for pain 10 min ago. which of the following findings is the nurses priority

bradypnea

a nurse is preparing to insert IV catheter to a client. which of the following actions should the nurse plan to take

choose a vein that is palpable and straight

a nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. which of the following actions should the nurse take to evaluate the effectiveness of the procedure

compare the client's current weight with pre procedure weight

a nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. for which of the following therapeutic effects should the nurse monitor the client

deep tendon reflexes 2+

a nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. which of the following actions should the nurse take

determine if the clients health care surrogate is aware of the ricks and benefits of the procedure

a nurse in an emergency department is caring for a client who has a close head injury which of the following actions should the nurse take first

determine the client's Glasgow Coma Scale

a nurse on a medical unit is notified that a mass casualty event has occurred in the community. which of the following actions should the nurse plan to take

determine the medical needs of incoming clients through the emergency department

a charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. which of the following conflict-resolution strategies should the charge nurse use

encourage collaboration between the two nurses when making the assignments

a Home health nurse is caring for a child with lymes disease, what is the correct action for the nurse to take

ensure the state health department has been notified

a nurse is caring for a child who has a vented NG tube set to low intermittent suction and has vomited. which of the following actions should the nurse perform first

evaluate functioning of the suction device

a nurse is preparing to reposition a client who has a stroke. which of the following actions should the nurse take

evaluate the client's ability to help with repositioning

a nurse in an emergency department is caring for a child who reports being sexually abused by a family member. which of the following actions should the nurse take

explain to the child what will happen when the abuse is reported

a nurse is reviewing a client's cardiac rhythm strips and notes a constant P.R. interval of 0.35 seconds. which of the following dysrhythmias is the client displaying

first-degree atrioventricular block

a nurse is caring for a client who is experiencing aphasia and right hemiparesis following a stroke. which of the following actions by the nurse best promotes communication among staff caring for the client

having interdisciplinary team meetings for the client on a regular basis

a nurse is assessing a client immediately following a cardiac catheterization. the nurse should notify the provider for which of the following findings

hematoma over the insertion site

a nurse is caring for a client who has acute glomerulonephritis. which of the following findings should the nurse expect

hematuria

a nurse ins a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. the nurse should identify which of the following conditions as a contraindication for receiving this treatments

herpes zoster

a nurse is performing postmorten care for a recently deceased client prior to the clients family visits. which of the following actions should the nurse plan to take

hold the client's eyes shut for a few seconds

a nurse is providing discharge teaching to a partner of a client who has a tracheostomy. which of the following information should the nurse include in the teaching

how to operate the portable suction machine

a nurse is caring for a client who has end-stage kidney disease. the client's adult child asks the nurse about becoming a living kidney donor for their parent. which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure

hypertension

a nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. which of the following conditions should the nurse include in the teaching

hypertension

a nurse is caring for a newborn whose mother was taking methadone during her pregnancy. which of the following findings indicate the newborn is experiencing withdrawal

hypertonicity

a nurse is caring for a client who has experienced a stroke and is moving in with their adult child . which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles

implement firm bur flexible boundaries in their relationship

a nurse is planning to teach a client about taking prednisone. which of the following instructions should the nurse include

increase dietary calcium

a nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications, which of the following information should the nurse include in the teaching

increase exercise activity

a nurse is reviewing lab data of a client who received 2 unites of packed RBC. which of the following lab findings should the nurse expect following the transfusion

increased hct

a parish nurse is leading a support group for the clients whose family members have committed suicide. which of the following strategies should the nurse plan to use during the group session

initiate a discussion with clients about ways to cope with changes in the family dynamics

a nurse is caring for an adolescent who has hyperthermia. which of the following actions should the nurse take

initiate seizure precautions

a nurse is planning for a client who is scheduled for a thoracentesis. which of the following actions should the nurse plan to take

instruct the client to avoid coughing during the procedure

a nurse is caring for a client receiving penicillin G via intermittent IV piggyback. what action should the nurse take

instruct the client to notify the provider if diarrhea develops

a nurse is assessing a child who has bacterial pneumonia. which of the following manifestations should the nurse expect

malaise

a nurse is assessing a 2-year old toddler, which of the following findings should the nurse expect

nontender, protruding abdomen

a nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. which of the following interventions should the nurse anticipate

obtain a urine specimen for culture and sensitivity

a nurse is performing a skin assessment on a client who has dark skin. which of the following locations on the client's body should the nurse observe to assess for cyanosis

palms of the hands

a nurse is assessing a client who has an abdominal incision. which of the following findings should the nurse report to the provider

partial seperation of the upper part of the incisional site

a nurse is preparing to assess fetal heart tones for a client who is 12 weeks of gestation, which of the following actions should the nurse take

position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart tone

a nurse is providing teaching about the use of crutches using a 3-point gait to a client who has a tibia fracture. which of the following actions by the client indicates an understanding of the teaching

positioning both hands on the grips with his elbows slightly flexed

a charge nurse is teaching new staff members about the factors that increase a client's risk to become violet. which of the following risk factors should the nurse include as the best predictor of future violence.

previous violent behavior

a public health nurse working in a rural area is developing a program to improve health for a local population. which of the following actions should the nurse plan to take

provide anticipatory guidance classes to parents through public schools

a nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. which of the following is an appropriate action by the nurse

provide humidification of the room air

a nurse is developing a care plan for a client who is in Bucks tractions and is scheduled for surgery for a fractured femur of the right leg. which of the following interventions should the nurse delegate to an assistive personnel

remind the client to use the incentive spirometer

a nurse is setting up a sterile field to perform wound irrigation. which of the following actions should the nurse take when pouring the sterile solution

remove the cap and place it sterile-side up on the clean surface

while performing a routine assessment, a nurse notices fraying on the electrical cord of the clients continuous passive motion (CPM) device. which of the following actions should the nurse take first

remove the device from the room

a nurse is assessing a client who is taking haloperidol and experiencing psuedoparkinsonism. which of the following findings should the nurse document as a manifestation of pseudomarkinonism

shuffling gait