practice q's

A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make?

"Bring the child to the funeral service before visitors arrive."

A nurse is teaching a newly licensed nurse about advance directives for clients who have schizophrenia. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Clients can appoint a health care surrogate for when they are unable to make decisions."

A community health nurse is teaching a group of restaurant workers about hepatitis A. Which of the following statements should the nurse make?

"Hepatitis A can be spread by fecal-oral contact."

Calculate the expected delivery date for a newly pregnant primigravida. October 4.

0710

A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

1800

1. nurse is admitting an unidentified female who was brought to the emergency department

3 month old

A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern?

A brainstorming session with nurses

A nurse is planning care of a group of clients at the beginning of their shift. Which of the following clients should the nurse care for first?

A client who had an appendectomy 6 hr ago and has diminished bowel sounds

A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?

A client who has a traumatic arm amputation

A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care? A. Remind the client to place the cane on the unaffected side. B. Adjust the length of the cane to equal the distance from the client's iliac crest to the floor. C. Remove the rubber tip from the cane to enhance ambulation. D. Place the cane safely in the closet during naps and at bedtime.

A. Remind the client to place the cane on the unaffected side.

1. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?

A1C

A nurse is caring for a client who is near the end of life. The client's partner asks the nurse to ease the client's breathing difficulty. Which of the following actions should the nurse take?

Administer a bronchodilator to the client.

A nurse is caring for a client who is receiving IV moderate (conscious) sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?

Administer flumazenil

A nurse is assessing a client who has schizophrenia. The nurse should identify that which of the following manifestations indicates a risk for self-harm? Anergia Auditory hallucinations Avolition Visual hallucinations

Auditory hallucinations

A nurse is assisting with inserting an endotracheal tube for a client who will receive mechanical ventilation. Which of the following actions should the nurse take first following tube insertion? Suction the oropharynx Collect arterial blood gas Suction the tube Auscultate lung sounds

Auscultate lung sounds

A nurse is assessing a client who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?

Change in vocal tone after drinking liquids

A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actioned the nurse perform first?

Determine the client's living situation

A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting, Which of the slowing instructions should the nurse include?

Ear a dry carbohydrate before getting out of bed

A nurse suspects another nurse is experiencing chemical impairment during their shift. Which of the following is an appropriate action for the nurse to take?

Report to the nurse manager.

A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following task should the nurse delegate to the AP

Sit with the client who has anorexia nervosa during meals

A community health nurse is caring for a client who request a referral for family therapy. The nurse should include who from interdisciplinary team?

Social worker

A nurse is planning care for a dient following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge? Limit your meals to three times per day Consume at least 25 grams of fiber daily Start each meal with a protein source Check your blood glucose level before each meal

Start each meal with a protein source

A nurse is reviewing the medical records of four clients. Which of the following prescriptions correct documentation?

Sucralfate 1 g PO 1 hr ac

An infection control nurse is reviewing the medical records of several clients. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention?

Syphilis

A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

The client has a cough reflex

A nurse is assessing the vital signs of a newborn who was born 8hrs ago. Which of the following findings require interventions by the nurse?

blood pressure

1. A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis

boots

1. A nurse in the emergency department is caring for a client following a motor vehicle crash. priority?

c spine

common manifestation of food allergies

vomiting

A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?

"I should place my baby's car seat rear-facing until 6 months of age."

A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching?

"Include the complete name of the medication morphine sulfate."

A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?

"My advance directives communicate my decision to remain on a breathing machine"

A nurse is providing teaching to a client who has a new prescription for lithium carbonate. Which of the following statements should the nurse include in the teaching? "Notify your provider if you experience diarrhea." "You should limit your fluid intake to 1 liter per day." "This medication can cause urinary retention." "You should take this medication on an empty stomach."

"Notify your provider if you experience diarrhea."

A nurse is providing teaching to a client who has mild persistent asthma and has just been prescribed montelukast. Which of the following statements should the nurse include in the teaching?

"This medication should be taken 2 hr before exercise or physical activity"

A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic?

"You're curious why I am interested in you and not the others?"

A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include?

A client who has a history of MRSA can still transmit the infection

A nurse is performing change-of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first

A client who has gastroenteritis and is lethargic and confused

A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first?

A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days

A nurse on a mental health unit receives report on four client. Which of the following clients should the nurse attend to first

A client who is having auditory hallucination and is becoming agitated

A nurse is reviewing morning laboratory values for several clients. Which of the following findings is the highest priority for the nurse to report to the provider?

A client who is prescribed digoxin and furosemide and has a potassium level of 3.1 mEq/L

A nurse is caring for a client who is 2 hr postoperative following an ileal conduit procedure for bladder cancer. For which of the following findings should the nurse notify the provider?

A dusky-colored stoma

A nurse working in an inpatient mental health facility observes a client who is agitated and threatening staff members in the day room. Which of the following actions should the nurse take first

Accompany the client away from the common area

Anurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose? Alanine aminotransferase (ALT) Thyroxine (Tal Serum amylase Creatinine kinase (CK)

Alanine aminotransferase (ALT)

A nurse in an emergency department is caring for a client who has multiple wounds due to a motor vehicle crash. Which of the following actions should the nurse take? (Select all that apply.)

Apply direct pressure to bleeding wounds. Cover the wounds with a sterile dressing Determine the date of the client's last tetanus toxoid immunization

A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. Which of the following should the nurse include in the teaching? Maintain foot above the level of the head Expect numbness and tingling for the first 24 hr. Apply ice on the ankle for 20 min intervals Perform range of motion exercises for the affected joint

Apply ice on the ankle for 20 min intervals

A nurse is teaching a client about smoking cessation. Which of the following client statements should the nurse identify as an understanding of the teaching? A. If I stop abruptly I cannot use a nicotine replacement. B. After 6 months, my risk of heart disease is the same as that of a nonsmoker C. I will set a specific date to stop smoking D. I will use high carbohydrate snacks as a substitute for cigarette

C. I will set a specific date to stop smoking

1. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?

Clothe the newborn in light cotton

A nurse is counseling a cilent whose partner has recently died. The client reports continuing to cook their partner's favorite meals. The nurse should identify that the client is using which of the following defense mechanisms? Compensation Dissociation Rationalization Denial

Compensation

A nurse is assessing a client who has COPD and experienced recent weight loss. Which of the following findings should the nurse report to the provider?

Coughing and wheezing after eating

A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding? A. Metallic taste in mouth B. Abdominal fullness C. Feeling flushed and warm D. Swollen lips

D. Swollen lips

A nurse is assessing a client who is taking buspirone. Which of the following findings should the nurse identify as an indication that the medication has been effective?

Decrease in anxiety

A nurse is caring for a client who will be receiving a transfusion of platelets. The nurse recognizes that the expected outcome of this treatment will be which of the following?

Decrease in bleeding from puncture sites

A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication

Decreased reflexes

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). For which of the following findings should the nurse monitor as a potential complication of TPN? Constipation Respiratory depression Hypotension Electrolyte imbalance

Electrolyte imbalance

A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention?

Empty the bladder before and after intercourse

A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest?

Engaging in a meditation exercise led by the nurse

A nurse on a med-surg unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter

Female who is prone to development of blood clots in the urine

1. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?

Fever

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). The nurse should place the diaphragm of the stethoscope at which of the following locations?

Fifth intercostal space at the left midclavicular Iine

A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?

HbA1C

A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?

Hospice care improves quality of life through palliative care

1. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?

Hyperemesis

A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect?

Hypotension

At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Indigestion

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?

Inform the client of available community resources.

A nurse is assessing a client who is at 40 weeks of gestation and in the first stage of labor. Which of the following findings should the nurse report to the provider?

Late decelerations noted on fetal monitor

A nurse is planning care for a client who has a deep vein thrombosis in the right leg. Which is the following actions should the nurse include in the plan?

Maintain client on bed rest

A nurse is assessing a client who is 1 hr postpartum and notes that the client's uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first? Administer IV oxytocin. Massage the fundus. Monitor blood pressure. Insert an indwelling urinary catheter.

Massage the fundus.

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP), When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Measure the amount of gastric drainage every 2 hr

A nurse is assessing a client whe has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider? No bowel movement for 3 days Report of dry mouth Respiratory rate 14/min Potassium level 4.8 mg/L 3.5 to 5 minutes

No bowel movement for 3 days

A nurse is setting up a sterile field for a dressing change on a postoperative client. Which of the following actions should the nurse plan to takes maintain the sterile field?

Open the first flap of the sterile package away from the nurse's body.

A nurse is caring for a client who is undergoing peritoneal dialysis and notes that the dialysate outflow has become cloudy. Which of the following complications of this procedure should the nurse suspect? Bleeding Peritonitis Poor dialysate flow Fibrin clot formation

Peritonitis

A nurse in a pediatric unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions?

Pertussis

A nurse is caring for a client who has left-sided hemiplegla due to a cerebrovascular accident (CVA). Which of the following interventions should the nurse perform to prevent footdrop?

Place positioning boots on the client's feet

A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min In frequency and 1 min in duration. Which of the following actions should the nurse take?

Prepare the client for a cesarean section

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

Rephrase sentences the client does not understand.

A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?

Take the client outdoors.

A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective?

The child has increased sputum production

A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints?

The client apologizes for their aggressive behavior

A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

The infusion pump for administering contimuous feeding is turned off.

A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique

This technique decreases the risk of subcutaneous infiltration

A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity

Tinnitus

An occupational health nurse at a group of health care clinics is planning activities to prevent and control the spread of communicable disease The nurse should identify that which of the following activities is a secondary level of prevention?

Tuberculosis screenings

A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the lab values will you report to the provider?

WBC 3,000

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following assessment findings requires immediate intervention by the nurse? Blood glucose of 120 mg/dL Prealbumin level of 20 mg/dL Temperature of 37.6C (99.7F) Weight increase of 2 kg/day

Weight increase of 2 kg/day

A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter line. Which of the following information should the nurse include in the teaching?

Your PICC line will allow long-term access for antibiotic therapy

1. A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?

a. Extend the client's legs above heart level

A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?

a. Hallucinations

1. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

a. Monitor for abdominal ascites

1. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

a. Monitor the client for 1 hr after meals

1. A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

a. Report the incident to Adult Protective Services

1. A nurse is admitting a client who has chronic gout what med should the nurse admin?

allopurinol

A nurse in a postpartum unit is caring for several clients. After receiving a change-of-shift report, which of the following clients should the nurse assess first? a. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus b. A client who is 1 day postpartum and has not voided in 8 hr c. A client who is 3 days postpartum and has not had a bowel movement since prior to admission d. A client who is 4 days postpartum and has lochia serosa

b. A client who is 1 day postpartum and has not voided in 8 hr

A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? a. shivering b. oliguria c. bradypnea d. constricted pupils

b. oliguria

A nurse is about to administer an injection to a client when the client states, "I don't want that injection. The last time i got that I was sore for a week." The nurse goes ahead and administers the injection against the client's wishes. The nurse committed which of the following!

battery

A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?

egg whites

1. A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine?

hypertension

A nurse is preparing to mix NPH insulin and regular insulin for a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take?

inject air into the NPH insulin vial first

A nurse from the State Health Development is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention?

lyme disease

A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications?

shellfish allergy