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The adolescent tells the school nurse she is planning to start sexual relations with her boyfriend. Which is the BEST response by the nurse?

"Have you discussed this decision with your parents?"

The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The client reports pain at 1600. The nurse notes that the hydrocodone was last administered at 1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering the error, how should the nurse record the occurrence?

"Hydromorphone given at 1615; health care provider notified. B/P 122/80, RR 16."

The nurse provides care for the client diagnosed with pneumonia who has postural drainage twice a day. Which client response indicates to the nurse that treatment is effective?

"I am coughing up more sputum."

The nurse obtains a health history for the school-age child diagnosed with asthma. It is most important for the nurse to follow up on which statement made by the child?

"I live in a rural area".

The home care nurse visits the client diagnosed with late stage Parkinson's disease. The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective?

"My Client should push the hips up from the wheelchair for about 10 seconds every hour or so."

The nurse prepares the client diagnosed with myxedema for discharge. Which action should the nurse teach related to body temperature?

"Put on multiple layers of clothes until you fell comfortably warm."

A nurse in the pediatric clinic receives a call from a parent stating, "it looks like my 10- year-old has chickenpox, but my child had the immunization". Which response by the nurse is BEST

"You should keep the child home for the next week".

The nurse cares for the client diagnosed with partial thickness burns to the entirety of both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage?

18%

The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met if which is recorded on the intake and output (I&O) sheet for an eight-hour shift?

480 ml

The nurse care for the clients in the Sleep Study Unit. The nurse recognizes which client is at GREATEST risk for developing obstructive sleep apnea?

60 year old male, 55 pounds over ideal weight.

After receiving report from the evening shift charge nurse, which client should the nurse see FIRST?

A 67-year old client diagnosed with pneumonia with a pulse oximeter reading of 88%

The nurse prepares to administer digoxin for the 5-year-old child. The nurse should withhold the drug and contact the physician for which finding?

A apical heart rate of 88 assessed. (60 or less adult, 90 or less children)

The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should assign the client to a room with which client?

A client diagnosed with Cushing's Syndrome.

A nurse in the oncology clinic receives messages from four clients. Which client should the nurse see FIRST?

A client diagnosed with non-Hodgkin's lymphoma reports facial swelling.

The nurse instructs the client after a total hip arthroplasty. The client will utilize which assistive devices in the home?

A long-handled shoehorn. A reaching device. A raised toilet seat. A shower bench.

The nurse observes client care on a geriatric unit. The nurse should intervene in which situation?

A student nurse assists the client to stand from a sitting position by grasping the client's elbows.

The nurse cares for the child diagnosed with cystic fibrosis. The nurse should intervene if the child is eating which food?

A vanilla milkshake.

The nurse cares for the client after colostomy surgery. Eight hours after surgery, what observation would the nurse expect?

Absence of any output from the colostomy.

The nurse cares for the school-aged child newly diagnosed with type 1 diabetes. The nurse instructs the family that the child's insulin needs will decrease during which situation?

Active exercise

The nurse suspects that the client with severe uterine bleeding is in the early stages of shock. Which is the PRIORITY nursing action?

Administer oxygen per nasal cannula.

The nurse cares for the adolescent diagnosed with Hodgkin's lymphoma. The adolescent receives nitrogen mustard, vincristine, procarbazine and prednisone. Which adverse effect of the drugs requires early preparation of the adolescent?

Alopecia

The male client asks the nurse, "Why am I experiencing erectile dysfunction (ED)?" The nurse reviews the client's medications. The nurse recognizes that which classification increases the risk for ED?

Antihypertensive medications.

The nurse cares for the client admitted to the critical care unit. The nurse observes splinter hemorrhages in the nails, painful nodules on the fingertips and splenomegaly. It is MOST important for the nurse to take which action?

Auscultate the precordium for murmurs (ENDOCARDITIS)

Which indicates to the nurse that a 41-year-old woman who is 5'5'' tall is obese?

Body mass index is 31 kg/m2

The charge nurse has received change-of-shift report on a medical-surgical unit. Which activity can be delegated to an LPN/LVN?

Change a dressing on a client with a stage IV pressure ulcer. Obtain vital signs on a client whose BP was 88/64 an hour ago. Irrigate an urinary catheter. Administer water through a gastrostomy tube.

The nurse cares for a client diagnosed with pneumonia. The client receives intravenous antibiotic therapy twice daily. The client reports three liquid stools the past six hours. Which action should the nurse take FIRST?

Collect a stool sample for Clostridium Difficile.

The nurse cares for the client reporting a burning sensation and itching of the right eye. On examination, the eye is red, with watery yellow discharge. The nurse understands which is the MOST likely cause of the client's symptoms?

Conjunctivitis

The nurse counsels the client diagnosed with herpes simplex virus (HSV) infection. Which suggestion by the nurse BEST meet the client's needs to cope with this diagnosis?

Contact information for a local support group.

The nurse cares for a toddler diagnosed with croup. The nurse notes the toddler's respiratory and heart rates have increased significantly. Sub sternal and intercostal retractions are pronounced, and the child is restless. Which action should the nurse take FIRST?

Contact the health care provider.

Two days after a short leg cast was applied for a fractured tibia, the client reports new, severe pain over the calf area. Which action should the nurse take FIRST?

Contact the health care provider.

The nurse cares for the teenager recovering from mononucleosis. The teenager is upset and reports feeling too weak to resume normal home and social activates. The friends no longer come visit, and the parent is tired of "doing everything." Which response by the nurse is MOST appropriate?

Convalescence is lengthy and people often report fatigue for several months.

The nurse teaches the mother of a 3-month-old infant. When planning accident prevention, the nurse emphasizes which goal?

Crib rails will be kept in the highest position.

The nurse reviews a diet containing broiled catfish, baked green beans, a roll, a brownie, and tea. The nurse identifies this diet is most appropriate for which condition?

Crohn's disease.

The client reports vomiting and diarrhea for three days. Which assessment finding does the nurse anticipate?

Decreased blood pressure.

The nurse provides care to a client diagnosed with cirrhosis. Which is the BEST explanation for the development of edema?

Decreased concentration of plasma albumin.

The adolescent diagnosed with acute mania is started on lithium. Which behavior indicates to the nurse the medication is effective?

Decreased euphoria and slower rate of speech noted.

The nurse cares for a 6-month-old infant. The parents report that the infant had severe diarrhea for twelve hours. The nurse anticipates which finding?

Depresses anterior fontanel.

The client diagnosed with type 1 diabetes reports to the nurse, "I feel really nervous and jittery all over". The nurse notes regular insulin was administered two hours ago. Which action should the nurse take FIRST?

Determine the client's recent dietary intake.

The nurse cares for the client diagnosed with obsessive-compulsive personality disorder (OCD). Which does the nurse expect the client to demonstrate?

Doubts, fears, and indecisiveness

The nurse cares for the client with a pacemaker. When monitoring pacemaker functions, which should the nurse assess FIRST?

Electrocardiogram (ECG)

The nurse cares for a three-year-old child diagnosed with severe anemia. The nurse observes weakness and fatigue. Which will the nurse expect to observe?

Increased heart rate.

The nurse evaluates the results of the client's purified protein derivative (PPD) 2 1⁄2 days after the injection. The nurse noted the induration is 4 mm. which action by the nurse is most appropriate?

Inform the client the results are negative

The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP) discuss the client's condition. What is the PRIORITY action for the nurse to take?

Inform the employees about patient confidentiality and the client's right to privacy.

The nurse witnesses a co-worker put one of two narcotic tablets in the co-workers purse twice during the shift. Which action should the nurse take?

Inform the nursing supervisor

The nurse cares for a child following corrective surgery for tetralogy of Fallot. The nurse should include which in the child's plan of care?

Instruct the child's parent about food allowed on a 2 gram sodium diet.

The nurse prepares to administer medications to the following clients. Which medication should the nurse pass FIRST?

Ipratropium to the newly-admitted client diagnosed with chronic obstructive pulmonary disease.

The nurse instructs the client about a lumbar puncture. In which position will the client be placed?

Lateral recumbent position.

The nurse prepares the 3 year old for discharge after a tonsillectomy. The nurse recommends the parents offer the child which food during the first 24 hours?

Lemon-lime soft drink

The nurse instructs the client about stable angina. The nurse determines teaching is effective if the client makes which statement?

My chest pain can occur if I overexert myself.

The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne precautions, the nurse must confirm which?

No acid-fast bacteria are in the sputum.

The nurse cares for the client diagnosed with anorexia nervosa. The nurse should include which in the client's plan of care?

Observe client during and one hour after each meal.

The home care nurse makes a visit to the client diagnosed with heart failure. The client reports having difficulty sleeping at times. The nurse should take which action FIRST?

Obtain a thorough sleep assessment history.

The home care nurse cares for the client diagnosed with benign prostatic hyperplasia. The client reports not voiding since the previous evening. Assessment reveals a distended bladder. Which action should the nurse take NEXT?

Obtain an order for a straight catheter.

The client reports severe lower back pain radiating down the left leg. The client identifies the pain as 9 on a 0-10 scale and states, "It feels like I've been stuck with a hot poker". Which order should the nurse anticipate?

Opioid analgesic.

The nurse cares for the client just admitted to the surgical unit from recovery after a total hip replacement. It is MOST important for the nurse to take which action?

Position the client with the legs abducted.

The nurse prepares to administer medications. Which medication cannot be given directly intravenously?

Potassium chloride (KCI)

When providing respiratory care for the client with a tracheostomy, it is MOST important for the nurse to take which action?

Preoxygenate the client prior to suctioning.

The nurse educator presents an in-service on acyanotic heart disease. Which is the most common symptom of this disorder that the nurse educator should include?

Presence of an audible heart murmur.

The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST important?

Prevent infections.

The nurse develops a plan of care for the client diagnosed with osteoporosis. Which is the best description on the PRIORITY goal?

Prevention of falls and accidents.

The nurse cared for clients diagnosed with AIDS. The nurse recognizes which statement is true regarding therapy?

Protease inhibitors affect cell replication and have been successful.

The nurse cares for the primigravida during the transition phase of labor. Which is MOST important for the nurse to include in the client's plan of care?

Provide comfort measures including position changes.

The nurse cares for the newborn with a port wine stain covering the face and half the body. The nurse notes that the mother refuses to look at the newborn. Which response by the nurse is MOST appropriate?

Reinforce the health care provider's explanation of the defect and allow time for the mother to discuss her fears.

The nurse cares for the client diagnosed with bipolar disorder. The nurse determines which activity is appropriate for the client during a period of mania?

Relaxation exercises. Scheduled rest periods. Aerobic exercises. Listening to soft music.

The intensive care nurse cares for the client two hours after a myocardial infarction is diagnosed. The nurse's PRIORITY is to focus on which action?

Relieve pain.

The nurse cores for the client with a history of schizophrenia. The nurse expects to note which speech pattern?

Repetition of the words used by the nurse.

The nurse cares for the client with a chest tube. Immediately after the tube is removed, it is MOST important for the nurse to take which action?

Request a STAT portable chest X-ray.

The client receives enteral nutrition at 50 ml/hour due to dysphagia. Which nursing action diagnosis would be the priority?

Risk for aspiration.

The health department nurse cares for the client diagnosed with tuberculosis and positive HIV status, sharing concerns over financial and childcare issues and life expectancy. Which referral is MOST appropriate for this client?

Social worker from social services department.

The nurse cares for the client diagnosed with a hearing impairment. Which is a PRIORITY action for the nurse to take?

Speak at a slightly slower pace.

The nurse cares for the infant diagnosed with hydrocephalus immediately after placement of a ventriculoperitoneal (VP) shunt. The nurse should place the infant in which position?

Supine lying on the non-operative side

The parent of an adolescent diagnosed with hemophilia calls the nurse to discuss the adolescent's desire to participate in sports. Which activity should the nurse recommend?

Swimming

The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate which activity to the LPN/LVN?

Take the blood pressure and heart rate before administration of enalapril.

The nurse on the pediatric unit receives report from the previous shift. Which client should be seen FIRST?

The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285 mg/dl.

The nurse cares for the three-year-old prior to a surgical procedure. Which behavior indicates that the child is coping with preoperative preparation?

The child talks about the picture of a nurse and client while coloring the picture using a number of bright colored crayons.

The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a candidate for induction of labor?

The client diagnosed with preeclampsia.

The nurse cares for the client receiving lactulose. The nurse determines the medication is effective if which is observed?

The client is alert and oriented to person, place and time.

The nurse cares for the client in pain. Which factor is MOST important to determine if the client is a candidate for patient controlled analgesia?

The client is mentally alert.

The nurse received report from the previous shift. Which client should the nurse see FIRST?

The client scheduled for discharge later in the day and is reporting increased shortness of breath.

The nurse cares for a client after an involuntary admission to a mental health facility due to threatening to harm self. The family asks the nurse if they can take the client home. Which response by the nurse is MOST appropriate?

The courts determine how long the client is hospitalized.

The nurse assists the client to obtain a sputum specimen. Which action should the nurse take first?

The nurse performs hand hygiene and dons clean gloves.

The home care nurse instructs the client receiving long-term prednisone therapy. Which information should the nurse include?

There are changes in fat distribution over several areas of the body.

The home health nurse instructs the family how to "allergy-proof" their preschooler's bedroom. The nurse determines teaching is successful if which of the following is observed?

There are no pictures hung on the walls.

The nurse provides discharge instructions to the client with a tube after traditional cholecystectomy. The nurse determines teaching is effective if the client makes which statement?

This tube will stay in for 1-2 weeks and drainage will decrease.

The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion. Which action should the nurse take FIRST after initiating the infusion?

Time and record the length and strength of the contractions.

The client reports dyspnea, sever chest pain, nausea, and increased anxiety. Which lab value would cause the nurse to contact the physician?

Troponin T 0.9 ng/mL.

The nurse determines which lunch menu is the BEST choice for a patient diagnosed with fluid volume excess?

Turkey on wheat bread, carrot sticks, chocolate cake, 6 oz iced tea.

The nurse prepares a list of delegated tasks for the nursing assistive personnel (NAP). Which task would be APPROPRIATE?

Turn and reposition the client diagnosed with quadriplegia.

The nurse cares for infants in the newborn nursery. Which observation requires the nurse to contact the physician?

Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6 hours ago.

Nurses working in hospital environments should follow which guideline related to effective hand washing?

Wash for at least fifteen seconds covering all surfaces.

An adolescent undergoing hemodialysis tells the nurse, "My friends are all going on a big trip over spring break and I can't go. I don't think they'll miss me much anyway." Which is the BEST response by the nurse?

You must be disappointed. Describe what you are feeling right now.

The nurse cares for the client in the emergency department. The client's friends state the client inhaled varnish remover and passed out. The nurse notices a rash around the client's nose and mouth, axillary temperature 97.8 degrees, pulse 66, respiration 12, blood pressure 168/88, pulse oximetry 98%. Which action should the nurse take FIRST?

Evaluate pupillary response.

The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration?

Failure to follow routine policy and procedures.

The nurse cares for the school-age child receiving phenytoin. The nurse should observe for which known adverse effect?

Gingival hyperplasia.

The client after radical prostatectomy expresses concern related to ongoing urinary incontinence. Which response by the nurse is BEST?

Have you been doing Kegel exercises?

The nurse assigns the nursing assistive personnel (NAP) to the mother who is first day postpartum following a vaginal birth. Which tasks are appropriate for the nurse to delegate to the NAP?

Help the mother to ambulate shortly after delivery. Assist the mother with changing the perineal pad.

The nurse reviews the arterial blood gas (ABG) report. The PH is 7.50; CO2 is 40mm; HCO3 is 30 mm. Which is the MOST important question to ask the client?

How long have you been vomiting?

The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makes which statement to her husband?

I'm sorry to tell you we can't have sexual relations

The nurse cares for a client diagnosed with pancreatic cancer. When talking to the client about the diagnosis, the nurse anticipates the client will make which statement?

I've been feeling fine and didn't go to the doctor until my skin was kind of yellow.

The nurse presents information about misuse of medications to the senior citizen group. Which client response indicates a safe medication practice?

If I miss a dose of medication, I should not double up on the next dose.