EXIT

A charge nurse is observing a newly licensed nurse performing dressing change on a peripheral IV site. For which of the following actions by the new nurse should the charge nurse intervene

Use a sterile glove to remove the old dressing

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the clients prescribed medications the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

Veracity

A nurse is performing nasopharyngeal suctioning for an adult which technique should the nurse use?

Wait 1min between suctioning attempts

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

Wash hands with soap and water for 20 seconds.

A nurse is reinforcing teaching with the client family about home oxygen use via nasal cannula which of the following statements by a family member indicates an understanding of the teaching

We will frequently check the top of his ears for sores

A nurse in a long term care facility is caring for a client who has methicillin resistant staphylococcus aureus (MRSA) which of the following actions should the nurse take

Wear a gown when assisting the client with personal hygiene

HELLP syndrome

disorder that's usually associated with preeclampsia

non-stress test-fetal activity

fetal well being take about 2 hours to do

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?

"Alert the staff if any of your newborn's identification bands are missing."

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?

"Anger toward the health staff is expected."

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?

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

A nurse is reinforcing with a client who is about to start using albuterol metered dose inhaler. Which of the following instructions should the nurse include in the teaching?

"Close your mouth around the mouthpiece."

A nurse is reinforcing teaching with a client who has new prescription for ciprofloxacin. Which of the following information should the nurse include in the teaching?

"Expect to experience diarrhea while taking this medication."

A nurse is collecting data from a client who reports difficult sleeping at night. Which of the following client comments indicates an understanding of sleep promotion?

"I am going to bed at the same time every night."

A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states,

"I guess I have to take some of the blame because of the way my friends and I abuse"

A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

"I know I can change my advance directives if I need to in the future."

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

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

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 should expect pain relief in 1 to 3 minutes."

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

"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."

A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching?

"I will instruct the client to sit when putting on a pair of pants."

A nurse is reinforcing with the client about monitoring his blood pressure at home with a digital device. Which of the following statements by the clients understanding of the teaching?

"I will know my blood pressure is too high if I get a reading of 140 over 90 or higher."

A nurse is reinforcing dietary teaching with a client who has Cushing's syndrome. Which of the following statements by the client indicates an understanding of the teaching?

"I will limit my sodium intake."

A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

"I will notify my doctor if the stoma starts to look purple."

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 put soiled dressings in a tied plastic bag before placing them in the trash."

A nurse is reinforcing teaching about ADLs with a client who has multiple sclerosis. Which of the following statements should indicate to the nurse an understanding of the teaching?

"I will take rest periods throughout the day."

A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching?

"I will use a cool mist vaporizer in my baby's room."

A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching?

"I will walk barefoot to prevent slipping." "I will check my smoke alarms once a month."

A nurse is reinforcing teaching about home safety with the parents of a 6-week-old infant. Which of the following instructions should the nurse include?

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

A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?

"My partner will use condoms with spermicides."

A nurse is teaching with the parents of a child who has ADHD and taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

"Our child has a better grasp of reality."

A nurse is assisting in the care of an older adult 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 responses should the nurse make?

"Prednisone can cause blood glucose levels to increase."

A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?

"The client receives the prescribed antibiotic every 8 hr."

A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching?

"The staff will watch me closely for 1hour after each meal."

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 will feel a tingling sensation in your mouth when taking a nitroglycerin tablet."

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."

A nurse is reinforcing teaching to the parents of an infant who has Pavlik harness. Which of the following statements should the nurse include in the teaching?

"the harness promotes hip joint development."

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?

'Sometimes I get angry about it, but I know that just creates other problems."

A nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room. Identify the order of performance.

* Move the clients to a safe location * Pull the nearest fire alarm * Shut all doors and windows * Attempt to extinguish the fire

A nurse is planning to complete the incision dressing change for a client who is postoperative following an open cholecystectomy. In which of the following areas should the nurse expect to find the clients incision?

- Picture A - left--- upper ride side of your belly or abdomen

A nurse is reviewing the medical records of five clients. Which of the following events should the nurse write an incident report? (Select All That Apply)

-A client received an 0900 daily medication at 1000 -A client fell when ambulating to the bathroom alone

C. Diff precautions

-Contact precaution -Gloves and gown

A nurse is preparing to administer a nasal drop medication to a client. Identify the sequence of actions the nurse should take?

-Have the client blow their nose gently -position the client's head -place the dropper -instill the medication -position the client on her back

A nurse in a long-term care facility is delegating care for a group of clients for the upcoming shift which of the following tasks the nurse delegate to assistive personnel (select all that apply)

-Measure vital signs for a client who requires contact precaution. -Record urine output for a client who has a super pubic catheter. -Trees for a client who is receiving radiation therapy to radiology.

Actions to take for suspected epiglottitis

-Take to hospital immediately. -Difficulty breathing call 911.

A nurse is reinforcing teaching with a client who has hypertension about decreasing sodium intake. Which of the following foods should the nurse recommend?

1 baked potato

Teaching about an IV pyelogram

1. Ask you to change into a hospital gown and remove jewelry, eyeglasses and any metal objects that may obscure the X-ray images. 2. Ask you to urinate to ensure your bladder is empty for the exam.

Cardiovascular disease modifiable risk factor

1. High BP 2. High blood cholesterol 3. Smoking 4. Diabetes 5. Overweight 6. Obesity

Manifestations of torticollis

1. Neck muscle pain or pain down the spine 2. Head tilts one side 3. Inability to turn the head

A nurse is receiving a telephone prescription from a client's provider which of the following actions should the nurse take select all that apply

1. ask the provider to spell out the name of the medication 2. request the provider to confirm and read back the prescription 3. record the date and time of the telephone prescription

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

A client has full thickness burns to face and trunk

A nurse in a mental health facility receives a change of shift report on 4 clients. Which of the following clients should the nurse plan to assess first?

A client placed in restraints for aggressive behavior

A nurse on a medical surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

A client who had a radical mastectomy 36 hr. ago and has a surgical drain

A nurse is assisting with discharge planning for a group of clients during a mass casualty incident which of the following client should the nurse recommend for discharge

A client who had diabetic ketoacidosis and has a blood glucose level of 120 mg/dL

A nurse is recommending a client for discharge to allow for admission of a client following a tornado disaster. Which of the following clients should the nurse recommend for discharge?

A client who has a sodium level of140meq/L after one episode of diarrhea

A nurse is receiving change of shift reports from four clients. Which of the following clients should the nurse see first?

A client who has cirrhosis and hematemesis

A nurse is receiving change of shift report on four clients. Which of the following clients should the nurse plan to see first?

A client who has femur fracture and reports numbness of the toes

A nurse is caring for a group of clients. Which of the following clients should the nurse recognize is experiencing fluid volume excess?

A client who has heart failure and has had orthopnea for 2days

A nurse is preparing to irrigate a wound of a client who has methicillin-resistant Staphylococcus aureus (MRSA).The nurse should use which of the following personal protective equipment?

A face shield

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse discovers that a clients family member has administered a PCA dose

A nurse is reviewing confidentiality with a group of newly nurses. Which of the following situations should the nurse as an example of breach in confidentiality?

A nurse tells the chaplain that a client has a new diagnosis of cancer

A nurse is assisting with the planning of an in service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

A peer reviewed journal article

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

A social worker who is assigned to an involuntarily committed school age client

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Administer the medication to the toddler each evening

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?

Advance directives include a living will

A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Allow the client to choose treatment times

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Anterior fontanel closed

A nurse is providing site care for a child who has a skin-level gastrostomy enteral tube. Which of the following actions should the nurse take?

Apply a skin barrier protectant to the skin.

A nurse is delegating client care assignments. Which of the following tasks should the nurse assign to an assistive personnel?

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

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?

Apply dressings with sterile gloves

A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema, which of the following intervention should the nurse include in the clients plan of care?

Apply support stocking

A nurse is caring for a client who has depressive disorder the client states everyone will be better off if I were not around which of the following responses should the nurse make

Are you thinking of hurting yourself?

A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take?

Assess the fetal heart rate

A nurse at long term care facility is reviewing the plan of care who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to assistive personnel?

Assist the client with range of motion exercises of the hands

a nurse is reinforcing with a client who is at 16 weeks of gestation and has a prescription for ferrous sulfate to treat iron-deficiency anemia. which of the following recommendation should the nurse to improve the absorption of the medication?

Avoid drinking milk the iron supplement

A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?

Avoid exposing the neck to the cold

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

Baked chicken breast

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school age brother should the nurse expect?

Believes his bad behavior is causing his brother's death

A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse?

Benzodiazepines are administered every 4hr

A nurse is assisting with a prenatal examination of a client who is at 8weeks 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?

Chadwick's sign

A nurse is caring for a 3-year-old child immediately ff a tonic closure seizure. Which action should the nurse to take?

Check the child for oral injuries

A nurse is assisting care of a client who is 6hr postoperative following right total knee arthroplasty. Which of the following actions should the nurse take?

Check the client's pedal pulses every hour

A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?

Check the client's status every hour.

A nurse is collecting data from a client who has diabetes mellitus and a blood glucose of 40 mg/dl. Which of the following findings should the nurse expect?

Clammy skin

The nurse is caring for an older adult who wears hearing aids with detachable ear molds. Which of the following actions should the nurse take when caring for the hearing aids?

Clean the hearing aids with a soft cloth.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Clean the stoma using an inward to outward circular motion.

A nurse is reinforcing teaching about preventing dental caries with the parent of a 12month old toddler. Which of the following instructions should the nurse provide?

Clean the teeth with a small soft bristled toothbrush

A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?

Client report of uterine cramping

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

Client's telephone number

A nurse is caring for a client who has femur fracture with the leg in Bucks traction. Which of the following actions should the nurse take?

Compare bilateral pedal pulses

A charge nurse is observing a newly licensed nurse who is having difficulty finishing all client care activities by the end of his shift. Which of the following statements should the nurse make to help the newly licensed nurse improve his time management skills?

Complete the task for one client before moving onto the next client

A nurse is collecting data from a client who is at 20 weeks of gestation and has taking ferrous sulfate. For which of the following findings should the nurse monitor as a common adverse effect of iron supplementation and report to the provider?

Constipation

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

A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

Contact precautions

A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

Cover the wound with a sterile saline soaked gauze

A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the findings should the nurse report to the provider?

Dark red urine

A nurse is reinforcing teaching with a client who has new prescription for propranolol. The nurse should include which of the followings a potential adverse effect of this medication?

Decreased heart rate

A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Deep tendon reflexes 2+

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? SATA

Delegate collection of vital signs to the assistive personnel on the team. Keep track of how long it takes to complete certain tasks. Make a priority to list at the beginning of the shift

A nurse is caring for an older adult who has acute delirium. Which of the following actions should the nurse take first?

Determine the client's level of consciousness

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

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?

Diminished pulses on the affected extremity

A nurse is providing a client with IV fluids and finds that the IV pump screen us malfunctioning. Which of the following actions should the nurse take?

Discontinue use and tag the IV pump

A nurse is assisting with the care of a client who is receiving continuous IV infusion. Which of the following indicates fluid volume excess?

Distended neck veins

A nurse on a medical surgical unit is assisting with the admission of a client who has advanced lung cancer. Which of the following actions regarding advance directives should the nurse take?

Document the client's decision about end-of-life care in the medical record

A nurse is contributing to the plan of care of a client who has urinary incontinence which of the following interventions should the nurse suggest to help prevent skin breakdown

Dry the skin thoroughly after cleansing the perineal area

A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effect?

Elevated blood pressure

A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?

Empty the client's ostomy pouch before removing the skin barrier.

A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?

Encourage client to take frequent walk

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instruction should the nurse include in the teaching?

Encourage the client to be assertive

A nurse is caring for a client who is 2 days postoperative following above the knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

Encourage the client to use the overbed trapeze

A nurse is contributing to the plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. The client reports hearing voices. Which of the following intervention should the nurse take?

Ensure that avoid auditory stimulation

A nurse is caring for a client who has peptic ulcer disease and is schedule to undergo esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Ensure that the clients gave informed consent

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?

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

A nurse is caring for a 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?

Epistaxis

A nurse discovers a fire in the trash can of a client's room. Which of the following actions should the nurse take first?

Escort the client to a secure area.

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

Gently stroke her abdomen during contractions

A nurse is caring for a client who is on isolation precautions. Which of the following pieces of personal protective equipment should the nurse remove first?

Gloves

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

Glycosylated hemoglobin

A nurse is caring for a client who has toxoplasmosis and asks about the cause of the infection. Which of the following responses should the nurse make?

Handling cat feces

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

Heat the skin one minute prior to placing the program

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

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

A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain. Which of the following conditions in the client's history should the nurse identify as contraindication?

Hepatitis C

A nurse is reviewing the medical record for a client who is at 30 weeks of gestation and has anemia which of the following laboratory values should the nurse expect

Hgb 9.9 g/dL

A nurse is collecting data from a client who is 1 day postoperative following a cesarean birth. Which of the following findings is the nurse's priority? (Click on "exhibit" button for additional information about the client. There are tabs that contain separate categories of data.)

Hgb and Het

ways to improve Nutrition on patients with COPD?

High fiber foods

Which of the following beverages contains the least amount of caffeine?

Hot cocoa

A nurse is administering hydromorphone to a client who is experiencing pain. Which of the following findings is an adverse effect of this medication?

Hypertension

A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?

Hypertension

Contraindication for oral contraceptives?

Hypertension

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

Hypokalemia

A nurse is reinforcing teaching with a client about advance directives and a healthcare proxy which of the following client statements shows understanding of the teaching

I do not need to name a relative as my designee in my health care proxy

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

I have to take this medication on an empty stomach

A nurse in an inpatient medical health facility is reinforcing teaching with a client who signed a consent form for electro convulsive therapy which of the following statements about a client indicates an understanding of the procedure

I might have short term memory loss after the procedure

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching?

I need to keep the cap in place for at least 6 hours after intercourse

A nurse is reinforcing teaching with a client about collecting a stool specimen to check for occult blood. Which of the following statement by the client indicates an understanding of the teaching?

I should avoid eating red meat for 3 days before my test

A nurse is reinforcing teaching with a group of adolescent male clients about testicular examination which of the following statements by a client indicates an understanding of the teaching

I should expect one testicle to be larger than the other

A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the nurse indicates an understanding of the teaching?

I should practice pursed lip breathing exercises

A nurse is reinforcing discharge teaching with a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?

I should throw away my used tissues in a closed plastic bag

A nurse is reinforcing teaching with a female client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

I should use supplemental birth control while I am taking this medication

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

I understand immunization will be held if my child lactose intolerance

A nurse in a provider office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

I will dry my skin by patting it with towel

A nurse is reinforcing teaching with a client who is at 12 week's gestation and has hyperemesis gravidarum. Which of the following client statement indicates an understanding of the nurse's instruction?

I will eat or drink something every 2 to 3 hours throughout the day

A nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parent indicates an understanding of the teaching?

I will make sure that I can fit one finger between the mattress and the side of my newborn's crib

A nurse working in a clinic is reinforcing teaching with a client who has hepatitis A. which of the following client statements indicates an understanding of the teaching?

I will use different hand towels than others in my home

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

I will wash my baby's face with a warm, wet washcloth without soap

A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching?

I'll have my friend drive me home after the procedure

A nurse is caring for a client who has a prescription for acetaminophen 300mg with codeine 30mg, 1 tablet every 3 to 4 hr. PRN for pain. Th nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Incident report

A nurse is reinforcing teaching with a client who is postoperative following a partial gastrectomy. Which of the following instruction should the nurse to prevent dumping syndrome?

Include one serving of protein with each meal

A 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?

Increases daily intake of thiamin- rich food.

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?

Information regarding client health be e-mailed if encrypted

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.

A nurse is caring for a client who has schizophrenia. Which of the following behaviors of the client should the nurse identify as a negative symptom?

Initiates speech rarely

A nurse is caring for a client who has a prescription for NPH insulin 10units and regular insulin 15units subcutaneously. After injecting 10 units of air into the NPH insulin vial. Which of the following actions should the nurse take next?

Inject 15units of air into the regular insulin

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?

Instruct the client to change positions frequently

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?

Instruct the client to exhale while inserting the rectal tube.

A nurse is planning to obtain a 12 lead ECG for a client who has history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?

Instruct the client to remain as still as possible during the recording

A nurse is reinforcing teaching about hand hygiene with a newly licensed news which of the following information should the nurse include in the teaching

Interlace the fingers while rubbing hands together

A nurse is collecting data from a client who is in renal failure. The nurse should identify that following finding is a manifestation of hyperkalemia?

Irregular heart rate

A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?

Irritability

A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect?

Is eager to review the birth experience

A nurse is using glucometer to measure a client's capillary blood glucose level. Which of the following should the nurse take?

Keep the finger in a dependent position

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 C degrees (40F)

A nurse is positioning a client in preparation for a lumbar puncture. Which of following positions should the nurse place the client?

Lateral recumbent

A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states "I can't seem to do anything right. What should I do?" which of the following responses should the nurse make?

Let me show you how to swaddle and cuddle him, then you try.

A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?

Let's talk about what the voices are saying to you

A nurse is reinforcing teaching about the common discomfort during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include?

Leukorrhea

A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription?

Lorazepam 0.5 mg PO PRN at bedtime

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the ff findings should the nurse expect?

Loss of taste

A nurse is preparing to apply a thigh-length sequential compression for a client who is postoperative. Which of the following actions should the nurse take?

Measure the circumference of the client's upper leg

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that the slipped on some water outside of the shower. Which of the following action should the nurse take first?

Measure the client's vital sign

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

Move the client's bed to the main floor of the house

A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

My baby will receive the rotavirus immunization orally

A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. Thu nurse should instruct the client that which of the following over the counter medications interacts adversely with clopidogrel?

Naproxen

A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?

Nuchal rigidity

A nurse is monitoring a client is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

Observe the movements of the client's chest wall

A nurse is caring for a client who has rheumatoid arthritis and is having difficulty with ADLs, such as cooking and eating. The nurse should ensure that the client has a referral to which of the following members of the interprofessional team?

Occupational therapist

A nurse is reviewing the immunization records of a 9-year-old child during a routine physical exam. Which of the following should indicate to the nurse the child is not current with the minimum required immunization?

One MMR vaccine.

A nurse is supervising assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

Oral suction equipment

A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?

Pain in the right upper abdomen

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?

Perform pelvic rocking exercises several times per day.

A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B?

Performing oral hygiene.

A nurse in an acute care setting is assisting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Physical assessment findings

A nurse is collecting data during a musculoskeletal examination of a client who has a spinal column deformity and reports back pain. Which of the following images should the nurse identify as an identity as indication that the client has kyphosis?

Picture KUBA- the one who has bump on the back

A nurse is caring for an older adult client who reports dry itchy skin. Which action should the nurse take?

Place a humidifier in the client's room

A nurse enters the room of a school age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the child's head

A nurse is caring for a client who is unable to perform ADLs and wears dentures. Which of the following actions should the nurse taken when providing denture care?

Place a towel in the sink when cleaning the dentures

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has dysphagia. Which of the following instruction should the nurse include in the teaching?

Place oral suction equipment next to the client's bedside

A nurse is preparing a sterile field to perform a dressing change. Which of the following actions should the nurse take?

Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field.

A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention?

Place the client in a room that is ventilated to the outside.

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

Place the shoulder harnesses at the level of the infants' shoulders

A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Plan to remove the restraints as soon as the clients is calm

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy has a racing heart and becomes pale while lying on their back. Which of the following actions should the nurse take?

Position the client on their left side

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?

Postural hypotension

A nurse 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?

Potassium 3.5 meq/L

A nurse is reviewing the medical record of a client who has COPD. Which of the following laboratory findings indicates a need to requests a dietary referral for the client?

Prealbumin 13 mg/dl

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following action should the nurse take?

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?

Press firmly with the fingertips on edematous areas.

A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy ECT for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?

Provide frequent reorientation after ECT

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following actions should the nurse take?

Provide step-by-step instructions for performing ADLs.

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?

Provide the client with high calorie finger foods.

A nurse is contacting an occupational therapist for a client who had a stroke with right sided weakness and has difficulty eating. Which of the following roles should the nurse expect the occupational therapist to perform?

Provides and adjusts devices to assist the client with daily living activities

A nurse is caring for a client who is taking warfarin and has an INR of 5.5 The nurse should expect which of the following instruction from the provider?

Reduce the dosage of the medication

A nurse is administering pancreatic enzymes to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Reduced fat in the stools

A nurse is administering pancrelipase 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

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Remind the client of the day and time often.

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?

Remove bibs when the infant is going to sleep.

A nurse is caring of a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

Remove the restraints from the client's wrists every 2 hr.

A charge nurse is monitoring a group of assistive personnel AP regarding the use of gloves in contact pre caution isolation. For which of the following actions by an AP should the charge nurse intervene?

Removes gloves last after other personal protective equipment

A nurse delegates a task to an AP and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?

Report the AP to the risk manage

A home health nurse is caring for an adult who lives with a family caregiver and has urinary incontinence. The clients say "I guess I will be locked in my room again for wetting the bed". Which of the should the nurse take?

Report the suspected abuse to the nurse manager

A home health nurse is caring for an adult who lives with a family caregiver and has urinary incontinence. The clients say "I guess I will be locked in my room again for wetting the bed". Which of the should the nurse take?

Report the suspected abuse to the nurse manager

A nurse is caring for a client who speaks a different language than the nurse. The clients partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the ff actions should the nurse take?

Request the services of an interpreter to determine the clients wishes

A nurse is discussing risk factors for child abuse with members of the parenting group the nurse should identify which of the following findings as that characteristic of perpetrators of a child abuse

Rigid expectations of behavior

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

Roasted salmon

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?

Roll gown inside out for disposal.

A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

Sit back down for a few minutes when this occurs."

A nurse is administering enteral feeding through a client's NG tube. During the installation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

Slow the rate of the formula installation.

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measure. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Soiled dressings should be placed in biohazard trash receptable

A nurse manager in a long-term care facility is discussing evidence-based practice with a group of staff nurses which of the following activities should the nurse manager identify as an example of evidence-based practice

Staffing the unit based on client acuity and needs

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?

Stop the infusion.

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris which of the following statements by the client indicates an understanding of what to do when chest pain occurs

Stop what I'm doing and lie down

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Supplement spoken language with pictures. Or review the facility policy about the use of an interpreter

A nurse is caring for a client who is in stage kidney disease the client has decided to stop dialysis treatment which of the following actions should the nurse take

Support the client's decision and stop the treatment

A nurse is reinforcing teaching about passive range of motion exercises with the family of a client who has had stroke. Which of the following instruction should the nurse include in the teaching?

Support the extremity above and below each joint during exercises

A nurse is caring for a client who has Graves' disease which of the following findings should indicate to the nurse that the client is developing a thyroid storm?

Tachycardia

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 crackers.

A nurse is assisting with care of a client who is receiving chemotherapy and radiation for advances breast cancer. The client states "I am thinking about stopping the treatment. Which of the following responses should the nurse make?

Tell me more about what are you thinking

a nurse is assisting with care of a client who is receiving chemotherapy and radiation for advances breast cancer. The client states "I am thinking about stopping the treatment. Which of the following responses should the nurse make?

Tell me more about what are you thinking

A nurse is caring for a client who reports diarrhea for the past 48 hours which of the following finding's indicates the client is experiencing dehydration

Temperature 37.2 (99.1)

A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a transfusion reaction?

Temperature 38.8 C (101.8 F)

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure?

Temporary memory loss

A nurse is about to administer an intermittent enteral feeding to a client who has NG tube in place. Besides obtaining x-ray. Which of the following methods should the nurse use to verify the placement?

Test the pH of the gastric aspirate

A nurse is observing assistive personnel take a client tympanic temperature which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure

The AP pulls the pinna up and back

A nurse is preparing to delegate client care to an assistive personnel AP. Which of the following information should the nurse verify prior to delegation?

The AP's job description

A nurse is assisting developing list of internet sites for clients to obtain valid health information. When evaluating internet resources. Which of the following findings indicates the information likely contains credible medical information?

The author cites references to statements made

A nurse in a pediatric clinic is collecting data from a school-age child and their parent. Which of the following findings should the nurse report as an indication of potential maltreatment?

The child has symmetric burns on the feet.

A nurse is collecting data from a client whose partner died 1 year ago. Which of the following findings indicates that the client is experiencing complicated grief?

The client develops chest pain each time he talks about his partner

A nurse is caring for client who has major depressive disorder and is taking antidepressant. The nurse should identify which of the following findings as the priority to report to provider?

The client has a sudden increase of energy

A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

The client is unable to grasp eating utensils

A nurse is collecting data from a client who has anorexia nervosa which of the following findings should the nurse identify as a positive outcome to treatment?

The client resumes menstruation

A nurse is assisting with the care of a client who is recieving IV therapy of 0.9% sodium chloride. The client recieved 200mL more than prescribed in 1 hr because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because

The client was not harmed as a result of the incident.

A nurse is reinforcing teaching with a client who is to have their plaster cast applied to his right arm Which of the Following information should the nurse include in the teaching

The client's extremity Should be elevated after the cast is applied

A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching?

The infant is lying in the crib with a stuffed animal.

Which of the following findings should the nurse identify as a risk factor for child maltreatment?

The infant is younger than 1 year of age.

A nurse determines that clients who receive zolpidem postoperatively have an increased fall rate compared to other postoperative clients. Which of the following members of the health care team should the nurse report these findings?

The risk manager

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 two bruises on the front of his leg.

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 of the following findings an as indication of proper CPAP use?

There is one finger width between the strap on the mask and the client's face

A nurse is preparing a vitamin K injection to give to a newborn. The newborns mother questions the purpose of the medication. Which of the following responses should the nurse make?

This medication will decrease the risk of hemorrhage in your newborn

A nurse is transcribing a clients prescription for erythromycin 500 mg four times per day which of the following information shared the news clarify with the provider

Time

A nurse is preparing to give change of shift report on a client who is 2 days postoperative following total knee arthroscopy. Which of the following information should the nurse include in the report?

Time of last pain medication

a nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

Urine output 12 ml/hr.

nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

Urine output 12 ml/hr.

A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?

Urine protein 3+

A nurse is contributing to the plan of care for a client who is experiencing panic level anxiety and reports visual hallucinations. Which of the following actions should the nurse recommend including in the plan of care?

Use a low-pitched voice when speaking to the client

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following intervention should the nurse include in the plan

Use a no rinse perineal cleanser after incontinence