RN Comprehensive Practice B
A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicated an understanding of isolation precautions?
"A client who requires airborne precautions should be placed in a negative pressure airflow room"
A nurse in a provider's office is assess an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?
"Have you had any stomach pain or bloody stools?"
A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?
"How does this make you feel?"
A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?
"I can designate my partner as my health care surrogate"
A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism?
"I told my doctor that I would like to start a support group for other women who are sick in my community"
A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?
"I will be checking you once with your eyes open and once with them closed"
A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching?
"I will cover my baby's body when I wash her hair" "I will use the bulb syringe first in her mouth and then in her nose"
A nurse is providing education to the parent of a school age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
"I will make sure my child receives a yearly influenza immunization"
A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?
"I will need to measure your weight daily"
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?
"I will not allow anyone to smoke near my baby"
A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I will wear a supportive bra overnight"
A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?
"I would like to talk to you about the unit policies regarding break time"
A home health nurse is evaluating a school age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?
"My child has only a small amount of mucus after percussion therapy"
A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?
"Notify your provider if you experience increased thirst" The nurse should recognize that an increase in thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider.
A nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? SATA
"Shake the medication bottle well before each dose is given "Store the medication in the refrigerator" "Report diarrhea to the provider immediately"
A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?
"Tell me more about your understanding of the options"
A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?
"We can expect the hospice nurse to provide support for us after our mother's death"
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?
"You have the right to change your mind about the procedure at any time"
A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?
"You seem to be having a difficult time right now"
A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule for a 3 hour oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?
"You will need to fast the night before the test"
A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donator states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make?
"You're afraid that your other kidney will fail at some point after the organ donation"
A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?
"Your body temperature might decrease slightly just prior to ovulation" - Body temperature rises after ovulation and remains elevated until 2 to 4 days prior to the start of menstruation. The client should measure their body temperature upon waking each morning prior to getting out of bed.
A nurse is preparing to administer lactated ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
13 gtt/min
A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer?
18 g
A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect?
45 seconds This value is above the expected reference range of 30 to 40 seconds and indicates a risk for spontaneous bleeding, which is a manifestation of hemophilia A.
A nurse on a pediatric unit has received change of shift report for four children. Which of the following children should the nurse assess first?
A 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism?
A client who channels their energy into a new hobby following the loss of their job
A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?
A client who has cellulitis and is receiving oral antibiotics every 8 hr
An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?
A client who is at 33 weeks of gestation and has severe gestational hypertension
A nurse has just received change of shift report on four clients. Which of the following clients should the nurse assess first?
A client who is postoperative with abdominal distention and no bowel sounds - abdominal distention and no bowel sounds indicates a paralytic ileus
A nurse has received change of shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
A client who is receiving an MAOI and is requesting a cheeseburger for dinner - The client's food selection contains tyramine. Clients prescribed an MAOI must restrict intake of foods that contain tyramine due to adverse effects, such as HTN
A nurse at a mental health clinic is caring for four clients. The nurse should recognize the following clients is using dissociation as a defense mechanism?
A client who was abused as a child describes the abuse as if it happened to someone else
A home health nurse is caring for a group of older adult clients. The nurse should indicate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?
A client whose caregiver requests adult day care services PACE provides adult day care services along with in-home assessments and supportive services
A nurse is working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?
A middle adult client who has unstable vital signs
A nurse in a community center is providing an education session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?
Abdominal bloating
A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?
Acute confusion An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia.
A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?
Administer high-dose antibiotic therapy Children who have CF metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections
A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?
Advocacy is a leadership role that helps others to self-actualize
A rural community health nurse is developing a plan to improve health care delivery for migrant farm workers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?
Agency for Healthcare Research and Quality The goal of AHRG is to improve the quality of health care services for all populations, including low-income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations.
A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding?
Albumin 2.8 g/dL The nurse should recognize that an albumin level of less than 3.5 indicates malnutrition and a need for additional nutritional supplementation. The expected reference range for albumin is 3.5-5
A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
Allow for frequent rest periods throughout the day clients who have rheumatoid arthritis should balance rest with exercise to maintain muscle strength, joint function, and range of motion.
A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessment is the nurse's priority?
Amount of vaginal bleeding A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vaginal bleeding is the priority.
A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?
An older adult client who is anxious and attempting to pull out an IV line
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider?
Apply a cold pack to the client's ankle for 30 min every hour
A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an AP?
Arrange the lunch tray for a client who has a hip fracture
A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?
Ask another nurse to witness the disposal of the new patch
A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
Ask the partner to list specific concerns
A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?
Aspirate the contents from the tube and verify the pH level The nurse should verify that the pH level of the client's gastric aspirate is less than 5 to determine proper placement of a client's NG feeding tube prior to administering a bolus feeding.
A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?
Assign the client to a private room with negative air pressure
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?
Assist with deep breathing and coughing
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
Auscultate the apical pulse at least 1 min
A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?
Autonomy
A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?
Avoid including raw fruits in the client's diet
A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?
Blurred vision
A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?
Borderline Clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation.
A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make?
Broccoli Yogurt Cream cheese Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine. Broccoli, yogurt, and cream cheese do not contain tyramine.
A nurse is caring for a 2 month old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD?
C The nurse should assess the infant's abdomen for distention and visible peristalsis, which are manifestations of HD
A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth?
Cervical laceration
A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first?
Change the position of the client
A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?
Check the client's oxygen saturation level
A nurse in an emergency department is assessing a school age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?
Contact Child Protective Services
A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?
Cough
A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?
D abducting the hip joint by moving the leg away from the midline of the body.
A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?
Decreased hallucinations Chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia
A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?
Delegate non-nursing tasks to ancillary staff
A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
Determine the client's reading skills
A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?
Difficulty performing ADL's
A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?
Droplet The nurse should initiate droplet precautions for this client by placing the client in a private room and wearing a surgical mask when caring for the client.
A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?
Dry mouth Clonidine is an indirect-acting antiadrenergic agent used for HTN, severe pain, and attention deficit disorder. The nurse should inform the client that dry mouth, or xerostomia, is a common adverse effect of clonidine.
A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
Dyspnea Fluid overload can lead to the backup of fluid in the pulmonary system resulting in shortness of breath.
A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?
Edema Compartment syndrome causes increased pain, pallor, and paresthesias from increased edema in the compartment involved
A home health nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include?
Empty the appliance when it is one-third to one-half full To prevent stool leakage and skin irritation
A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?
Ensure that the client understands the medication regimen
A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?
Explore the client's reasons for refusing the treatment
A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?
Facilitate an interdisciplinary conference at the new facility for the family
A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According Nägele's rule, which of the following should the nurse document as the client's estimated date of birth (EDB)?
February 15 - Add 7 days to the first day of the client's LMP (8+7=15) and then subtract 3 months
A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?
Fiber To reduce diarrhea and inflammation
A nurse manager is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using?
Flight of ideas Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes.
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?
Floating dark spots
A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?
Form a committee of staff members to investigate current staffing issues
A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
Have the client wear a surgical mask while being transported outside the room
A nurse is assessing a client who received 2 units of packed RBC's 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?
Hemoglobin 14.9 g/dL Normal levels - females: 12 to 16 g/dL males: 14 to 18 g/dL
A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?
Hold the insulin pen device perpendicular to the client's skin to inject the medication - the nurse should hold the pen in place briefly for 6 to 10 seconds after injecting the insulin into the subcutaneous skin to ensure that the insulin is received.
A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect?
Hyponatremia The nurse should expect the client to have a decrease in sodium levels because sodium is drawn to the edematous burn area and lost through plasma leakage.
A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess?
Ideas of self-harm
A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?
Implement fall precautions for the client Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls.
A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?
Increase the client's dietary iron intake Clients who have rheumatoid arthritis require food high in protein, vitamins, and iron to promote tissue repair.
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?
Increased opacity of the lens A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration
A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?
Initiate continuous cardiac monitoring The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.
A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
Initiate transmission-based precautions The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection.
A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?
Insert a lubricated gloved finger and advance along the rectal wall
A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.
Inspection Auscultation Percussion Palpitation
A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?
Instruct the client to avoid coughing during the procedure
A nurse is caring for a client who has a deep-vein thrombosis. Which of the following actions should the nurse take?
Instruct the client to elevate the affected extremity when sitting The nurse should instruct the client to elevate the affected extremity to reduce edema and facilitate venous return
A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?
Instruct the client to void
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?
Irrigate the catheter with 0.9% sodium chloride irrigation Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter and notify the provider if the obstruction does not clear.
A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?
Irritability when being held Irritability is a manifestation of increased ICP, which is an indication that the VP shunt is malfunctioning.
A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
Jaundice Clients who take valproic acid are at risk for liver damage, which can lead to jaundice.
A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
Maintain sterile objects within the line of vision
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
Make a referral for social services
A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?
Making a list of activities to complete
A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an AP?
Measure the client's daily weight
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?
Monitor the client's mouth every 8 hr
During the change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
Move the client to a room near the nurses' station
A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?
Nasal flaring The nurse should report any indications of respiratory distress such as nasal flaring, retractions, and grunting
A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?
Noting the progress of the group toward assigned goals
A nurse is assessing a school age child who has bacterial meningitis. Which of the following findings should the nurse expect?
Nuchal rigidity
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?
Occlusive dressing on the insertion site Occlusive dressing on the insertion site prevents air from leaking and is an expected finding
A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer?
Oxytocin
A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the nurse plan to delegate to the AP?
Perform gastrostomy feedings through a client's established gastrostomy tube
A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Pink, frothy sputum due to fluid leaking across the pulmonary capillaries and into the lung tissue
A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased ICP?
Place the client in a quiet environment - Limit suctioning the client's airway to 15 seconds at a time to reduce the risk of hypoxia and increased ICP. Spread out nursing activities throughout the day to minimize fatigue and the risk of increasing ICP. Avoid flexing the client's neck to reduce the risk of reduced cerebral venous outflow.
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse in unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?
Proceed with provision of medical care
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?
Radial vein of the inner arm
A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging?
Rapid decrease is blood pressure
A nurse in a provider's office is caring for an 18 month old toddler who has a blood lead level of 3 mcg/dL. Which of the following actions should the nurse take?
Recommend rescreening in 1 year - A blood lead level of 3 mcg/dL is within the expected reference range. The nurse should schedule chelation therapy for a blood lead level greater than 45 mcg/dL. The nurse should contact the poison control center for a blood lead level that is greater than 20 mcg/dL. The nurse should consider a referral to social services for a blood lead level greater than 5 mcg/dL.
A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?
Report of chest pain Epinephrine increases cardiac workload and oxygen demand, which can result in angina.
A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60, and HCO3 of 25. The nurse should identify that the client has which of the following acid-base imbalances?
Respiratory acidosis A client who has respiratory acidosis will have a decreased pH below the expected reference range of 7.35, and increased PaCO2 above the expected reference range of 35 to 45, and an HCO3 within the expected reference range of 22 to 26.
A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?
Sedentary lifestyle
A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?
Seeks input from the other nurses
A nurse is caring for a school age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?
Serum liver enzyme levels
A nurse is caring for a child who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?
Serum sodium 1.36 mEq/L A child who has hypotonic dehydration has a serum sodium level below 130 mEq/L. A serum sodium level of 136 mEq/L, which is within the expected reference range of 135 to 145, indicated that this child is responding well to the oral rehydration solution.
A nurse is providing teaching to a client who is schedule for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?
Short-term memory loss
A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?
Sodium 148 mEq/L normal range: 135-145 Clients who have kidney disease often retain sodium and require sodium-restricted diets.
A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?
Starts a task then determines what supplies are needed
A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?
Strict adherence to routines
A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?
Support the client's left arm on a pillow while sitting
A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?
Survey the scene for potential hazards to staff and children
A nurse is providing teaching to a school age child who has asthma about using an albuterol metered dose inhaler. Which of the following instructions should the nurse include?
Take medication 15 min before playing sports The nurse should instruct the child to take the medication 5 to 20 min prior to exercise to promote bronchodilator. The medication's effects begin immediately, peak in 30 to 60 min, and can last for up to 5 hr.
A nurse is caring for client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?
Tension pneumothorax The nurse should monitor the client's lung sounds hourly for indications of a tension pneumothorax, such as tracheal deviation, absent breath sounds, and distended neck veins.
An RN is observing a LPN and an AP move a client up in bed. For which of the following situations should the nurse intervene?
The LPN and the AP grasp the client under his arms to lift him up in bed
A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?
The child exhibits discomfort while walking
A nurse on an impatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?
The client is pacing around the chair in which their partner is sitting Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences.
A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?
The client reports a decrease in episode of nausea
A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change of shift report?
The time of the client's last dose of pain medication
A nurse administers an incorrect dose of medication to a client. The nurse recognized the error immediately and completes and incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
Time the medication was given
A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?
Tremors Tremors are a manifestation of hyperthyroidism along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia.
A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn of the CPM machine during mealtime
A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?
Urine specific gravity 1.052 The nurse should recognize this urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates dehydration from vomiting.
A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?
Use a protective cover on the scale when weighing the infant
A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?
Use a reward system to modify the child's behavior
A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
Use a three-point gait
A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?
Use the ventrogluteal site
A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
Verify the client and blood product information with another licensed nurse
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?
Wear clothing made with cotton fabrics while oxygen is in use
A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?
Wheezing
A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take?
Withhold the heparin infusion The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced, or the infusion withheld, until the aPTT returns to the therapeutic range.
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?
aPTT
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
irritability
A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
pH 7.31 Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35 to 7.45. A pH level less than 7.35 indicated acidosis. For a client who has COPD a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45, indicating respiratory acidosis.
