EEXAM2

A nurse is reviewing the laboratory values of the client who has COPD. Which of the following findings should the nurse report to the provider? - potassium 3.7 mEq/L - iron 150 mcg/dl - hgb 13,000/mm3

- hgb 13,000/mm3

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect? - Rigid abdomen - Persistent uterine contractions - Increased fetal movement - Bright red vaginal bleeding

- Bright red vaginal bleeding

A nurse is reinforcing teaching with a newly licensed nurse about strokes. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - " A sudden, severe headache is a warning sign of stroke." - "Women using hormone replacement therapy protect themselves against stroke." - " Strokes are most frequently caused by ruptured blood vessels in the brain." - " A client experiencing a right hemispheric stroke will have difficulty talking."

- " A sudden, severe headache is a warning sign of stroke."

A nurse is collecting data from an adolescent who has experienced sexual abuse. Which of the following statements by the client should the nurse recognize as the use of the defense mechanism of suppression? - " My mother is the real reason for it all because she doesn't live in the real world." - " I drink beer as often as I can so that I don't have to think about all of the times it happened." - " I guess I have to take some of the blame because of the way my friends and I dress." - " Sometimes I get angry about it, but I know that just creates other problems."

- " I drink beer as often as I can so that I don't have to think about all of the times it happened."

A charge nurse is reviewing communication skills with a group of newly licensed nurses. Which of the following should the nurse include as example of assertive communication? - " I'm sorry having childcare issues, but you need to try to get to work on time when possible." - " I feel frustrated when you assign me the most difficult clients. We should develop a way to divide the work evenly." - " Haven't you finished everything yet? You never finish your assignments by the end of the shift." - " If you don't come in to cover an extra shift tomorrow, we won't offer you overtime anymore."

- " I feel frustrated when you assign me the most difficult clients. We should develop a way to divide the work evenly."

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation? - " An incident report has been completed and sent to risk management." - " The client fell because the assistive personnel did not place non skid slippers on the client." - " The client does not appear to have any injuries resulting from the fall." - " I lost my balance and fell when I got out of bed to go to the bathroom."

- " I lost my balance and fell when I got out of bed to go to the bathroom."

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has a mild hypertension. Which of the following statements by the client indicates an understanding of the teaching? - " I can have two glasses of wine with dinner." - " I will set my blood pressure goal at 130 over 84." - " I should decrease my salt intake to 2 grams a per day." - " I should exercise for 15 minutes two times per week."

- " I should decrease my salt intake to 2 grams a per day."

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements the client indicates an understanding of the teaching? - " I can use isopropyl alcohol to clean the nasal cannula when necessary." - " I will increase the flow rate if I feel short of breath." - " I can use synthetic blankets on my bed." - " I will check my oxygen equipment at least once daily."

- " I will check my oxygen equipment at least once daily."

A charge nurse in a long term care facility is discussing ethical theories with a group of newly licensed nurses. Which of the following statements should the charge nurse identify as an indication that a newly licensed nurse understands utilitarianism? - " I will consider what is going to benefit the most people when making decisions." - "I will place a higher emphasis on human dignity than on the needs of a group." - " I will respect the decision of a client who has chronic illness to stop treatment." - " I will withhold a terminal diagnosis from a client who has cancer."

- " I will consider what is going to benefit the most people when making decisions."

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following? - Chloasma - Ballottement - Hegar's sign - Chadwick's sign

- Chadwick's sign

A male nurse is assigned to care for an older adult female client. The client tells the nurse that she wants a female nurse to care for her. Which of the following statements should the nurse make? - " I will ask to have you assigned to a female nurse." - " I will get a female assistive personnel to provide your bath." - " I care for other female clients and they do not mind a male nurse." - " You will need to speak with the nurse manager about this."

- " I will get a female assistive personnel to provide your bath."

A nurse is reinforcing dietary teaching with a client who has Cushing's syndrome. Which of the following statement by client indicates an understanding of the teaching? - " I will limit potassium intake." - " I will increase my carbohydrate intakes." - " I will limit my sodium intake." - " I will increase my caloric intake."

- " I will limit my sodium intake."

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 disinfect contaminated hard surface with a 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." - " I will use animal-skin condoms when having sex."

- " 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."

A nurse is reinforcing teaching about a low sodium diet with a client who has hypertension.Which of the following statements by the client indicates an understanding of the instructions? - "I will put ketchup on my hot dogs." - " I will use frozen vegetables rather rather than canned." - " I will eat turkey sausage for breakfast." - " I like to use store-bought spaghetti sauce."

- " I will use frozen vegetables rather rather than canned."

A nurse is reinforcing teaching about home safety with the parents of 6-week-old infant. Which of the following instructions should the nurse include? - " Keep your baby secured in the infant carrier if you must leave him unattended on a high surface." - " Keep one hand on your baby's abdomen if you must turn away while he is on the changing table." - "Keep the crib mattress in the highest position until your baby is sleeping." - " Keep the bumper pads secured to the crib rails while your baby is sleeping."

- " Keep one hand on your baby's abdomen if you must turn away while he is on the changing table."

A nurse is preparing to test a client's plantar babinski reflex. Which of the following instructions should the nurse give to prepare the client for this task? - "Place your foot in my hand and I will tap the back of your heel." - " Relax your arm across your chest and I will test your elbow extension." - "Sit on the edge of the bed while I tap your knee." - " Lie down and I will stroke the bottom of your foot."

- " Lie down and I will stroke the bottom of your foot."

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 indicates that medication is effective? - " Our child is able to complete his homework on time." - "Our child has a better grasp of reality." - " Our child has lost some weight since his last appointment." - " Our child has increased his daily caloric intake."

- " Our child is able to complete his homework on time."

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following should the nurse make? - "Albuterol treatments can cause blood glucose level to decrease." - " Prednisone can cause blood glucose levels to increase." - " Older adult are at risk for developing type 1 diabetes mellitus." - " Having COPD causes blood glucose levels to fluctuate."

- " Prednisone can cause blood glucose levels to increase."

A nurse is preparing to administer a medication to a client. To help verify the client's identity, which of the following questions should the nurse ask the client? - " What is your room number here." - " Is your name victoria?" - " What is your telephone number?" - " What is your doctor's name?"

- " What is your telephone number?"

A nurse is talking with client who refuses a blood transfusion for religious reason. Which of the following responses should the nurse make? - " Making this decision is wrong." - " You have a right to change your mind." - " If I were you, I would contact your spiritual director." - " I'm sure that everything will be all right, regardless of your decision."

- " You have a right to change your mind."

A nurse is reinforcing discharge teaching with a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following information should the nurse include in the teaching? - " You should carry one nitroglycerin tablet in a small plastic bag at all times." - " You will feel a tingling sensation in your mouth when taking a nitroglycerin tablet." - " Take nitroglycerin immediately following heavy physical activity." - " Contact your provider if you get a headache after taking nitroglycerin."

- " You should carry one nitroglycerin tablet in a small plastic bag at all times." - " Contact your provider if you get a headache after taking nitroglycerin."

A nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to undergo an amniocentesis. Which of the following information should the nurse include in the instructions? - " You will need to have an empty bladder for the test." - " You will have to drink 50 grams of oral glucose before the test." - " You will have to lie on your lie on your left side during the test." - " I will need to give you a Rh(D) immune globulin because you are Rh positive."

- " You will need to have an empty bladder for the test."

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks," Why is colostrum so important for my baby?" Which of the following responses should the nurse make? - " Colostrum contains iron, which is important for a newborn's brain development." - "Colostrum provides many important antibodies that the newborn lacks." - "Colostrum provides vitamin K, which is an essential nutrient for newborns." - " Colostrum contains a natural diuretic that stimulates the newborn to void."

- "Colostrum provides vitamin K, which is an essential nutrient for newborns."

A nurse is caring for client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider? - weight gain' - Anorexia - Epistaxis - Bradycardia

- Epistaxis

A nurse is caring for a client who has advanced colorectal cancer and reports that her daughter insists on caring for her at home without assistance. The client states she would prefer help from home health care and hospice. Which of the following responses should the nurse make? - "Why do you have doubts about your daughter caring for you?" - "What you need to do now is rest so you'll be better able to deal with your home care issues." - "I can be with you while you explain your feelings about your care to your daughter." - "I am sorry to hear that you and your daughter have conflicting opinions."

- "I can be with you while you explain your feelings about your care to your daughter."

A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching? - "This medication will darken the color of my eyes." - "I should take a zinc supplement while taking this medication." - "I should check my heart rate while taking this medication." - "This medication will dilate my eyes."

- "I should check my heart rate while taking this medication."

A nurse is reinforcing teaching with a client about how to collect a fecal occult blood. sample. Which of the following statements by the client indicates an understanding of the teaching? - "I should repeat the process three times." - "I should collect the sample regardless of my hemorrhoids bleeding." - "I can continue to eat meat because it will not affect the sample" - "I can continue to take my daily aspirin."

- "I should repeat the process three times."

A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablets. Which of the following statements by the client indicates an understanding of the teaching? - "I will swallow the tablet for faster absorption." - "I should expect pain relief in 1 to 3 minutes." - "I should stop taking the medication if I get a headache." - "I will wait 15 minutes before taking a second tablet."

- "I should stop taking the medication if I get a headache."

A nurse is reinforcing teaching with a client who is at 12 week gestation and has hyperemesis gravidarum. Which of the following client statements indicates an understanding of the nurse's instruction? - " I will try to eat balanced meals instead of only foods that appeal my taste." - "I will wait 1 hour after getting up in the morning to have breakfast." - "I will eat a low-protein snack 30 minutes before going to bed each night." - "I will eat or drink something every 2 or 3 hours throughout the day."

- "I will eat or drink something every 2 or 3 hours throughout the day."

A nurse is reinforcing teaching with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching? - "I will carry my baby to the nursery." - "I can take my baby to the lobby to visit family." - "I will have an identification band that matches to one my baby wears." - "I can remove my security band to give it to a family member."

- "I will have an identification band that matches to one my baby wears."

A nurse is reinforcing discharge teaching with the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? - "I will limit my baby's feedings so he does not become overweight." - "I will place my baby on his back for sleeping." - "I will change my baby's diaper every 4 hours." - "I will notify my provider if my baby sleeps more than 10 hours per day."

- "I will place my baby on his back for sleeping."

A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of the teaching? - "I will remove the patch if I develop a headache." - "I will place the patch on a hairless area of the skin." - "I will apply the patch in the same place every day." - "I will replace the patch every 12 hours."

- "I will place the patch on a hairless area of the skin."

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make? - " Have you considered how your decision to refuse medication will affect your family?" - " You will suffer serious health issues if you don't take your medication." - "I'd like to hear your thoughts about giving yourself insulin." - "Why don't you want to learn how to give yourself your medication?"

- "I'd like to hear your thoughts about giving yourself insulin."

A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching? - "Avoid making eye contact with the client." - "Label the door to the bathroom with a symbol." - "Give the client several choices of foods for meals." - "Increase environmental stimuli."

- "Label the door to the bathroom with a symbol."

A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse? - "The important thing is that he gets better, not how long it takes." - "We've seen steady improvement in other clients who are depressed." - "No one really knows the answer to that question." - "Tell me what you know about depression."

- "Tell me what you know about depression."

A nurse is reinforcing teaching with the family of a client who is terminally ill about the grief process. Which of the following should the nurse include in the teaching? - "Anticipatory grieving prolongs the grief process." - " The grieving should be complete within 1 year." - "The stages of grief occur in sequential order." - "Anger toward the health staff is expected."

- "The stages of grief occur in sequential order."

A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? - "Why do you feel the staff is the FBI?" - "This must be very frightening for you. Let's talk more about it." - "What makes you think the staff is following you?" - "The psychiatric staff is not FBI. They are here to help you."

- "This must be very frightening for you. Let's talk more about it."

A nurse is reinforcing dietary teaching with a client whose pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy? - 32 lb - 8 lb - 16 lb - 24 lb

- 16 lb

A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply) - A client fell when ambulating to the bathroom alone - aAn approximate amount of urine was recorded after the urine leaked from the client's catheter bag. - A client received the first dose of antibiotic 1 hour before the collection of blood for culture and sensitivity. - A client received an 0900 daily medication at 1000. - A client who has an infection refused the evening meal.

- A client fell when ambulating to the bathroom alone

A nurse is collecting data from a group of clients who have major depressive disorder. The nurse should identify that which of the following clients is at the greatest risk for suicide? - A client who exhibits an increase in energy - A client who reports an inability to concentrate - A client who experiences persistent insomnia - A client who has psychomotor retardation

- A client who exhibits an increase in energy

A nurse on a medical - surgical unit receives change - of - shift report for a group of adult clients. Which of the following clients should the nurse attend to first? - A client who needs his wound staples removed - A client who has a small amount of bleeding around his new stoma - A client who has a blood pressure of 186/130 mm hg - A client who received oral pain medication 10 minutes ago

- A client who has a blood pressure of 186/130 mm hg

A nurse is receiving change of shift reports of four clients. Which of the following clients should the nurse see first? - A client who has sickle cell disease and hyperbilirubinemia - A client who had a hernia repair 4 hr ago and is reporting nausea - A client who has cirrhosis and hematemesis - A client who is 1 day postoperative and reports a pain level of 7 on a scale from 0 to 10

- A client who has cirrhosis and hematemesis

A nurse is caring for a group of client. Which of the following clients should the nurse recognize experiencing fluid volume excess? - A client who has COPD and an oxygen saturation of 92% - A client who is 1 day postoperative and has an Hgb level of 16 g/dL - A client who has heart failure and has had orthopnea for 2 days - A client who has urinary tract infection with bladder distention two fingerbreadths below the umbilicus

- A client who has urinary tract infection with bladder distention two fingerbreadths below the umbilicus

A nurse should recognize that a client's right confidentiality has been breached in which of following situations? - A facility risk manager includes information from a client medical record in a written report. - A newly licensed nurse discusses his client's postoperative complication during shift report. - A nurse tells the chaplain that her assigned client has a new diagnosis of cancer - A social worker reads clients chart as follow- up to requested consultation.

- A facility risk manager includes information from a client medical record in a written report. - A nurse tells the chaplain that her assigned client has a new diagnosis of cancer

A nurse is contributing to the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? - Obtain the diet history from a client who has heart failure. - Administer a client's nighttime dose of milk of magnesia - Perform basic life support - Educate a client about the use of an incentive spirometer

- Administer a client's nighttime dose of milk of magnesia

A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering hypotonic enemas to a client. Which of the following instructions should the nurse include in the teaching? - Administer a second enema if the first has poor results. - Instruct the client to exhale while inserting the rectal tube. - Insert the tip of the rectal tube 1.5 cm (6in) - Administer the enema using cool tap water.

- Administer the enema using cool tap water.

A nurse is obtaining a capillary blood specimen to measure a client's blood glucose. Which of the following actions should the nurse take? - Apply sterile gloves. - Allow the antiseptic to dry before puncturing. - Massage the client's finger away from the puncture site. - Hold the lancet at a 45 degrees angle.

- Allow the antiseptic to dry before puncturing.

A nurse is collecting data from a toddler during a well- child visit. Which of the following actions should take to prepare the toddler for a physical examination? - Start the examination with routine immunizations. - Thoroughly explain Each procedure to the toddler. - Completely undress the toddler. - Allow the toddler to handle the equipment.

- Allow the toddler to handle the equipment.

A nurse is delegating client care assignments. Which of the following tasks should the nurse assign to an assistive personnel? - Reinforcing teaching about how to use a glucometer with a client who had diabetes mellitus. - Repositioning a client who is experiencing increased intracranial pressure. - Apply antiembolic stockings for a client who is 2 days postoperative. - Monitoring a client's sacral pressure ulcer to determine the need for a dressing

- Apply antiembolic stockings for a client who is 2 days postoperative.

A home health nurse is caring for a client who has Alzheimer's disease. The client's son is concerned about his mother becoming frustrated. Which of the following interventions should the nurse include? - Have several family members visit daily - Make a schedule of daily tasks - Ask questions that require more than one answer - Limit the use of familiar objects

- Ask questions that require more than one answer

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 an assistive personnel? - Instruct the client's family about the purpose of mitten restraints. - Assist the client with range-of-motion exercises of the hands. - Determine the circulation status of the affected extremities every 2 hours. - Evaluate the need to for the client to remain in mitten restraints.

- Assist the client with range-of-motion exercises of the hands.

A nurse at a provider's office is caring for a client who is in the third trimester of pregnancy. Which of the following findings should the nurse report to the provider? - Blurred vision - Shortness of breath when climbing stairs - Periodic numbness of the fingers - Leukorrhea

- Blurred vision

A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider? - Constipation - Blurry vision - Joint pain - Tinnitus

- Blurry vision

A nurse is caring for a 3-year - old child immediately following a tonic clonic seizure. Which of the following actions should the nurse take? - Place the child in a supine position. - Offer the child child sips of clear fluids. - Check the child for oral injuries. - Administer an oral antiepileptic medication

- Check the child for oral injuries.

A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? - Secure the tubing with adhesive tape to the lower abdomen - Instruct the client to hold the drainage bag at waist height when ambulating - Collect a sterile specimen from the urinary drainage bag - Coil the tubing on the bed above the collection bag

- Coil the tubing on the bed above the collection bag

A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take? - Remove the weights for 20 min for the client's report of severe pain. - Compare bilateral pedal pulses. - Position the knot of the rope at the top of the pulley. - Apply 6.8 kg (15 lb) of weights for use in traction.

- Compare bilateral pedal pulses.

A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching? - Consume soft, bland foods. - Rinse the mouth with an alcohol based mouthwash - Use lemon glycerin swabs. - Eat foods high in vitamin B12

- Consume soft, bland foods. - Eat foods high in vitamin B12

A nurse is caring for a client who has hepatitis A. In addition to using standard precautions, the nurse should implement which of the following isolation precautions? - Airborne - Contact - Droplet - Protective

- Contact

A nurse is caring for a client who is postoperative following abdominal surgery and has wound evisceration. Which of the following actions should the nurse take? - Hold gentle, direct pressure on the protruding organ - Place the client's knees in an extended position - Cover the wound with sterile, saline-soaked gauze - Raise the head of the bed at a 45 degrees angle

- Cover the wound with sterile, saline-soaked gauze

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease. Which of the following instructions should the nurse include in the teaching? - Decrease sodium intake - Increase phosphorus intake - Increase protein intake - Decrease carbohydrate intake

- Decrease sodium intake

A nurse is caring for an older adult who has acute delirium. Which of the following actions should the nurse take first? -Keep lights out in the client room - Administer an anxiolytic medication. - Encourage visits from family members. - Determine the client's level of consciousness.

- Determine the client's level of consciousness.

A nurse is assisting with the development of an education program for a group of adult clients. Which of the following actions should the nurse take first? - Establish learning outcomes - Schedule a time to implement the program - Create handouts for participants - Determine the literacy level of participants

- Determine the literacy level of participants

A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following adverse effects should the nurse include in the teaching as an indication of serotonin syndrome? - Diaphoresis - Hypotension - Peripheral edema - Decreased body temperature

- Diaphoresis

A nurse is reinforcing teaching with a client who has a new prescription for metformin. Which of the following should the nurse include as an adverse effect of this medication? - Diarrhea - Red-tinged urine - Hypertension - Weight gain

- Diarrhea

A nurse is caring for a client who is experiencing alcohol withdrawal. The nurse prepare to administer which of the following medications? - Diazepam - Naloxone - Clonidine - Methadone

- Diazepam

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority? - Ecchymosis on the inner left thigh - Diminished pulses on the affected extremity - Client report muscle spasms of the left leg - One fingerbreadth of space between the cast and the skin

- Ecchymosis on the inner left thigh

A nurse is caring for a client who is 2 days postoperative following the surgical creation of an ileostomy and is tolerating oral intake. Which of the following actions should the nurse take? - Apply sterile dressing to the stoma - Insert catheter to drain liquid feces - Empty the ileostomy pouch every 2 to 3 hour - Irrigate the ileostomy with sterile water

- Empty the ileostomy pouch every 2 to 3 hour

A nurse is caring for a client who has moderate anxiety. Which of the following actions should the nurse take? - Administer a PRN dose for an antipsychotic medications with a client. - Encourage the client to rest as much as possible. - Maintain eye contact when talking with the client. - Place the client in seclusion.

- Encourage the client to rest as much as possible.

A nurse is caring for a client who is 12 hr postpartum, has had an episiotomy, and reports perineal pain. Which of the following actions should the nurse take? - Place a heat lamp at the perineal area for 15 min - Instruct the client to perform Kegel exercises. - Encourage the client to use the sitz bath twice daily for 20 min - Recommend that the client sit on a soft pillow

- Encourage the client to use the sitz bath twice daily for 20 min

A nurse is reinforcing discharge teaching with the family of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching? - Limit the client's social interactions. - Assume responsibility for making decisions. - Maintain a verbal no-harm contract with the client - Encourage to client to be assertive.

- Encourage to client to be assertive.

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include? - Clamp the chest tube every 4 hour. - Ensure the device is kept below the level of the client's chest. - Empty the collection chamber every 8 hr. - Place the client in a supine position.

- Ensure the device is kept below the level of the client's chest.

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? - Autonomy - Fidelity - Nonmaleficence - Justice

- Fidelity

A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? - Clammy skin - Fruity breath odor - Bound pulse - Elevated blood pressure - Elevated blood pressure

- Fruity breath odor

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates effective time management? - Skipped breaks throughout the shift - Gathering supplies for each client prior to care - Setting specific times for low priority tasks - Performing charting at the change of shift

- Gathering supplies for each client prior to care

A nurse is providing care to a client who reports he one at home to help him after his outpatient surgery. Which of the following action should the nurse take? - Call the provider about admitting the client to the facility overnight. - Give the client a list of home care assistants to contact. - Assist with a referral to a home health care agency. - contact the next of kin to assist the client at home.

- Give the client a list of home care assistants to contact.

A nurse is caring for four clients. Which of the following situations requires a signed consent form? - Inserting a nasogastric tube - Administering an iron injection using Z track technique - Giving a Haemophilus influenzae B vaccine to an infant - Performing a wound irrigation with antibiotic solution

- Giving a Haemophilus influenzae B vaccine to an infant

A nurse is contributing to the plan of care for a client who has hypothyroidism. Which of the following interventions should the nurse include in the plan? - High-calorie, high-protein diet - Administer levothyroxine with client's breakfast - Increase the temperature of the client's room - Tape client's eyelids shut at bedtime

- High-calorie, high-protein diet

A nurse is checking for gastric residual volume (GRV) on a client who is scheduled to receive an intermittent enteral feeding. The nurse finds that the client has a GRV greater than 250ml on two consecutive measurements. Which of the following actions should the nurse take? - Hold the feeding and recheck the GRV in 1 hr. - Administer the scheduled feeding as prescribed. - Instill one-half of the prescribed dose of enteral nutrition. - Place the client in a left Sim's position until GRV is less than 250ml

- Hold the feeding and recheck the GRV in 1 hr.

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication? - Hyperglycemia - Hypertension - Tinnitus - Hematuria

- Hypertension

A nurse is collecting data from a client who reports recently using cocaine. Which of the following manifestations should the nurse expect? - Hyperthermia - Hypotension - Sedation - Increased appetite

- Hyperthermia

A nurse is caring for a client who has chronic diarrhea. Which of the following findings should the nurse expect? - Hypertension - Hypermagnesemia - Hypokalemia - Respiratory acidosis

- Hypokalemia

A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this error? - Nursing care plan - Incident report - Provider's progress notes - Controlled substance inventory record

- Incident report

A nurse is contributing to the plan of care for a client who has chronic pancreatitis. Which of the following recommendations for the client's nutrition should the nurse make? - Decrease the client's daily fiber intake. - Increase the client's daily fat intake. - Increase the client's daily protein intake. - Decrease the client's daily calcium intake.

- Increase the client's daily protein intake.

A charge nurse is participating on a performance improvement committee to implement changes to reduce the number of the client falls in the facility. When implementing changes, which of the following actions should the nurse take first? - Spend time with staff to be reinforce the changes. - Inform staff of the reasons for the changes. -integrate the changes as part of the staff's regular work. - Allow staff to provide feedback about the changes.

- Inform staff of the reasons for the changes.

A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching? - A client is restricted from accessing his own medical records. - Unwanted printed health information can be discarded in a trash can - Information regarding client health be e-mailed if encrypted - Members of a health care team can share a computer password.

- Information regarding client health be e-mailed if encrypted

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? - Assign the client to a positive airflow room - Initiate contact precautions - Have visitors remain at least 0.91(3 feet away) from the client - Administer aspirin if the client develops a fever

- Initiate contact precautions

A nurse is caring for a 2 - year - old child who has Clostridium difficile. Which of the following actions should the nurse take? - Initiate contact precautions - Instruct parents to avoid bringing fresh flowers into the room. - Use an N95 respirator. - Place the child in a room that has a HEPA filtration systems.

- Initiate contact precautions

A nurse is reinforcing teaching about food safety with a group of adult clients. Which of the following information should the nurse include? - Keep the refrigerator temperature at 4.4 degrees C (40F) - Refrigerate leftover food within 3 hours - Keep the freezer's temperature at -15 degrees C (5F) - Eat leftover food within 7 days.

- Keep the refrigerator temperature at 4.4 degrees C (40F)

A nurse is positioning a client in preparation for a lumbar puncture. In which of the following positions should the nurse place the client? - Lithotomy - Lateral recumbent - Prone - Semi-fowler's

- Lateral recumbent

A nurse in a clinic is reviewing the medical record of a toddler and notes that he has previously had a severe allergic reaction to gelatin. Which of the following immunizations should the nurse identify as unsafe for this client to receive? - Hepatitis A - Measles, mumps, and rubella - Pneumococcal conjugate - Haemophilus influenzae type b

- Measles, mumps, and rubella

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan of care. - Restrict the client's sodium intake to 3 g per day. - Position the client supine with his legs elevated. - Measure the client's abdominal girth. - Keep the client's daily protein intake below 0.8 g/kg.

- Measure the client's abdominal girth

A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client reports a pain level of 6 on a scale from 0 to 10. Which of the following medications should the nurse administer? - Oxycodone - Ibuprofen - Celecoxib - Acetaminophen

- Oxycodone

A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation? - Respiratory rate 20/min - Oxygen saturation 90% - Oral temperature 37.6 degrees C ( 99.7F) - Apical pulse rate 88/min

- Oxygen saturation 90%

A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect? - Pain radiating to the jaw - Discomfort with urination - Increased abdominal discomfort prior to meals - Pain in the right upper abdomen

- Pain in the right upper abdomen

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team? - Pediatric nurse practitioner - Case manager - Nutritionist - Primary care provider

- Pediatric nurse practitioner

A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program? - Perform chart audits - Define the problem. - Identify data collection methods. - Review the facility's policy and procedure manual

- Perform chart audits

10. A nurse in a provider's office is collecting data from a client who was just diagnosed with tuberculosis. Which of the following actions should the nurse take first? - Communicate with personnel about the need for prophylaxis - Place a mask on the client - Notify local health department - Contact those who live with the client

- Place a mask on the client

A nurse enters the room of a school-age child and finds him on the floor experiencing tonic- clonic seizure. Which of the following actions should the nurse take? - Place a padded tongue blade in the child's mouth. - Restrain the child's upper extremities. - Place a pillow under the child's head. - Turn the child onto his back.

- Place a pillow under the child's head.

A nurse and an assistive personnel are repositioning who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions? - Place a small pillow under the client's head. - Lower the client's bed to the lowest position. - Stand next to the client's shoulders. - Flex his hips while pulling the client

- Place a small pillow under the client's head.

A nurse is preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take? - Hold the irrigation solution bottle 5cm (2in) above the sterile container. - Open the outer wrapper of the sterile package toward her body - Place the irrigation solution bottle cap on the sterile field. - Place sterile objects at least 2.5cm (1in) from the edge of the sterile field

- Place sterile objects at least 2.5cm (1in) from the edge of the sterile field

A nurse on a medical - surgical unit is caring for a client immediately following a bronchoscopy. Which of the following actions should the nurse take? - Check the pressure dressing for indications of bleeding - Place the client in the lateral position. - Inform the client that he might experience a flushed feeling. - Offer the client in a full liquid diet

- Place the client in the lateral position.

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include? - Put a small cushion under the newborn's head for support. - Place the shoulder harnesses at the level of the infant's shoulders. - Keep the airbag on if the car seat is in the front seat. - Position the car seat at a 90 degree angle.

- Place the shoulder harnesses at the level of the infant's shoulders.

A nurse is reinforcing teaching with a client who has a new prescription for spironolactone. Which of the following foods should the nurse instruct the client to avoid? - Cooked carrots - Whole grain pasta - Dried apricots - Popcorn

- Popcorn

A nurse is reinforcing teaching with a group of assistive personnel about partner violence. The nurse should include which of the following as a common characteristic of a perpetrator of intimate partner violence? -Self- blaming -Social involvement -High self- esteem - Possessiveness

- Possessiveness

A nurse is collecting data from an older adult client who has been taking furosemide for the past week. If the client has developed dehydration as an adverse effect of this medication, which of the following findings should the nurse expect? - Peripheral edema - Bradycardia - Postural hypotension - Distended neck veins

- Postural hypotension

A nurse is collecting data from a client who has obsessive - compulsive personality disorder. Which of the following manifestations should the nurse expect? (select all that apply) - Suspicious of others - Exploitative - Preoccupied with details - Perfectionistic - Highly critical of self

- Preoccupied with details - Perfectionistic - Highly critical of self

A nurse is preparing with a client is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take? - PLace the client in Sims' position for catheter insertion. - Verify the amount of TPN solution the client is receiving every 4 hour - Use clean technique when changing the catheter dressing. - Prepare the client for a chest x - ray to verify catheter placement.

- Prepare the client for a chest x - ray to verify catheter placement.

A nurse is collecting data from a client who has heart failure and edema of the lower extremities. Which of the following actions should the nurse take to monitor for pitting edema? - Observe the skin color for edematous areas. - Compress the nail beds of the client's toes. - Lightly pinch the skin over the client's calf. - Press firmly with the fingertip on edematous areas.

- Press firmly with the fingertip on edematous areas.

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing acute mania. Which of the following interventions should the nurse include in the plan of care? - Allow the client to establish his own schedule. - Encourage the client to participate in group activities. - Provide the client with high calorie finger foods. - Check the client's vital signs every 4 hr.

- Provide the client with high calorie finger foods.

A nurse is administering pancreatic enzymes to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as therapeutic effect of the treatment? - Reduced fat in the stools - Improved respiratory function - Decreased sodium excretion - Improved absorption of vitamins B and C

- Reduced fat in the stools

A nurse is reinforcing teaching about home safety precautions with the parents of a 3 month old. Which of the following instructions should the nurse include in the teaching? - Start using a highchair for feedings. - Make sure the crib is soft. - Place no more than one small pillow in the crib. - Remove bibs when the infant is going to sleep.

- Remove bibs when the infant is going to sleep.

A charge nurse is monitoring a group of assistive personnel regarding the use of gloves in contact isolation. For which of the following actions by an AP should the charge nurse intervene? - Washes hands after removing gloves - Removes gloves last after other personal protective equipment - Pull gloves off inside - out when tasks are completed - Changes gloves between tasks for the same client

- Removes gloves last after other personal protective equipment

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who is on isolation precautions. Which of the following instructions should the nurse include in the teaching? -Shake soiled linen before placing it in a hamper. - Roll used gowns indie out for disposal. - Take gloves off last when removing personal protective equipment. -Remove soiled face shields once in the hall outside the client's room.

- Roll used gowns indie out for disposal.

A nurse is reinforcing teaching dietary teaching with a client who experienced a myocardial infarction. The nurse should instruct the client to limit which of the following in her diet? - Complex carbohydrates - Saturated fats - Dietary fiber - Omega - 3 fatty acids

- Saturated fats

A nurse is administering enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take? - Chill and read minister the formula. - Replace the NG tube. - Slow the rate of the formula instillation. - Lower the head of the bed of 15 degree.

- Slow the rate of the formula instillation.

A nurse is planning a health- promotion program for high school students. Which of the following facts about smoking is likely to be most effective in changing the adolescent's attitudes toward smoking? - Quitting smoking can help to save money for other things. - Smoking is the number one cause of preventable death. - Smoking causes unattractive stains on the teeth and hand. - Smoking can lead to substance use disorders

- Smoking causes unattractive stains on the teeth and hand.

A nurse is preparing to document care for a group of clients. Which of the following abbreviations should the nurse use when documenting? - Stat - AD - SC - Qhs

- Stat

A nurse is caring for a client who is receiving continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first? - Stop the infusion - Document the infiltration - Elevate the arm - Apply a warm compress.

- Stop the infusion

45.A nurse is caring for a client who is terminally ill and comatose. The client has a living will that includes a do- not- resuscitate (DNR) order. The client's son requests removal of the DNR order. Which of the following actions should the nurse take? - Inform the son that current DNR order is to be followed. - place a hold on the DNR order until review by the ethics committee. - Suggest that the family meet with an attorney and sign a revised living will - contact the provider about changing the living will.

- Suggest that the family meet with an attorney and sign a revised living will

A nurse is reinforcing teaching with a client who has coronary artery disease and a new prescription for warfarin. Which of the following information should the nurse include in the teaching? - Take the medication at the same time every day. - Increase intake of vitamin K rich foods - Drink 4 oz (120ml) of cranberry juice with each dose - Have blood drawn for a PTT twice monthly

- Take the medication at the same time every day.

A nurse is caring for a client who has chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make? - Take the medication with an antacid. - Take the medication with crackers. - Take the medication with calcium fortified orange juice. - Take the medication and then lay down for 30 min.

- Take the medication with crackers.

A charge nurse working in a long-term care facility overhears two assistive personnel in the nurse's station discussing a client who was just admitted. Which of the following actions should the charge nurse take? - Tell the APs to stop the conversation. - Submit an incident report to the risk manager. - Document the event in the client's progress notes. - Inform the client of the AP's actions.

- Tell the APs to stop the conversation.

A nurse is monitoring a client who has psychosis for adverse effects of clozapine. Which of the following findings should the nurse identify as an indication of agranulocytosis? - Sodium 135 mEq/L - Temperature 35.6 degree C (96 F) - WBC 1,000/mm3 - HbA1C 5.4%

- Temperature 35.6 degree C (96 F)

A nurse is reinforcing teaching with client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reaction can occur following the procedure? - Neck pain - Temporary memory loss - Tingling of the scalp - voice alteration

- Temporary memory loss

A nurse is preparing to delegate client care to an assistive personnel. Which of the following information should the nurse verify prior to delegation. - The AP's years of experience - The client's length of facility stay. - The AP's job description. - The client's age.

- The AP's job description.

A nurse is collecting data from a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper CPAP use? - There is one finger width between the strap on the mask and the client face - The mask fits loosely so air can escape from underneath - The mask is secured over the client's mouth and the client's nose is undercovered. - The therapeutic dose of albuterol is being inhaled.

- The mask is secured over the client's mouth and the client's nose is undercovered.

A nurse in a provider's office is collecting data from an 18 month- old toddler. Which of the following findings should the house nurse identify as a potential indication of child maltreatment? - The toddler has a temper tantrum when he is told "no." - The toddler cries when his stuffed animal is taken away. - The toddler has two bruises on the front of his leg. - The toddler is overly affectionate toward the nurse.

- The toddler has two bruises on the front of his leg.

A nurse in a provider's office is collecting data from a client who has candidiasis. Which of the following findings should the nurse expect? - Thick, white vaginal discharge - Frothy, malodorous discharge - Hard, painless chancre - Feeling of pelvic heaviness

- Thick, white vaginal discharge

A nurse is preparing to give change of shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information about the client should the nurse include in the report? - Preferred bath time - Time of last medication - Steps required for dressing changes - Admission vital signs

- Time of last medication - Steps required for dressing changes - Admission vital signs

A nurse is caring for a client who is to undergo a subtotal thyroidectomy. Which of the following items should the nurse place at the client's bedside? - Tracheostomy kit - Vacuum assisted wound device - Turning fork - Thoracotomy set

- Tracheostomy kit

A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication? - Hypertension - Tachypnea - Dilated pupils - Urinary retention

- Urinary retention

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching? - Place oral suction equipment next to the client's bedside. - Use a needleless syringe to instill feedings. - Provide thin liquids to help the client swallow. - Give the client a straw to use for drinking.

- Use a needleless syringe to instill feedings.

A nurse is assisting with a community health education course for family members of clients who have Alzheimer's Disease. . Which of the following information should the nurse include? - Provide a stimulating environment for the client - Limit the number of choices for the client - Use written signs to assist the client with locating the bathroom - Use confrontation to manage the client's behavior

- Use written signs to assist the client with locating the bathroom

A nurse is reviewing the health history of middle adult client who is receiving chemotherapy for leukemia. Which of the following immunizations should the nurse recommend that the client receive? - Inactivated influenza immunization - Varicella immunization - Human papillomavirus immunization - Herpes zoster immunization

- Varicella immunization

A nurse begins to bathe a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following? - Promoting trust - Boundary crossing - Veracity - Countertransference

- Veracity

A nurse is caring for a school-age child who has scoliosis and reports skin discomfort under his brace. Which of the following actions should the nurse suggest to manage the discomfort? - Keep the skin under the brace dry with corn starch. - Loosen the straps of the brace over areas of discomfort. - Wear a T - shirt under the brace. - Remove the brace during periods of rest.

- Wear a T - shirt under the brace.

A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea? - Coffee - Ice cream - Apple juice - Yogurt

- Yogurt

A nurse is performing a heel stick on a newborn to obtain blood for glucose monitoring. Which of the following actions should the nurse take? - Puncture the inner lateral part of the newborn's heel. - Use a 25- gauge butterfly needle. - apply a warm cloth to the heel 10 min prior to the procedure. - Place the newborn in the prone position during the procedure.

- apply a warm cloth to the heel 10 min prior to the procedure.

A nurse is reinforcing with a client who has hypothyroidism and a new prescription for levothyroxine. The nurse should instruct the client to notify the provider of which of the following manifestations? - Polyuria - Pruritus - Cough - nervousness

- nervousness

A nurse is contributing to the plan of a care for a client who has HIV. Which of the following interventions should the recommend? -Cleanse the client underarms and perineal area daily with a moisturizing soap. - remove raw and vegetable from client diet Take the client temperature every other day. -Launder the clients bed linens with 120mL (4oz) of bleach.

- remove raw and vegetable from client diet

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions? - Left lateral - Supine - Dorsal recumbent - semi-fowler's

- semi-fowler's

A nurse is reinforcing teaching with a client about measures to reduce the manifestations of irritable bowel syndrome. Which of the following statements should the nurse make? - you should use honey to sweeten your tea - you should chew sugarless gum to decrease bloating - you can take peppermint oil to soothe your discomfort. -You should increase your intake of fructose.

- you can take peppermint oil to soothe your discomfort.

A nurse in a long - term care facility has just received change-of-shift report. Which of the following clients should the nurse attend to first? -A client who had a hip arthroplasty and is request pain medication -A client who has a temperature of 38.4 C (101.1F) and appears confused -A client who is receiving an enteral tube sting pain medication and has a blood glucose level of 155 mg/dl -A client who has a spinal cord injury and needs a dressing change.

-A client who has a temperature of 38.4 C (101.1F) and appears confused

137.A nurse is community clinic is discussing informed consent with a group of newly licensed nurses. Which of the following statement should the nurse include? -A client admitted to a mental health unit cannot provide informed consent. -A pregnant adolescent can provide informed consent for herself. -A daycare provider can provide can informed consent for a child in his care. -A client requiring life- saving emergency surgery must have informed consent from a family member.

-A pregnant adolescent can provide informed consent for herself.

A nurse is collecting data from a client who is 5 hr prospective following a transurethral resection of the prostate. Which of the following finding should the nurse report t tot the provider? -Absence of bladder spasms -Hgb 14 g/dl -Decreased urinary output - Pink- tinged urine

-Absence of bladder spasms

A nurse is caring for an older adult client who had a stroke 3 weeks ago and has left sided facial paralysis. Which of the following actions should the nurse take to prevent aspiration? - Administer medications between meals - Place food on the stronger side of the client's mouth - Instruct the client to swallow pills together - Provide a straw for beverages

-Administer medications between meals - Place food on the stronger side of the client's mouth

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? -Cleanse the most contaminated wounds first. -Apply dressing with sterile gloves. -Use hydrogen peroxide for wound cleaning. -perform dressing changes every other day.

-Apply dressing with sterile gloves.

A nurse is reinforcing discharge teaching with a client who is postoperative following cataract removal. Which of the following instruction should the nurse include in the teaching? - Rinse the eye gently with warm water when showering. -Avoid lying on the affected side. -Apply a warm compress to the operative eye. -Do not bend at the knees.

-Avoid lying on the affected side.

A nurse collecting data from an older adult client who has hypertension and is taking amlodipine. The nurse should identify which of the following manifestations as an adverse effect of the medication? -Tachycardia -Hypertension -Alopecia -Dizziness

-Dizziness

A nurse is reinforcing discharge teaching with a client following a gastrectomy. which of the following food should the nurse instruct the client to avoid to prevent dumping syndrome? - Poached eggs - canned tuna - steamed spinach -ice cream

-ice cream

A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statement by the client indicates an understanding of the teaching? -I have to take this medication on an empty stomach. - I should take this medication in the morning and at bedtime. - I have remain upright for 1 hour after taking the medication -I should expect my tongue to turn black after I take this medication.

-I have to take this medication on an empty stomach.

A home health nurse is collecting data from a client following a myocardial infarction. Which following statements by the client should the nurse address first? -I keep my bottle of nitroglycerin tablets on the windowsill in my kitchen. -I'm worried my body will never be the same as it was before. -I will be ready to leave the cardiac rehabilitation program after 1 week. -I might need some help learning about low- sodium food options.

-I keep my bottle of nitroglycerin tablets on the windowsill in my kitchen.

A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following by the client indicates an understanding of the teaching? -I should call the provider if I have increased flatulence after the examination, -I should expect moderate rectal bleeding after the examination. - I will drink clear liquid the day before the examination - I will taking laxative for 1 week before the examination.

-I should expect moderate rectal bleeding after the examination.

nurse is participating in an interprofessional care conference for a client who has alcohol use disorder. The nurse should collaborate with the dietitian to Promote which of the following dietary changes? -Reduce daily intake of calories. -Increases daily intake of thiamin- rich food. -Eat three meals each day. - limit foods that contain tyramine.

-Increases daily intake of thiamin- rich food.

A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is anticoagulant therapy. Which of the following actions should the nurse take? -Initiate bed rest. - Apply an ice pack to the affected extremity for 20 min every 2 hr. -Administer aspirin for pain. Massage the affected extremity every 4 hr

-Initiate bed rest.

A nurse is monitoring a client for hyperkalemia. Which of the following findings should the nurse report to the provider? -Trousseau's sign -Hyperactive reflexes -Jaundice -Irregular heart rate

-Irregular heart rate

A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first? -Refer the client to a support group for adolescents who have eating disorders. -Suggest that the client assist with meal planning. -instruct the client about effective coping strategies. -Observe the client during and after meals

-Observe the client during and after meals

A nurse is caring for a client is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following should the nurse identity as an indication that the behavioral plan is effective? -Sodium 130 meq/L -Potassium 3.5 meq/L -BMI 14.5 -Hgb 10 g/dL

-Potassium 3.5 meq/L

A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an RN? -Providing discharge teaching about home IV medication therapy. -Administering a subcutaneous insulin injection -Removing an NG tube. - Collecting a sputum culture

-Providing discharge teaching about home IV medication therapy.

A nurse is reinforcing teaching with a client who has a new diagnosis of hypertension and a new prescription for captopril. Which of the following instructions should the nurse include? - Rise slowly when moving from sitting to a standing position. - Expect to develop a loose, productive cough - Increase your intake a potassium- rich foods - Do not get a flu shot while taking this medication.

-Rise slowly when moving from sitting to a standing position. - Expect to develop a loose, productive cough

A nurse is providing change- of - shift report for a client. Which of the following should the nurse include in the report? -The clients mother died 4 years ago from breast cancer. - The client's reports pain is reduced when he is positioned on his side. -The clients partner visited earlier today for 3 hours. -The clients received the prescribed antibiotic every 8 hours.

-The clients received the prescribed antibiotic every 8 hours.

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching? - Wear sterile gloves when in contact with body fluids. - Wash hands with soap and water for 20 seconds. - Artificial nails can be worn when performing direct client care. - Use alcohol-based cleanser when hands are visibly soiled.

-Wash hands with soap and water for 20 seconds. - Artificial nails can be worn when performing direct client care.

A charge nurse in a long- term care facility observes an assistive personnel (AP) arriving late to his shift and slurring his words. The charge nurse suspects the AP has alcohol intoxication and remove the AP from performing client care. Which of the following actions the nurse takes when reporting the incident? -Write a clear description of the incident. -Request the risk manager to follow through with the report. -Interview other staff members about the incident. -Report the incident to the highest level in the agency hierarchy

-Write a clear description of the incident.

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? -Leave your newborn in the bassinet in your room while you use the bathroom. -Request that the nurses show their nursing license prior to removing your newborn from the room. -Carry your newborn back to the nursery in your arm when you need to rest. -alert the staff id any of your newborn identification bands are missing

-alert the staff id any of your newborn identification bands are missing

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take? -Encourage intake of caffeinated beverages. -offer toileting every 6 hours -check for residual urine after voiding -Limit fluid intake to 15,00 ml a day.

-check for residual urine after voiding

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations 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.

-perform pelvic rocking exercises several times per day.

A nurse is preparing to perform a 12- lead ECG for a client who reports palpitations. Which of the following actions should the nurse take to help ensure an accurate of the client's heart rate and rhythm? (Select all the apply) - instruct the client to hold his breath when the ECG recording begins. - Tell the client to expect sensations similar to static electricity during the test. - position the electrodes on the client's chest and extremities. - ask the client to lie on his side during the recording of his heart rhythm. - Explain to the client that movement can later the test results.

-position the electrodes on the client's chest and extremities. - ask the client to lie on his side during the recording of his heart rhythm. - Explain to the client that movement can later the test results.

A charge nurse asks a staff nurse to recommend a client for discharge in response to mass casualty disaster. Which of the following clients should the staff nurse recommend? - A client is 3 days postoperative following knee arthroscopy and requires rehabilitation. - A client who has hypertension and a new onset of slurred speech?? - A client who has diabetes mellitus and ketonuria - A client who has aortic stenosis and a 2 kg (4.4) weight gain in 24 hr

A client who has hypertension and a new onset of slurred speech??

A nurse is providing support to the family of a school-age child who has a new diagnosis of a terminal illness. Which of the following actions should the nurse take? - Offer the family opinions about the child's care - Provide the family with time to talk openly - Tell the family to avoid discussing the illness around the child - Express sympathy when discussing the terminal diagnosis

Express sympathy when discussing the terminal diagnosis

A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take? -Write the information at an 8th - grade reading level. -Explain medical terminology using basic, one- syllable words. -Present information from complex to simple. -Use a 12- point size

Use a 12- point size

A community nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include? - grapes - Corn - Potatoes - Oranges

grapes