NURS 120 proctored

nurse is inserting IV catheter for an older pt in preparation for an outpatient procedure. which vein should nurse select

median vein in the forearm

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will place a bath seat in my shower to use when I bathe"

a nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. which of the following client statements indicates an understanding of the teaching?

"I will use ink pens for writing"

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.) - Brace all side rails on the clients bed. - Obtain a prescription to restrain the clients PRN. - Check on the client hourly - Instruct the client in the use of the call light - Apply an ambulation alarm to the clients leg

- Check on the client hourly - Instruct the client in the use of the call light - Apply an ambulation alarm to the clients leg

A registered nurse (RN) and an experience licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (SELECT ALL THAT APPLY)

- Obtain vital signs from a client who is 6 hours post-operative - Administer a tap-water enema to a client who is preoperative. This task is appropriate for an LPN. - Catheterize a client who has not voided in 8 hours.

a nurse is providing care for four client on a medical surgical unity. which of the following clients should the nurse identify as being at risk for development of pressure ulcers

- client who has protein caloric malnutrition -client who has right-sided heart failure and 4+ edema to LE -a client who has postop delirium

A nurse is performing care activities for a client in the zone of touch that requires consent. Which of the following activities should the nurse perform in this zone? (select all that apply.)

-Removing the client's dentures -Palpating for pedal edema -Counting a radial pulse

a nurse is admitting an older adult who has suspected cognitive disorder. which of the following inventories should be included as part of the admission assessment

mental status examination (MSE

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding

-Verify tube placement -Check the residual feeding contents -Administer the feeding -Evaluate tolerance of feeding

a nurse is preparing to insert an IV catheter for a client and has selected the insertion site. place the following steps in the order in which the nurse should perform them

-apply a tourniquet or bp cuff -cleanse the site with an antiseptic swab -dilate vein -insert catheter -flush the catheter

a nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative care plan

-discontinue suction when assessing for peristalsis -irrigate the NG tube with 0.9% sodium chloride -place sequential compression devices on the bilateral lower extremities -reposition the client from side to side Q 2 hr

a nurse is planning care for a group of clients. the nurse should delegate obtaining vital signs to an AP for which of the following clients

A client who has a history of heart failure and is ready for discharge A young adult client who is 24 hr postoperative following an appendectomy An older adult client who is 36 hr postoperative from a traditional cholecystectomy

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following client statements indicates a need for further teaching?

I have a set of spare crutches in my basement I can also use."

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Adopt a neutral attitude when providing care

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed? A. NPO until dysphagia subsides B. Supplements via nasogastric tube C. Initiation of total parenteral nutrition D. Soft residue diet

B. Supplements via nasogastric tube

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply)

B. The preschooler mispronounces words D. The preschooler speaks in a nasally tone

a nurse is caring for a client who is cognitively impaired. A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? A. A room adjacent to the nursing station B. A room without a window C. A room with dim lighting D. A room containing personal belongings

D. A room containing personal belongings

a nurse is caring for a client who is scheduled for surgery. the nurse's role in regard to informed consent is which of the following?

Determining the client's level of understanding about the procedure

A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?

Do not apply heat to the area of irradiation

​A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The nurse finds that the client has mild anxiety about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings?

Document the findings in the client's medical record.

a nurse is completing a client assessment for admission to the medical unit. which of the following abdominal assessment findings require further investigation by the nurse?

Ecchymosis

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushed the clients toilet after emptying the urinary catheter's drainage bag

a nurse is caring for a client who has thrombophlebitis and is receiving Heparin by continuous IV infusion. The client asks the nurse how long it will take for the Heparin to dissolve the clot. Which of the following responses should the nurse give

Heparin does not dissolve clots. It stops new clots from forming

a nurse is assessing a client following a natural disaster who is experiencing difficulty sleeping due to nightmares, feeling of survivor guilt, and difficulty concentrating. which of the following diagnoses describe the client's symptoms

PTSD

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

Place a waterproof pad under the client's leg, apply clean gloves to remove dressing, clean site using circular motion, open sterile kit, irrigate wound

a nurse is discussing the use of mechanical restraints with a newly licensed nurse .which of the following situations should the nurse include as an indications for placing a client in mechanical restraints

Self-destructive behavior despite alternative in interventions

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?

The nurse has already considered alternatives to restraints

A nurse is obtaining informed consent from a client who is preoperative. Which of the following actions should the nurse take?

Validate the signature is authentic Verify the client understands the surgical procedure Confirm that the consent is voluntary

a nurse and an AP are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. the nurse should delegate meal assistance for which of the following clients to the AP?

a client who has lumbosacral spinal tumor

a nurse is caring for four postoperative clients. the nurse can delegate obtaining vital signs to an assistive personnel for which of the following clients?

a client who is 3 days postop following gastric bypass surgery

a nurse is planning care for a group of clients. the nurse should identify which of the following clients as having a contraindication for restraints

a client who is recovering from a heroin overdose

a nurse is teaching a class on torts. the nurse should include what situation as an example of negligence?

a nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon

a nurse on a medical-surgical unit is assigning tasks to an AP. which of the following task should the nurse delegate to the AP

ambulate a client who has a cane transfer a client to a stretcher record urinary output

a nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. the nurse should identify that which of the following clients is the greatest risk for a fall

an older adult client who is confused and has urinary frequency

a nurse is preparing to perform an abdominal assessment on a client. identify the sequence of steps

ask the client about having a history of abd pain, Inspect, Auscultate, percuss and palpate

a nurse is teaching a client who reports taking ginkgo biloba to improve his memory. which of the following adverse effects should the nurse include

bleeding gums Gingko biloba is an herbal medication used by clients to improve age-related memory loss as well as to decrease leg pain in clients with peripheral arterial disease (PAD). Although gingko biloba is generally well-tolerated, it may suppress coagulation. There have been reports of spontaneous bleeding in clients taking this herbal medication. Clients should be instructed to discontinue use and report increased bleeding, such as nosebleeds, bleeding gums, any cuts that do not stop bleeding, to their provider.

a nurse is caring for a client who has an indwelling urinary catheter. which of the following actions should the nurse take to prevent infection

check the catheter tubing for kinks or twisting

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical=surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

check to see if the suction equipment is working

a nurse is caring for a child who has a tracheostomy. after suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective

clear breath sounds

a nurse is assisting with the admission of a client to an inpatient unit. which of the following sources of information should the nurse rely on for accurate information about the client

client concerns

a home health nurse is assessing an older adult who reports falling a couple of time over the past week, which of the following findings should the nurse suspect is contributing to the clients falls

client takes alprazolam

A nurse is caring for a client who is receiving mydriatic eye drops. Which of the following manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect?

constipation

a nurse is instructing a client's family member about feeding safety for a client who has dysphagia following a stroke. which of the following instructions should the nurse include

encourage the client to take small bites

a nurse is assessing a client who has a peripheral IV with a continuous infusion. which of the following findings is a manifestation of phlebitis

erythema throbbing warmth at insertion site streak formation

a nurse in the pediatric clinic is talking with the mother of a preschool age child. The mother tells the nurse that her son is a picky eater. what is the most appropriate response by the nurse?

expect that food consumption might not decrease significantly

a nurse is teaching a client who take aspirin daily for CAD about herbal supplements. the nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin

feverfew

a charge nurse notes that a staff nurse delegates an unfair share of tasks to the AP and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. which of the following statements should the charge nurse make to resolve this conflict

i need to take to you about unit expectations regarding delegating and completing tasks

a nurse is caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with comed and styled hair, which of the following responses by the nurse is therapeutic

i see you have done some grooming today

a nurse is instructing a young adult client about healthful sleep habits. which of the following statements should the nurse identify as a indication that the client needs further teaching

i watch television until i fall asleep at night

a nurse is planning care for a client who has acute dysphagia. which of the following nursing interventions should be included in the plan of care

instructing the client to tilt head forward when swallowing

A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?

intimacy vs. isolation

a nurse is presenting a class about fall prevention to a group of assisted- living residents. which of the following statements by a resident best indicates an understanding of the teachings

its a good idea to use the handrails in the bathroom

a nurse is preparing to apply restraints to a client to prevent from pulling out an IV catheter. which of the following actions should the nurse takee

keep the padded portion of the restraints against the wrists

a nurse is caring for an older adult client who states "i am afraid that i may fall while walking to the bathroom during the night." which of the follow actions should the nurse take

leave a nightlight on in the client's room

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend? a. Diet cola b. Iced tea c. Chocolate milk d. Lemon-lime soda

lemon-lime soda

a nurse is caring for a client who has a gastric ulcer. which of the following herbal supplements should the nurse recommend

licorice

a nurse is teaching a client about crutch walking using the three-point gait. which of the following statements by the nurse should be included in the teaching

move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches

a nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. which of the following actions should the nurse take to address the client's safety needs

move the client to a room closer to the nurses station

a nurse is caring for a preterm newborn who has a nasogastric tube and who is recently began intermittent gavage feelings of formula. the nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. the nurse should suspect the following

necrotizing enterocolitis

a nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. which of the following actions should the nurse take

notify the nursing supervisor of the concerns.

a nurse has completed an informed consent form with a client. the client then states "I have changed my mind and do not want to have the procedure done" what should the nurse do

notify the surgeon that the client wishes to withdraw informed consent for the procedure

a nurse is preparing for admission of client who has suspected active tuberculosis. which of the following precautions should the nurse plan to implement to safely care for this client

place the client in a private room with a special ventilation system

a nurse is observing an assistive personel performing postmortem care on a Muslim client. Which of the following actions by the student nurse should prompt a nurse to intervene

prepares to cleanse the body

a nurse is planning to delegate client care tasks to an assistive personnel. which of the following actions should the nurse plan to take

provide a clear description of the task to the AP

a nurse overhears 2 AP from the medical-surgical unit discussing a hospitalized client while in the cafeteria.

quietly tell the APs that this is not appropriate

the nurse is evaluating a client who has a cardiac catheterization with a left antecubital insertion site. which of the following pulses should the nurse palpate

radial pulse in the left arm

a nurse on a medical-surgical unit is providing care for a group of clients. the nurse should delegate collection of which of the following specimens to the AP

random stool specimen

a nurse on an inpatient mental health unit admitting a client who has panic-level anxiety. after showing the client to his room, which of the following nursing actions is most therapeutic at this time

remain with the client for a while

a charge nurse is reviewing the list of tasks that have been delegated to the AP by the staff nurse. which of the following tasks should the charge nurse reassign to a licensed nurse

removing and cleaning the cannula of a client who has a new tracheostomy

a nurse in a long-term care facility is planning care for several clients. which of the following activities should the nurse delegate to the LPN

scheduling a diagnostic study for a client

a newly licensed nurse is applying prescribed wrist restraints on a client. which of the following action should the nurse take

secure the restraints using a quick release tie

a nurse is administering a cleansing enema to a client who reports mild cramping. the client ask the nurse to stop the enema and allow him to go to the bathroom. which of the following actions should the nurse take

slow the flow of enema solution breifly

a nurse is providing teaching to a client who has a new prescription for levothyroxine for hypothyroidism. the nurse should instruct the client the avoid which of the following herbal supplements

soy

a nurse is caring for client who is hospitalized for the treatment of severe depression. which of the following nursing approaches is terapeutic to include in the client's plan of care

spending time sitting with the client

a nurse is teaching a client who is start taking warfarin about herbal supplement. the nurse should inform the client that which of the following herbal supplements can interact adversely with warfarin

st. johns wort

a nurse has several tasks to delegate to an AP. which of the following tasks should the nurse ask the AP to perform first

take an ABG specimen to the laboratory

a nurse observes a client's spouse sitting alone in the waiting room crying. when approached, the spouse says, " i am really concerned about my husband." which of the following is a therapeutic nursing response

tell me what is concerning you

a nurse is working with a LPN to care for a client who is receiving a continuous IV infusion. which of the findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site

the area surrounding the insertion site feels warm to the touch

a nurse is caring for a client whose partner died five years ago. which of the following findings indicates that the client is experiencing maladaptive grief

the client has kept his partner's closet untouched since her death

a nurse is caring for a 48 year old client who is grieving following the death of her husband seven months ago. the clients reports that she lost 30lb, and have difficulty sleeping. which of the factors indicate the client is experiencing maladaptive grieving

the clients husband died seven months ago

a nurse is providing teaching to a client following a mastectomy. which of the following client statements indicates an improving body image

the incision looks like its healing

a nurse manager is observing an AP applying wrist restraints for a client. which of the following actions should the nurse identify as an indication that the AP understands the procedure

the padding of the restraints is against the clients bony prominences

a nurse is planning to delegate tasks to a licensed practical nurse. which of the following entities is important for the nurse to understand when delegating tasks to the LPN

the state nurse practice act

an AP comes to work with a new set of artificial nails. the nurse takes the AP to a private location to discuss the issue. which of the following statements by the nurse is appropriate

there is a higher risk of infection for our clients associated with artificial nails

A nurse is caring for a new mother who is concerned that her infant's eyes cross. Which of the following statements is a therapeutic response by the nurse?

this occurs because newborns lack muscle control to regulate eye movement

a nurse is caring for a client who has a stage I pressure ulcer. which of the following dressing should the nurse plan to apply

transparent dressing

a charge nurse delegates to a LPN the task of changing a clients dressing. several hours later the client reports the dressing has not been changed. which of the following actions should the charge nurse take

verify the LPN knows how to do a dressing change

a nurse is reviewing the laboratory results of a client who has a pressure ulcer. the nurse should identify an elevation in which of the follow laboratory values as an indication that the client has developed an infection

wbc count

a nurse is caring for a client who is scheduled for an elective surgical procedure. which of the following actions should the nurse tak regarding informed consent

witness the clients signature

A nurse is preparing to insert an indwelling urinary catheter for a female patient. which of the following instructions should the nurse give the client as the catheter is inserted

bear down

The nurse is caring for a client who has paraplegia following an automobile accident. the client is on an intermittent urinary catheterization program. which of the following findings indicates the need for catheterization

dribbling of urine

a nurse is administering timolol eye drops to a client who has glaucoma. which of the following actions should the nurse take

drop prescribed amount of medication into the conjunctival sac

a nurse is teaching a client who is to begin medicated treatment of tuberculosis. the nurse should instruct the client that which of the following herbal supplements can interact adversely with the treatment

echinacea

a nurse is assessing an IV infusion site on an infant's left hand . which of the following findings should the nurse identify as an indication of a infiltration

edema in the palm of the hand

a nurse is caring for a client with a tracheostomy. the client's partner has been taught to perform suctioning. which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

performing the procedure independently

a nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye and pilocarpine eye drops which of the following instructions should the nurse provide?

administer the medications 5 mins apart

a nurse is organizing care for a group of clients. which of the following tasks should the nurse delegate to the AP?

assisting a client who is 12 hr postop following an appendectomy to use a bed pan

A new nurse is seeking advice from her preceptor on whether personal or professional liability insurance should be purchased. Which of the following statements by the preceptor is appropriate?

personal liability coverage is not mandatory, but you should consider purchasing your own coverage

a nurse is caring for a client who is confused and has pulled out her peripheral IV catheter three times. which of the following actions should the nurse consider

place mitten restraints on the client's hand

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates an understanding of the discussion? -"This stage involves constructive efforts on the part of the group members." -"This stage is when testing occurs to identify boundaries of interpersonal behaviors." -"Consensus evolves in this stage." -"Resistance is evident as subgroups for in this stage."

Consensus evolves in this stage."

a nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate the nurse notes that the client's indwelling urinary catheter is has not drained in the past hour. which of the following actions should the nurse take first

check the tubing for kinks

A nurse of a medical-surgical unite is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer?

d. observing a postoperative client who is confused

a nurse is teaching a client who has a prescription of a nasogastric tube to treat a pyloric obstruction. What rational for the use of the NG tube should the nurse include in the teaching

decompress the stomach

a nurse is caring for a group of clients. she plans to delegate obtaining morning vital signs to an AP on her team. Which of the following actions should the nurse plan to take?

determine the time frame the AP should report the results

a nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. which is the highest priority

determining if the client has psychotic thinking

a nurse is preparing an in-service for coworkers about various herbal supplements clients might report using. the nurse should include in the presentation that which of the following herbal supplements is used to help the client lose weight

ephedra

A nurse is preparing an in-service about the various supplements clients might use. Which of the ff. herbal supplements should the nurse include as potentially increasing the anticoagulant effects of aspirin and other oral anticoagulants?

feverfew

a nurse is caring for a client who reports having chronic constipation. which of the following herbal supplements should the nurse recommend

flaxseeds

a nurse has just finished a wound irrigation for a client who requires contact precautions. which of the following pieces of PPE should the nurse remove first

gloves

a nurse is about to explain a therapeutic procedure to a client who doesnt speak the same language as the nurse

have a medical interpreter present during teaching

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member request that the nurse apply restraints. Which of the following responses should the nurse take?

i will cover the catheter so he cannot see it

a nurse is providing teaching to an assistive personnel about caring for clients with restraints. which of the following statements by the AP indicates the an understanding of the teaching

i will tie a restraint to the portion of the bed that moves when the head of the bed is moved

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnosis should the nurse identify as being the priority in the client's care?

impaired tissue perfusion

a nurse identifies a pressure ulcer after the client had a long extensive recovery following a surgical procedure. when completing an incident report, the nurse should take which of the following actions?

include any relevant statements the client made about the ulcer

a nurse is caring for several clients who are at various developmental stages. the nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development

integrity vs. despair

a nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high level official to visit me!" the nurse responds," I understand, but it is time for group therapy and we expect everyone to attend. lets walk over together." for which of the following reasons is the nurse's response considered therapeutic

it clearly articulates what is expected of the client

nurse is preparing to obtain a blood specimen from a client by venipuncture. the client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. which sites should the nurse plan to use to obtain blood specimen

left forearm

a nurse is assisting a client during ambulation when the client begins to fall. which of the following actions should the nurse take

lower the client to the floor

a nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. which of the following statements should the nurse make

many herbal products have not undergone long term testing for safety and efficacy

a nurse is delegating client care assignment for the shift. which of the following tasks should the nurse delegate to an AP? -perform wound irrigation for a client -evaluate pain relief for a client following the administration of pain meds -measure and record intake and output for a client -teach a client about low-Na foods

measure and record intake and output for a client

A client smoking in his bathroom has dropped the discarded cigarette butt into the waste paper basket & it begins to smolder. The nurse recognizes that the priority action would be

move any clients in the immediate vicinity

a nurse asks a client to share personal stories. which of the following types of intervention is the nurse using to promote the development of the nurse client relationship

narrative interaction

a nurse is assessing a client who has a pressure ulcer. the nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer

necrotic subcutaneous tissue

a nurse is assessing the psychosocial development of a toddler. the nurse should recognize that this stage is characterized by which of the following

negative behaviors characterized by the need for autonomy

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the pt to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?-battery-negligence-malpractice-assault

negligence

a nurse plans to leave her schedule shift an hour early without permission or notification of the charge nurse. the clients in the nurse's assignment are stable. which of the following legal torts applies to this situation

negligence

an ap reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. which of the following tasks should the nurse delegate to the AP?

obtain V/s

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires which of =the following interventions?

pre-oxygenate

A nurse is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

preoxygenate client with 100% O2 for up to 3 mins

a nurse on the postpartum unit is caring for a group of clients with an AP. which of the following tasks should the nurse plan to delegate to the AP? a. Observe an area of redness on the breast of a client who is 1 day postpartum. b . Change the perineal pad of a client who just transferred from labor and delivery. c. Provide a sitz bath to a client who has a fourth degree laceration and is 2 days postpartum. d. Monitor vital signs during admission of a client who has a gestational hypertension

provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum

a nurse is preparing to bathe a client. which of the following actions should the nurse plan to take

pull the curtain around the client's bed

a nurse who his left-handed is preparing to perform a straight catheterization for a client. which of the following actions should the nurse take

raise the bed to a comfortable height

a nurse is assessing a client who has intravenous therapy-related phlebitis. the nurse uses the infusion nurses society phlebitis scale to assess the severity of phlebitis and documents the clients phlebitis as a grade level 1. which of the following assessment findings correlates with a grade level of 1

redness at the intravenous access site with pain

a nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

remain with client

a nurse is preparing a client for outpatient surgery. after the nurse inserts the IV catheter, the client reports pain in the insertion area. which of the following actions should the nurse take

remove catheter and insert another into a different site

a nurse is attempting to flush the IV saline lock for a client. the client reports pain above the catheter site. which of the following actions should the nurse take

remove the IV saline lock

a nurse is developing a plan of clare for a client who has a stage 3 pressure ulcer. which following interventions should the nurse include in the plan

reposition the client atleast every 2 hrs.

a nurse in a long term facility is planning care for several clients. which of the following activities should the nurse delegate to the LPN?

schedule a diagnostic study for a client

a nurse is caring for a client who has stage 3 pressure ulcer. the nurse should recognize that which of the following lab findings will affect wound healing

serum albumin 3.2 g/dl

a nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client which of the following actions should the nurse take

set limits for the relationship

a nurse is performing an admission assessment on a client. which of the following findings should the nurse identify as an indication that the client is dehydrated

skin tenting

a nurse is caring for a client who is experiencing dysphagia. the nurse should recommend a referral to which of the following members of the health care team

speech therapist

a nurse is obtaining a medical history from a client who is to start warfarin therapy and currently uses herbal supplements at home. the nurse should inform the client that which of the following herbal supplements can interact adversely with warin

st. johns wart

A nurse is caring for a client who has an indwelling urinary catheter and notes blood tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

bladder infection

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis

calf swelling

A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions that nurse should take. Place them in the order of performance.

-Adjust the suction -Don sterile gloves -Check the function of the suction catheter. -Hyperoxygenate the client -Insert the catheter without suction -Apply intermittent suction while rotating the catheter. -Check for secretion clearance

A nurse is caring for a client who is 1 day postoperative following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? Select all that apply

-Squeezing a rolled wash cloth -Flexing and extending her hand -Flexing and extending her elbow

A nurse in an urgent care center is caring for a client who fell and injured her ankle. the ankle appears swollen and ecchymotic. while the client waits for the technician to take x-rays, which of the following are appropriate nursing interventions?

-apply ice to the ankle -apply a compression bandage -elevate the foot

a nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. which of the following actions should the nurse take before requesting a prescription for restraints

-assist the client with toileting at frequent intervals -use an electronic position-sensitive device -provide diversionary activities for the client -involve the family in the client's care

a nurse is providing postmortem care for a client. identify the sequence of steps the nurse should follow

-make sure the provider has certified the client's dead -verify the client's organ and tissue donation status -remove medical equipment from the client -cleanse the body while adhering to body fluid precautions -attach ID tags to the body

a nurse is caring for a client and identifies an infiltration at the iv catheter site. identify the order the nurse should perform the following actions

-stop the infusion -remove the IV catheter -apply a sterile dressing -elevate the extremity -apply warm or cold compresses

a nurse is caring for a client who is at risk for falls. which of the following actions should the nurse take

-teach the client to use the call light -keep the clients bed in the lowest position -place fall-risk ID band on the clients wrist

A nurse manager hears a staff nurse on the unit speak openly about her dislike of a new policy regarding client care. When discussing the issue with the nurse, which of the following statements by the nurse manager is appropriate? A. You should support this policy change because it is based on EBP B. Being open to change is an expectation for nurses who work on this unit C. Why didnt you voice your concerns before the new policy was initiated? D. Lets talk about your concerns about the new policy

D. Lets talk about your concerns about the new policy

A nurse is providing postmortem care for an adult client. Which of the following actions should the nurse take? (select all that apply) a. Place client flat lying on bed b. Determine whether client will have autopsy c. Cover body with clean sheet and place arms outside of it d. If client had significant trauma, discourage viewing by family/friends e. Give client's personal belongings to family

b. Determine whether client will have autopsy c. Cover body with clean sheet and place arms outside of it e. Give client's personal belongings to family

charge nurse is making client care assignments. which of the following tasks should the nurse delegate to AP

bathe client who has amputation assist client to ambulate using hait belt feed client who had a stroke

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?

Specific characteristics of the medications

a nurse is reviewing the goals of the nurse-client therapeutic relationship with a client who is seeking counseling. which of the following information should the nurse include in this discussion

The client achieves optimal personal growth

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?

The medication should be applied on a regular schedule for the rest of the client's life.

a nurse is teaching a class on torts. the nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?

battery

a nurse is caring for a client who falls in his room. after the nurse assesses the client. notifies the client's provider, and completes an incident report, which of the following actions should the nurse take? a. make a copy of the incident report for the provider b.submit the incident report to the risk manager c.place the incident report in the client's chart d.document in the chart that incidence report has been filed

submit the incident report to the risk manager

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

surgeon

a nurse is assisting with the admission of a client who is about to have elective surgery. the client tells the nurse she feels anxious. which of the following responses should the nurse make

tell me more about your concerns

a nurse manager is talking with a staff nurse who was unable to sleep the night after experiencing unsuccessful client resuscitation. which of the following responses should the nurse manager make

tell me what are your concerns are

a nurse in an outpatient mental health unit is planning care for a client who is in restraints. which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit

the client follows directions

a charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. for which of the following actions by the nurse should the charge nurse intervene?

the nurse separates the client's labia with her dominant hand

a nurse is applying wrist restraints to a client who is confused and attempting to pull out a chest tube. which of the following actions should the nurse taking when using restraints

tie the restraint using a quick release knot

a nurse in an urgent care clinic is studying the developmental stages of various clients. in which of the following clients should the nurse expect to see manifestation of autism

toddler

nurse is planning care for an older adult client who is at risk for developing pressure ulcers. which of the following interventions should the nurse use to help maintain the integrity of the client's skin

use a transfer device

a nurse is providing discharge teaching about clean intermittent self-catheterization a client who has benign prostatic hyperplasia. which of the following instructions should the nurse include

use soap and water to wash the catheter after each us

a nurse is caring for a client who has a history of body dysmorphic disorder. which of the client statements indicates to the nurse that the client has a distorted body image

when i look in the mirror, all i see is a person with a horrible complexion