Uworld Assessment 1

The nurse assists with medication reconciliation for a client visiting the clinic for follow-up appointment. which medication report by the client requires further investigation?

200 mg of celecoxib PO once daily

an elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. after removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. what is your appropriate nursing action?

so the client's lower legs in a warm water bath

a client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. which nursing action would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

step slightly behind the client with feet apart, extend one leg, and let clients slide against it to the floor

The nurse reinforces teaching to a 15-year-old primigravid client at 16 weeks gestation during the initial prenatal visit. which information would be a priority to the nurse to include

stress the importance of consistent prenatal care

The nurse administers ondansetron to a hospital client. which statement would indicate to the nurse that the ondansetron was effective?

the nausea is a lot better

The nurse is assessing a client's peripheral post. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left post is diminished but still palpable. how should the nurse document these findings?

bilateral dorsalis pedis DP pulses palpable. Right DP 2+, left DP 1+

a pregnant client in the third trimester completes an intake form for a clinic visit. The nurse understands that which size of symptoms warrant further investigation

copious amounts of watery, clear vaginal discharge dysuria and right flank pain headache and blurred vision

The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. which response by the nurse is most helpful?

night fears are coming at this age. look under the bed with your child

The nurse is reinforcing education about injury prevention with the parent of a 6-month-old infant. which statement while the parent indicate that teaching has been effective?

I should place safety locks on the cabinets under the bathroom and kitchen sinks I will need to move sharp and breakable objects onto high shelves, out of reach

The nurse accidentally administers oral dissolving mirtazapine through a client's percutaneous endoscopic gastrostomy tube instead of the prescribed sublingual route. After assessing the client for adverse reactions, what is a nurse's priority action?

notify the prescribing healthcare provider

The nurse is walking through a mall parking lot and witness the collapse of a child. The child is not breathing and has a pulse of 50 beats a minute. after the nurse calls emergency services and delivers rescue breath for 2 minutes, the child is still not breathing and is now pale with a pulse of 49 beats a minute. what is the nurse's next action?

Begin chest compressions

The nurses reviewing the medical history of a client who has sustained a right tibia fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing

peripheral arterial disease

after a client with Alzheimer's disease is found wondering in the middle of the street at 3:00 a.m. and returned by police, the nurse reinforces teaching to family members about measures to keep the clients safe at home. what is the most important strategy for the nurse to include in the instruction?

place a chain lock on the door above or below the client's eye level

The clinic nursing structs a female client on how to collect a clean catch urine specimen for culture and sensitivity. which of the following client statements indicate the teaching has been effective?

I will be very careful not to touch the inside or rim of the container I will begin to urinate before passing the container into the stream for collection I will cleanse the area with single use antiseptic wipes prior to urinating

an African American client comes to the clinic for a follow-up visit two months after starting in enalapril for hypertension. which client statement should be reported to the healthcare provider immediately

Will you look at my tongue? it feels thicker than normal

The client admitted to a psychiatric unit with severe anxiety and patient rapidly in the room, crying, and hyperventilating. The client yells, I can't believe you took my belongings? where are you keeping them? this is so frustrating! what is the appropriate response by the nurse?

You're belongings are locked in a safe place to ensure that they are protected while you are here.

The new nurse, caring for a 3-month-old client who is sedated in the intensive care unit following surgery, needs to prevent skin breakdown. which action perform by the new nurse would cause the charge nurse to intervene?

placing a donut pillow under the head

The emergency department nurses caring for a client who requires gastric lavage for a drug overdose. which action would be appropriate

prepare intubation and suction supplies at the bedside

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. which action by the student would require the nurse to intervene?

provide supplemental formula feedings until improved breastfeeding occurs

The nurse on an impatient mental health unit is carrying for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. which intervention by the nurse is appropriate?

provide the client food and unopened single-serving packages

The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse asked the client about any allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. plan and order the steps the nurse should take when inserting the urinary catheter

1st perform hand hygiene and open stereo urinary catheterization 2nd apply sterile gloves and place fenestrated drape with shiny side down 3rd use non-dominant hand to grasp penis below glands 4th use dominant hand to cleanse meatus with cotton balls or swab sticks 5th use dominant hand to insert catheter until urine return is observed 6th advanced catheter to tubing bifurcation and inflate balloon

a client is a 28 week gestation with suspected preeclampsia. which are the potential signs and symptoms related to the syndrome

2 plus pitting pedal edema 300 mg/24-hour protein in urine headache and blurry vision

The nurse cares for a client with depression who states, if I tell you something, will you keep it a secret? what statement by the nurse is correct?

I cannot make that promise; I may need to share it with your therapist

The home health nurse visited client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. which statement by the client indicates that the client understands ileostomy care?

I cut the appliance opening slightly larger than my stoma

The nurses reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. which of the following statements about the client indicate the correct understanding?

I have switched from coffee to decaffeinated herbal tea in the morning I plan to join a smoking cessation program I brought myself up on a couple of pillows when I go to sleep I will switch to low-fat dairy product and avoid high-fat foods

The nurses reviewing home instructions with the client who just underwent cataract surgery with intraocular lens implantation. which of the following client's statements indicate appropriate understanding of the teaching?

I need to wear an eye patch at night I should avoid sexual intercourse until I'm healed I will increase my fluid intake and take docusate daily

The nurse is caring for a client who is being treated for depression and suicidal ideation. which client statement best indicates that the client is not currently at risk for suicide?

I plan to attend my granddaughter's graduation next month

which client's statements reflect the correct understanding of genital warts and the human papillomavirus HPV

I should consult my healthcare provider about pap testing at age 21 infection with HPV increases my risk of cervical cancer using condoms during sex will reduce the risk of spreading virus

a child was congenital heart disease who weighs 88 lb is prescribed for Rosamond 1 mg per kilogram by mouth every 8 hours. it is available as an oral solution of 10 mg per milliliter. how many milliliters of furosemide should the nurse administer to the client for each dose?

4ml

after listening to the parents' reports and seeing the following pediatric clients the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting

5-year-old whose x-ray reveals one new and two healed humorous fractures after falling from a tree

The nurse is preparing to administer Edison to a 4-year-old client weighing 43 lb. based on the prescription, what is the volume of the medication in milliliters that the child should receive with each dose?

9

The emergency department nurse is assigned for clients. which client needs to be seen first

9-year-old with recent pacemaker insertion with dizziness and purulant drainage at the incision site

The nurse is reinforcing client teaching about newly prescribed cyclosporine. which client statement indicates the need for further teaching

I am going to a concert with my friends this weekend

during a follow-up visit to the primary care clinic, the nurse evaluates a client's understanding about prevention of complications from varicose veins. which client statements indicate a correct understanding?

I avoid crossing my legs when sitting I have started wearing elastic compression holes I tried to elevate my legs as often as possible I tried to walk at least a mile everyday

a nurse assist a student nurse in formulating a care plan for a nonverbal hospice client who demonstrates restlessness and facial grimacing during repositioning. which statement by the nurse indicate a correct understanding of the goals of end of life care?

I can observe the client's agitation as an indicator of the client's pain level I should continue to explain interventions I am performing even though the client is unresponsive I will ask the family if they would like to hold the client's hand while I administer pain medication managing pain rather than treating disease is a priority goal for this client

The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. which statement by the parents indicates that teaching has been effective

I can start substituting breastfeeding sessions with whole cow's milk

The nurse is reinforce the education with the client with marfan syndrome who is recovering from an aortic root repair and mechanical aortic valve replacement via sternotomy and is prescribed warfarin. which of the following statements by the client indicate appropriate understanding of the teaching?

I will have my spouse list and carry heavy objects for me for several months I will need to take the prescribed warfarin for the rest of my life if I gain 3 lb or more in a week, I will need to tell my healthcare provider my usual razor blades will need to be replaced with an electric shaver

The charge nurse is educating a new nurse on intramuscular injection technique for a 6-year-old with autism spectrum disorder. which statement by the new nurse indicates that further teaching is required?

I will hold the child's hand as a soothing measure

The nurses reinforcing self care and medication teaching for the client diagnosed with vaginal candidiasis who has been prescribed my chronos all vaginal cream. which statement by the client indicates that further teaching is needed?

I will refrain from having sex until my partner is also tested and treated for the infection.

and nurses were enforcing teaching to a client newly prescribed verapamil for chronic migraine headaches. which statement by the client indicates the need for further teaching

I will take this medication at the first sign of a migraine

The nurse on a medical surgical unit maintain a shared social media page. which social media posts written by nurses breach client confidentiality?

I'm going to private message everyone a cute story about our sweet client with dementia it breaks my heart that are paraplegic client was so neglected by her husband The client in room five is positive for influenza so please remember your flu vaccines Wash your hands well if you had room for this week! cultures are now positive for c diff

a client with social anxiety disorder is receiving treatment at the local community mental health center. which situation most likely cause client to seek therapy?

The client's boss has acts a client to represent the company at an upcoming convention

a student nurse is accompanying the charge nurse when conducting daily rounds. which personal protective measure by the charge nurse does the student nurse question?

Wears two pairs of gloves when emptying the urinary catheter collection bag of a client with HIV

The nurse is caring for an adult client with advanced dementia, confusion, and a history of falls. which of the following interventions are appropriate to promote client safety?

activate the bed alarm before leaving the room place a bedside commode next to the bed place a client in a room close to the nursing station

a client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. at 7:30 a.m., the client's blood glucose level is 322 mg. The nurse expects the client's breakfast to arrive before 8:00 a.m. what action should the nurse take?

administer 37 units of insulin: 25 units of NPH insulin mixed with 12 units of regular insulin in the same syringe, drawing up regular insulin first

on a company 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2° f and a post of 120 beats a minute and is lethargic. The client's parents are out of town, and no guardians can be reached. how should this clients care be handled.?

administer care unto the parents or guardians can be reached

a client with the history of seizure disorder has a seizure while sitting in a chair. which nursing intervention are appropriate during the seizure activity?

administer oxygen as needed if client become cyanotic move the client from the chair to the floor to prevent a fall record the duration of seizure activity for documentation

a nurse is caring for a postpartum client who has breast engorgement following breastfeeding. which instruction should the nurse reinforce regarding relief of breast engorgement?

allow newborn to nurse for at least 10 to 15 minutes on each breast

a client is in cardiac arrest, the resuscitation efforts are in progress when the client spouse arrives. The clients spouse and system coming into the room. how should the nurse respond?

allow the spouse into the room and provide a chair

The nurses participating in community health presentation about prevention of tick bites and Lyme disease. what instruction should the nurse include?

apply a tick repellent spray before outdoor activities avoid hiking through areas of tall grass and thick under brush report bullseye rash or flu-like symptoms to the healthcare provider Wear a long sleeve shirt tucked into pants and clothes till shoes while hiking

which task can the charge nurse appropriately delegate to the unlicensed assistive personnel

apply protective skin ointment after perineal cleansing document daily wait for the client with congestive heart failure perform passive range of motion exercises for a client on a ventilator

The nurses reinforce an education about good sleep hygiene to a client with chronic insomnia. which instructions should the nurse include

avoid caffeine containing beverages for at least 4 hours before bedtime if you are still awake 20 minutes after going to bed get out of bed and read a book prepare the bedroom environment by making it dark, quiet, and cool

The new nurse is reinforcing teaching to a client scheduled for electroconvulsive therapy ECT. what information given by the new nurse would cause a charge nurse to intervene?

be sure to take your valproic acid prior to the procedure

The nurse assistant is caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. which statement by the student indicates a need for further teaching?

because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document

The nurse in a psychiatric unit is approached by the aggressive client who grabs a nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's graphs on harm. which action should the nurse take first?

beginning scoring other clients out of the room

The nurse responds to the bed alarm of a client with a severe urinary tract infection that finds a client lying on the floor and soil with urine. Which of the following entries by the nurse are appropriate to include when documenting the event and the client's electronic medical record

blood pressure 102/60, pulse 97 beats a minute, oxygen 98% on room air client found at 2310 soiled with urine, lying on the floor near foot of bed client states, my bottom hurts and I feel a little bit dizzy Jones, MD, notified at 2322. Will continue to monitor for indications of injury

The nurse is caring for an African-American client with immune thrombocytopenia. which locations are best to monitor for the presence of petechiae

buccal mucosae and conjunctivitis of the eyes

The nurse is caring for a client admitted three days ago was bacterial pneumonia who has become short of breath, restless, and difficult to arouse. which additional finding indicates to the nurse that the client may be developing sepsis

capillary refill time of 5 seconds

which client situation would be classified as an adverse event, requiring a nurse to complete an incident report?

cerebral spinal fluid sample is sent to the laboratory labeled as urine sample nurse does not report potassium result of 6.5 to healthcare provider postpartum client who is post epidural anesthesia falls while emulating to the bathroom provider prescribes 5,000 units of heparin, nurse gives 1 ml (10,000 units/ml) of heparin

for pediatric clients are brought to the emergency department at the same time. which client should be seen first

child with bruising behind the ears after football injury

a home health nurse is managing care for an adolescent client with cystic fibrosis. which of the following potential complications should the nurse consider when developing a nursing care plan?

chronic hypoxemia frequent respiratory infections vitamin deficiencies

The nurse has just received report on four clients. which client should the nurse see first

client receiving IV normal saline at 250 ml per hour who is reporting puffy legs and a new cough

The nurse working in a gastrointestinal clinic is reviewing the list of walk-in clients. which client should the nurse see first

client reporting constipation since having a barium enema 3 days ago

The nurse receives hand off of care report on four clients. which client should the nurse see first?

client who has a urinary tract infection, temperature of 102° f, and respiratory rate of 125 beats a minute

The nurse receives report on four clients. which client should the nurse see first?

client with a right-sided ischemic stroke who is confused and is reportedly getting out of bed without assistance

a nurse in the emergency department is caring for four clients. which client should the nurse see first

client with myasthenia gravis who has a fever and increasing difficulty swallowing

for which client is it most important for the nurse to reinforce teaching regarding ways to prevent the spread of the condition?

client with tinia corporis

a practical nurse is collaborating with a registered nurse educator to develop materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. which action should staff members be encouraged to perform if they experience workplace violence?

document the interactions with the bully observe interactions between the bully and other colleagues Tell the bully you will not tolerate the unprofessional behavior

The nurse is caring for five clients and is assisted by experience unlicensed assistive personnel. which task can the nurse safely delegate to the UAP

emptying a urinary drainage bag and recording output providing peroneal care for a client with urinary catheter reapplying sequential compression devices

The nurses reinforcing discharge teaching for a client who is hearing impaired. which of the following actions should the nurse implement?

encourage the client to repeat back teaching Ensure adequate lighting in the client's room Said directly in front of the client while speaking use printed materials with pictures and illustrations

The nurses cares for a client with a terminal disease who has an advanced directive supporting a do not resuscitate code status. The client stops breathing and loses a pulse. The client's adult child states I changed my mind. do whatever you can to save him. which intervention is most appropriate at this time.

explain the client's wishes to the client's child

a client is diagnosed with septic arthritis of the knee. what manifestations does the nurse expect to find?

fe joint swelling with effusion limited range of motion moderate to severe pain

The nurses reviewing a client's pre-operative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. which action is most appropriate at this time?

follow up with the client regarding the nature of the spiritual needs or religious practices

while the nurse is transporting a client to a new unit, the client's chest to drainage system falls off the bed and the two becomes dislodge from the chest wall. what is the nurse's priority action?

from the cover the insertion site with the palm of a clean, gloved hand

which herbal supplement pulls an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery?

garlic Ginger ginkgo bilob

The nurse is performing a home visit for a child with cystic fibrosis who had a percutaneous endoscopic gastronomy peg tube placed 6 weeks ago. during inspection of the peg tube, the nurse should correctly recognize which finding as expected?

gastrostomy tube movement of 0.2 in is noted when the client coughs

a 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. which is the most appropriate nursing action

give the client a schedule of daily activities

The nurse removes personal protective equipment PPE after completing a wound dressing change for client and airborne transmission based precautions. which PPE should the nurse remove first?

gloves

The nurse helps a client with in-stage renal disease and is sharing potassium of 5.2 MEQL to plan menu choices. which items would be best to include in the meal plan?

grilled chicken sandwich on white bread, applesauce

The nurse is preparing to dance sterile gloves before suctioning a client's tracheostomy. place the steps of doning sterile gloves in the correct order

hand hygiene and remove outer glove package open the inner glove package by folding back the edges use non-dominant hand to grab scuff on inside of dominant hand glove pull on dominant hand glove place dominant hand fingers under cuff on outside of non-dominant glove pull on non-dominant hand glove

The nurse is caring for a new mother whose infant has been diagnosed with down syndrome. The client says to the nurse, I'm so worried. my husband is so devastated that he won't even look at the baby. what is the best response by the nurse?

how are you feeling about your baby

charge nurse assisted student nurse preparing to apply needle compression stockings onto a client with chronic venous insufficiency. which actions by the student nurse would cause the charge nurse to intervene?

instructs client that stockings will be worn only at night rolls down any excess length at the top of the stocking celexa size larger to avoid friction against a leg laceration

The nurses were forcing teaching to the caregiver of the client with a new prescription for risperidone. which statement indicates that the caregiver needs further instruction?

is it normal for the client to become shaky and restless when agitated

The nurse is caring for a client taking a citalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. what is the best response by the nurse?

let's talk more about how you have been taking this medication

The nurses performing cardiopulmonary resuscitation CPR on an adult at a swimming pool. a bystander brings an automated external defibrillator AED. The nurse knows that the victim is wet, lying in a small pool of water, and wearing a transdermal medication patch on the upper right chest. what is the most appropriate action at this time

remove the transdermal patch and wipe the chest dry before using the AED

a 4-year-old boy is diagnosed with Duchenne muscular dystrophy. which nursing teaching is most appropriate to reinforce for this child's parents

remove throw rugs from the home

The experienced nurse on a medical surgical unit is supervising a new nurse who is caring for a client with constipation. which action by the new nurse could cause the experienced nurse to intervene?

request coffee to be included with breakfast trays

The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. which client report to the nurse is most concerning?

right shoulder pain and dizziness

unlicensed assistive personnel report for situations to the nurse. which situation warrants the nurse's intervention first?

room three puncture resistant sharps disposal container on the wall is full

a client comes to the emergency department after being bit by a bat. The nurse observes two small, non-draining puncture wounds resembling pinpricks in the fingertip. which action should the nurse implement first?

scrub the wound with povidone iodine solution or soap and water

The nurse cares for a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid field vesicles. which burn stage does the nurse document?

second degree

The nurse checks a client's blood pressure using an automatic, non-invasive machine. The nurse notes at the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and display an error message. which action by the nurse is appropriate?

send the machine for maintenance and repeat the measurement manually

The nurse on a medical surgical unit prepares scheduled daily medications for a client and places them in a pill cup. after receiving the cup the client states, I take whole tablet of metformin at home. why did you cut this one in half? what is the best response by the nurse?

show me which pill you're talking about so I can verify the prescriptions again

what nursing intervention is most appropriate when caring for a client with impairment to cranial nerve II?

verbally explain nursing interventions in detail

a female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with men. which question will help the nurse determine the client's risk for sexually transmitted infections?

what barrier methods do you and your partners use

The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. which statement by the nurse is most therapeutic at this time

what do you see at the door

The nurse is discussing the care needs of a client in the last stage of Huntington disease with a family. when the nurse mentions arranging the delivery of is prescribed hospital bed, the client's spouse becomes visibly upset and says, no hospital bed. I'm just not ready for it yet. what is the best response by the nurse?

what upsets you about having a hospital bed

The clinic nurses caring for 76-year-old client who has heart failure and is experiencing sudden weight gain and orthopnea. which question will be the most beneficial for the nurse to act at this time

when are you taking each of your medications

The staff nursery for preparing to presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. which recommendation included in the presentation indicates a need for further teaching?

working toward diversification of staff age and gender

The nurse is caring for an adult client who is in a soft wrist restraint. which nursing action should be included in the plan of care? I haven't tried

you got another one offer fluids, nutrition, and toileting every two hours and as needed perform neural vascular checks of the extremities every hour release restraints to perform range of motion exercises every two hours