UWORLD PN, Uworld Assessment 1

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs" 2."His heart has stopped and we are attempting to revive him" 3. "I do not know how he is doing but you need to come" 4. "I will have the health care provider talk to you once you arrive"

1

The community health nurse is preparing to reinforce teaching to a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. 1.Cervical cancer 2. Hypertension 3. Ishemic stroke 4. Osteoporosis 5. Skin Melanoma

1,2,3

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are torn and show signs of wear 2. The client has a 30 degree bend at the elbow when walking 3. The crutches and injured foot are moved simultaneously in a 3-point gait 4. There is a 3 finger width space noted between the axilla and axillary pad

1 he proper fit and use of crutches are important in preventing injury. They include: Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option 4). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option 2). Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option 3). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). (Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Educational objective: Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation continues. Copyright © UWorld. All rights reserved.

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. 1. Epoetin alfa 2. Frozen plasma 3. Homologous packed red blood cells 4. normal saline 5. platelet transfusion

1,4 Educational objective: Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringer's, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit? 1. High-fowler's position with affected side's arm resting on the bed 2. Semi-fowler's positin with the affected side's arm on several pillows 3. supine with the affected side's arm on several pillows 4. supine with the affected side's arm resting on the bed

2

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 practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply. 1. Check gastric residual every 12 hours 2. Keep head of the bed at >30 degrees 3. Maintain endotracheal cuff pressure 4. Monitor for abdominal distension every 4 hours 5. Use caution when adminstering sedatives

2,3,4,5

The practical nurse is collecting data on several clients and the antipartum unit. which client should the practical nurse report to the registered nurse for further assessment?

26 weeks gestation, hemoglobin is 9 g/dl

A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPPA 5. Teach about one intervention at a time and in the order it will occur 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tube once a week, then clean with hydrogen perioxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting

2.4.5 Incisions may take 4-6 weeks to heal. The nurse should teach clients how to care for their incisions by providing the following instructions: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Avoid tub baths due to the risk of infection (Option 3). Do not apply powders or lotions on incisions as these trap bacteria at the incision site (Option 3). Report any redness, swelling, drainage increase, or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling (Option 5). Educational objective: The nurse should instruct the client with chest and leg incisions from coronary artery bypass grafting to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions; to report any redness, swelling, or drainage increase; and to wear an elastic compression hose on the legs. Copyright © UWorld. All rights reserved.

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important? 1. Allowing the client's husband to be with her during clinical examinations 2. Assigning the client to a private room 3. Ensuring that female health care workers are available to provide care to the client 4. Obtaining the services of a local Muslim imam

3

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? 1. "Have you shared your concerns with your HCP" 2. "If I were you, I would be more worried about whether the melanoma has spread" 3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications" 4. "There is special make-up you can use to hide any facial scars left from the surgery

3

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? 1. "cancer is no longer a death sentence, you may live for many years" 2. "I will ask the chaplain to talk to you sometime today" 3. "People with cancer experience fear of dying, tell me about your concerns 4. "Tell me about your life and hopes for the future"

3

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help 2. Delegate the task to UAP 3. Premedicate the client for pain 4. Verify the client's activity prescriptions

4

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? 1. Arrange for the client's service dog to come to the health care facility as soon as possible 2. Describe the environment in detail so that the client can ambulate safely with a cane 3. Instruct the UAP to walk beside the client and lead by the hand 4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

4

A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal cannula 2. Non-rebreathing mask 3. Oxymizer 4. Venturi Mask

4 A Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume. The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased tidal volume, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with chronic obstructive pulmonary disease (COPD). (Option 1) A nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate tidal volume and normal vital signs. It is not the best choice in an unstable COPD client with varying tidal volumes because the inspired oxygen concentration is not guaranteed. (Option 2) A non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short-term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client. (Option 3) An Oxymizer is a nasal reservoir cannula device that conserves oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen to reach the same saturation (eg, 3 L/min nasal cannula is equivalent to 1 L/min Oxymizer). It is not the best choice in an unstable COPD client with varying tidal volumes as the inspired oxygen concentration is not guaranteed. Educational objective: Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable chronic obstructive pulmonary disease [COPD]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, COPD exacerbation).

for which client is it most important for the nurse to reinforce teaching regarding ways to prevent the spread of the condition? 1. client wit eczema on upper torso 2. client with oral candidiasis 3. client with psoriasis on hands 4. client with tinea corporis

4. client with tinea corporis

a healthcare provider prescribes Seth rogue sign 30 mg per kilogram per day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 34 lb. based on available concentration of Seth Rock sign, how many milliliters would the nurse administer per dose

4.6

a nurse is caring for a group of clients on a medical surgical unit. which client is most at risk for contracting and nonsocomial infection?

74-year-old client with stroke and an indwelling urinary catheter for 3 days

The nurses caring for the assigned client on a pediatric inpatient unit. which client is the priority?

8-year-old with sickle cell crisis who has sudden onset unilateral arm weakness

A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply. A. Report any itching, tingling, or numbness around your incisions B. Report any redness, swelling, warmth, or drainage from your incisions C. Soak incisions in the tube once a week, then clean with hydrogen perioxide and apply lotion D. Wash incisions daily with soap and water in the shower and gently pat them dry E. Wear an elastic compression hose on your legs and elevate them while sitting

B,D,E

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

which situations require that the nurse report to the appropriate authority

Clint is diagnosed with gonorrhea and request not to report under the health insurance portability and accountability act HIPAA Aaron thinks a teenage client sign are from abuse, but the healthcare provider does not RN thinks in elderly clients sign are from abuse but the client denies this syphilis is diagnosed in an 11-year-old who denies sexual activity

For the past month, the nurse has been providing care to a 7-year-old client recently diagnosed with type 1 diabetes mellitus. Initially, the family seemed devastated over the diagnosis. The client's parent stated, "Our lives will never be the same." What statement now made by the parent BEST indicates that nursing interventions have been effective? A. Our child will not be able to participate in sporting events B. Our whole family will have to make sacrifiices to deal with this disease C. We have set aside a place in the pantry foru our child's special foods D. We will not let this disease take control of our child's life

D.

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

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. which statement by the client indicates a need for further teaching

I can leave right after the shot as I didn't have a reaction last time

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

The pediatric nurses reinforcing education about medication administration to the parents of a 4-year-old client which statement made by the parents demonstrate correct readings?

I should measure liquid medications using an oral syringe I will encourage my child to help me as i prepare the medication

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

a client is in the cardiovascular clinic for a 3-month follow-up visit. at the first visit the client was prescribed hydrochlorothiazide and amlodipine for hypertension. which statement by the client would be concerning and should be reported to the registered nurse?

I started taking licorice root for occasional heartburn

prior to hospital discharge, the nurse discussed sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. which client statement requires further teaching

I will begin using condoms to prevent pregnancy once menses returns

The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. what is the priority outcome for the caregivers?

Knowing how to keep blood sugar stable

The student nurse observes the respiratory therapist preparing to draw an arterial blood gas from the radial artery. The respiratory therapist performs the Allen's test and the student acts why this test performed before the blood sample is drawn. which statement by the respiratory therapist is most accurate

The Allen's test is done to determine the patency of the ulnar artery.

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

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.

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

which actions by a nurse are reportable to the state board of nursing

administering hydromorphone without a prescription documenting an intervention that was not performed still in narcotics walking off duty in the middle of a shift

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

The nurses reviewing the plan of care for a 4-year-old client who will receive daily dressing changes for an infected leg wound. which of the following interventions should the nurse include in the plan of care for a preschool age child?

allow the child's parents to stay during the procedure emphasize that addressing changes are not punished for misbehavior encourage the child to voice questions and concerns about the procedure by the child place bandages on a doll when reinforcing education

The nurse cares for confused client who continues to pull at the intravenous IV catheter on the left forearm despite frequent instructions not to do so. what is the nurse's next action

apply a gauze wrap and elastic stockinette around the IV site

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

a client at 20 weeks gestation reports running to the bathroom all the time, pain with urination, and foul smelling urine. which question is most important for the nurse to ask when assessing the client

are you having any pain in your lower back or flank area

the school nurses called to the classroom to assist with the 7-year-old with attention deficit hyperactivity disorder who is throwing books and hitting the other children. what is the best initial action for the nurse to take?

ask a child to blow up a balloon

while caring for a client and skeletal traction, which task can the nurse assign to experience unlicensed assistive personnel to help prevent immobility hazards?

assist with active and passive range of motion exercises reapply pneumatic compression device after bathing the client remind the client to use the incentive spirometer

The nurses reinforcing discharge instructions with the client following a partial gas strike to me. which of the following instructions should the nurse include to prevent dumping syndrome?

at high protein foods to diet eat small, frequent meals lie down after eating

The registered nurse (RN) teaches the parents of a hospitalized 3-month-old about separation anxiety. The practical nurse noticed that the parents still seem concerned about leaving the infant while they work and so reinforces the information provided by the RN. which statement by one of the parents indicates that the teaching has been effective?

at this stage, my baby will not cry because we are leaving

The nurse is caring for a preschool age child whose grandparent died 3 days ago. which intervention is inappropriate?

avoid mentioning the loved ones death in the child's presence

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 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+

The nurse understands that which of these body substances are modes of transmission for hepatitis b

blood semen vaginal secretions

a client who has been on long-term omeprazole therapy for gastroesophageal reflux disease is admitted to the hospital for a urinary tract infection. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use?

c diff infection

The nurses reinforcing discharge teaching for the parents of a 1-year-old with a newly diagnosed cow's milk allergy. which nutrients normally provided by milk should be obtained from other sources

calcium vitamin d

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

The community health nurses preparing to reinforce teaching to a group of African-American women about prevention of disease common to their ethnic group. based on the incidence of disease within this group which disorders should the nurse plan to discuss?

cervical cancer hypertension ischemic stroke

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

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

a client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. which clinical data is most concerning to the nurse?

client takes indomethacin for osteoarthritis

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

for clients were involved in a major highway motor vehicle accident. which client requires priority care?

client with blood pressure of 90/70 and deviated trachea

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

which situation would prompt the health care team to use the client's advanced directive to make a decision regarding care

client's Glasgow coma scale score is 3 client with intracerebral hemorrhage has aphasia

The nurse is reinforcing proper insulin self administration technique to a client of American Indian heritage. as a nurse describes the necessary steps in the injection process, the client avoids eye contact and occasionally turns away from the nurse. what action is most appropriate for the nurse to take in this situation?

continue instructing the client and verify understanding by return demonstration

1 month ago, a client was prescribed phenytoin 100 mg orally three times daily. The client's current serum phenytoin level is 32 mcg/ml. which action by the health care provider does the nurse anticipate?

decrease phenytoin daily dose

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

a male client admitted with a traumatic open fracture for the femur hematocrit of 36%, and hemoglobin of 12 is being prepared for surgery? which prescription should the practical nurse validate with the registered nurse before administration?

enoxaparin

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

The nurses reinforcing education to a prenatal client about the 1-hour glucose challenge test that will be performed at the next visit. which client statement indicates a need for further education?

fasting is required before the 1-hour glucose challenge test

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

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

The clinic near supervisor is a graduate nurse who is reinforcing teaching about home management to the parents of a 2-year-old with acute diarrhea. The nurse would need to intervene when the graduate nurse reinforces which instruction?

follow the bananas, rice, applesauce, and toast diet for the next few days

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

The nurse is preparing 7:00 a.m. medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. based on the information from the medical and medication records, which prescription should the nurse question before administering?

furosemide

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

The nurse is caring for a young adult who is considering becoming pregnant. The client expressed concern, stating, one of my parents has Huntington's disease, and I am afraid my child will get it. how should the nurse respond?

genetic counseling is recommended. you will receive a referral before you leave

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

a client with asthma and sinusitis has increased wheezing and decrease peak flow readings. The nurse recognizes that which of the following over the counter home medications taken by the client could be contributing to increased asthma symptoms?

ibuprofen 400 mg orally every 6 hours for pain as needed

which infant should be the nurses priority for monitoring and intervention?

infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dl

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 reinforcing poor teaching for the parents of a child newly diagnosed with a hemophilia. which long-term complication is important for the nurse to discuss?

joint destruction

The nurse is caring for a 10-year-old diagnosed with attention deficit hyperactivity disorder ADHD. in addition to the three-core symptoms of ADHD hyperactivity, impulsiveness, and in attention, which of the following would the nurse expect to find?

low self-esteem and impaired social skills

The nurse is floated from the obstetrical floor to the medical surgical floor. which client is the best assignment for the OB nurse

male client with an open bowel resection with a fully catheter

and nurses reinforcing teaching to the parent of a child who has a new diagnosis of absent seizures. which statement by the parent indicates understanding of the teaching?

my child may stare and seem inattentive

a 12-month-old is found to have a moderately elevated blood lead level. which of the following is the most serious concern for this child?

neurocognitive impairment

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

a client with an acute head injury cannot accurately identify the sensation felt when the nurse touches the intact skin with a cotton ball or paper clip. The nurse is aware that the deficit reflects injury to which area of the brain?

parietal lobe

The nurse receives an obese client in the post anesthesia care unit who underwent a procedure under general anesthesia. The nurse notes and oxygen saturation of 88%. which is the most appropriate initial intervention

perform head tilt and chin lift

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 nurse is caring for a client diagnosed with chronic anxiety. which behavior demonstrates to the nurse that the client possesses resilience?

practices stress reduction techniques daily

The nurse is caring for 40-year-old client with acromegaly in an outpatient health clinic. which new finding is most important for the nurse to report

presence of S3 and S4 heart sounds

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

a nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. which is an appropriate action by the nurse?

pull the pinna upward and back

a home health nurses reinforcing teaching with the spouse of an elderly client who experienced a stroke regarding ways to reduce risk for falls in the home. which suggestion by the spouse would be the most effective plan to prevent falls

remove all area rugs and install grab bars in the bathroom

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

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

the nausea is a lot better

a client diagnosed with pneumonia is experiencing shortness of breath, chest pain, orthopnea. The chest x-ray reveals a very large right plural effusion. which intervention should the nurse anticipate for this client

thoracentesis

The nurse is measuring the uterine fundal height of a client at 36 weeks gestation in line in a supine position. The client suddenly reports dizziness, and the nurse observes power and damp, cool skin. what should the nurse do first?

turn the client to a lateral position

The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse?

type 1 diabetes mellitus with a blood glucose of 55 mg/dl

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 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

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

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.

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this dx must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent this from happening" 3. "Well, we are all going to die sometime" 4. "You should concentrate on getting better rather than thinking about death"

1

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube? 1. Flush and aspirate the tube with warm water 2. Instill a digestive enzyme solution into the tube 3.Instill cola or cranberry juice into the tube 4.Use a small-barrel syringe to flush the tube

1

The nurse is reinforcing proper insulin self-administration technique to a client of American Indian heritage. As the nurse describes the necessary steps in the injection process, the client avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue instructing the client and verify understanding by return demonstration 2. Discuss how important it is for the client to pay attention during the teaching 3. Maintain eye contact during the instruction by following the cient's movements 4. provide written instructions and a private place for the client to learn independently

1

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply. 1. Palliative care focuses on quality of life and can be provided at any time 2. Palliative care is only possible with a terminal dx of <6 months 3. Palliative care is provided by a multidiscplinary team 4. Palliative care is another term for hospice care 5. Palliative care provides relief from symptomx assoc with chronic illnesses

1,3,5

The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year old man with a head injury sustained during a college football game 2. 30-year old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year old man 2 weeks post myocardial infarction 4. 68-year old woman recently dx with pancreatic cancer 5. 74-year old man with portal hypertension related to alchol-induced cirrhosis 6. 82-year old woman 1 week post cataract surgery

1,3,5,6

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1. Ask the client to explain the bruises on the torso 2. Assess the client's general hygiene and nutritional status 3. Report bruises to the client's health care provider 4. Talk to the client's child about the injuries

2

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 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse? 1."How is your spouse's new job going" 2."Ive noticed that you seem frustrated lately" 3. "It's normal to be angry when you can't work anymore" 4. "We have a support group that can help you adjust to rehab"

2

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1. Ask the client to explain the bruises on the torso 2. Assess the client's general hygiene and nutritional status 3. Report the bruises to the client's health care provider 4. Talk to the clent's child about the injuries

2

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for health care workers of the same sex to provide care for client 2. Coordinate with the Registered Dietcian to provide halai meals 3. Reposition the immobile client to face the city of Mecca During Daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. upon death, provide the family with supplies for postmortem care

1,2,3,5

A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply. 1. Administer docusate sodium orally every day 2. Assist in applying an abdominal binder 3. Implement caloric restriction to promote weight 4. Monitor blood glucose to maintain tight control 5. Reinforce teachings to hug a pillow while coughing

1,2,4,5

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Leaving the television on for diversion at night 3. Opening the window blinds/shades in the morning 4. Scheduling interventions and activities during the day when possible 5. Turning off equipment alarms in the client's room at night

1,3,4

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 is reinforcing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. 1. Conduct teaching sessions while a family member is present 2. Discourage the client from using the internet to look up health information 3. Have client watch a DVD about heart failure management 4. Print out pictures of a food label and review where to look for sodium 5. Speak slowly and loudly so the client can understand you

1,3,4 The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: Using pictures and simplified text is beneficial to the older adult with low literacy. Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. Professionally produced programs are beneficial as they contain high quality visual content as well a delivery of auditory content in lay person's language. (Option 2) Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view. (Option 5) Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning. Educational objective: For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational programs, pictures with simplified text, and inclusion of a family member during teaching sessions. Copyright © UWorld. All rights reserved.

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

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication 2. Call the HCP to meet with family to obtain information consent 3. Complete the preop checklist 4. Perform the morning assessment

4

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time? 1. Call emergeny medical services and place ice packs on the client's axilla groin 2. Encourage the client to leave the venue to visit a health care provider 3. Evaluate whether the client may be intoxicated 4. Move the client to an air-conditioned booth and provide a cool sports drink

4

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? 1. Client scheduled for dx who has had a peripheral IV in place for 84 hours 2. Client with a do-not-resuscitate prescription who has swelling at the IV site 3. Client with a saline lock who had a scheduled IV saline flush due 15 minute ago 4. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

2 During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site.

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. 1. Ask a family member about the client's preferences for room arrangement 2. Offer the clent an elbow to hold, walk a half-step ahead for guidance 3. Say "goodbye" when leavning the room to help orient the client 4. Speak slowly and slightly louder so that client can understand 5. Use a clock-face pattern to explain food arrangement on the client's meal tray

2,3,5

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

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action? 1. Give the client gentle reminders that the client has already eaten 2.Say that the client can have a snack in a couple of hours 3. Serve the client half of the meal initially and offer the other half later 4. Take a picure of the client having a meal and show it when the client becomes upset

3

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing" 2. "I know you are frustrated with losing control of your life" 3. "It sounds like you are angry. Tell me what's bothering you" 4. "Okay. Ill just check your blood pressure and then go

3 T

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home? 1. Demonstrate the procedure using simple English phrases 2. Give the parents written instructions with picture illustrations 3. Tell the parents to have a friend or relative come into translate 4. Use an interpreter via the telephone interpretation service

4

The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? 1. "Do you have any questions about the dx?" 2. "There are medications available to treat Alzheimer disease 3. "This is a new dx must be frightening to you" 4. "We can help you make decisoins about your care"

3 Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of feelings and thoughts. (Option 1) Questions or statements that prevent the client from expressing feelings (eg, changing the subject) when a client and family are trying to cope with a new diagnosis are not therapeutic and can block communication. Once the nurse understands the client's thoughts and feelings, information can be provided. (Option 2) Providing false reassurance is not therapeutic and can block communication. A client and family may not fully understand the progression of Alzheimer disease immediately after receiving the diagnosis. Stating that medications are available to treat the disease may lead to a false belief that it can be cured. (Option 4) A client diagnosed with Alzheimer disease may need assistance with care planning, but the nurse should first support the process of coping when the client receives the life-changing diagnosis. Educational objective: When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication. Copyright © UWorld. All rights reserved.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help 2. Delegate the task to UAP 3. Premedicate the client for pain 4. Verify the client's activity prescription

4 A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. (Option 1) A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. (Option 2) Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. (Option 3) The nurse should assess the client's pain level before providing pain medication. Educational objective: The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel. Copyright © UWorld. All rights reserved.

The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately? 1.Elevate blood pressure 2. Heart rate irregularity 3. Low oxygen saturation 4. Noisy breathing

4 Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated.

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 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

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 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 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

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

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 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

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?

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

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 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 pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? 1. Blister with a garlic scent near the wrists 2.Circular bruised blemishes on the back 3. Markings appearing to be human bites on the arms 4. Welt-like linear lesions on the back

3

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 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

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse? 1. "i can see that you are very upset. Let's talk about what happened" 2. "Ill report the technician to the head of the radiology dept" 3. "The technician never should have said that to you" 4. "Your health care provider will discuss tx options with you"

1 Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening). This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations. (Option 2) This is not an appropriate response; the proper chain of command would have the nurse report the event to a supervisor. (Option 3) This statement may be true, but it does not facilitate a dialogue about the client's feelings and fears. (Option 4) This response does not address the client's feelings or what happened during the mammogram. Educational objective: Therapeutic communication techniques such as acknowledgement of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, nurturing, and caring.

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? 1. ask the mother's permision to touch the child's hand 2. Interview the mother about the reason for bringing the child to the clinic 3. Reassure the mother that there is no reason for distress 4. Suggest postponing the examination until mother calms down

1 In Latin American culture, an illness called "mal de ojo" ("evil eye") is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The "illness," or "curse," is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward (Option 1). Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets. If a child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse. (Option 2) Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress. (Option 3) This response is nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness. (Option 4) Postponing the examination does not address the cause of the mother's distress. Educational objective: Many Latin Americans believe in "mal de ojo," or "evil eye," a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward. Copyright © UWorld. All rights reserved.

home health nurse visits at 75-year-old client with mild Alzheimer's dementia who recently moved in with a caregiver. which observations would cause the nurse to suspect neglect

client breaks eye contact when discussing caregiver Klein has lost 8 lb in the previous 4 weeks client's eyeglasses have been visibly broken for one month client's prescription medication is expired

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? 1. Ask the HCP prescribe a difffereent calcium channel blocker 2. Consult with the pharmacist to see if an alternate form of the drug is available 3. Open the capsul and sprinkle the medication in a cup of applesauce 4. Warn the client about the dangers of uncontrolled hpertension

2 Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill. (Option 1) It is not necessary to ask the health care provider to prescribe a different medication unless the religious dietary laws cannot be relaxed or the client desires a kosher alternate form of diltiazem (Cardizem) that is unavailable. (Option 3) Extended-release capsules should be swallowed whole. Crushing or breaking the capsule may cause uncontrolled delivery of the medication and increase the risk of overdose or other serious adverse effects. (Option 4) Although it is important to perform client teaching, the nurse should first assess the reason for this client's nonadherence to the prescribed regimen. Additionally, the nurse should avoid using scare tactics in client teaching. Educational objective: Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill. Copyright © UWorld. All rights reserved.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply. 1. High fowler position in preparation for a paracentesis 2. Left side-lying position after percutaneous liver biopsy 3. Semi-fowler after cardiac catheterizeation via femoral entry 4. Sims during soap-suds enema administration 5. Supine position after a lumbar puncture

2,3 A paracentesis requires the client to be upright (semi- to high Fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it (Option 1). Before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of cerebrospinal fluid (Option 5). Sims position (left side-lying with right hip and knee flexed) is best for enema administration (Option 4). (Option 2) After a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding. (Option 3) After cardiac catheterization via femoral entry, place clients flat or in low Fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma. Educational objective: Clients undergoing paracentesis should be upright. After liver biopsy, clients should be in a right side-lying position to prevent hemorrhage. After femoral cardiac catheterization, clients should remain flat. After lumbar puncture, clients should be flat in bed to minimize risk of headache.

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPPA 5. Teach about one intervention at a time and in the order it will occur

2,3,5 Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive (Option 2). The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation (Option 3). Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health care provider after your procedure" (Option 5). (Option 1) The nurse should obtain feedback to be certain that the client understands. This feedback should extend beyond nodding as some people nod to indicate that they are listening or nod in agreement to "save face" even though they do not understand. It is better to use a tactic such as having the client repeat back information (which is then translated into English). (Option 4) Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client may not want the friend/relative to know about this personal situation, or the person may not be able to adequately translate medical concepts and/or understand client rights. Educational objective: When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding. Copyright © UWorld. All rights reserved.

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. 1. Address the interpreter directly 2. Ask the client's adult child to translate 3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences

3,4,5' Title IV of the Civil Rights Act of 1964 initiated national standards for appropriate care of culturally diverse clients. Clients with limited English proficiency have the right to receive medical interpreter services free of charge. When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to speak (Option 5) Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview (Option 3) Use a qualified professional interpreter whenever possible The nurse should avoid using interpreters from conflicting cultures (eg, Palestinian, Jewish) and be mindful of any cultural, gender, or age preferences (Option 4). (Option 1) The nurse should speak directly to the client, not the interpreter. (Option 2) A family member or friend may not have the vocabulary, knowledge, or skills to provide the best communication for the client. Untrained interpreters may omit or simplify critical pieces of information if they do not understand the terminology. Educational objective: When working with a medical interpreter, the nurse should apply best practices to maximize communication and understanding with the client. Key practices include speaking to the client directly; using short, simple sentences; avoiding the use of family members as interpreters; and being mindful of cultural, gender, or age preferences. Copyright © UWorld. All rights reserved.

a 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. when the automated external defibrillator arrives, the nurse note that it has only adult AED pads. what is the appropriate action at this time?

place one AED pad on the chest and the other on the back

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 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 nurse is admitting a client who is quadriplegic. Of these 4 different types of call devices, which one should the nurse provide for this client? 1. call device that requires pushing small button 2. call device that requires pushing small button 3. Specialty call cord that has an ultra-sensitive touch surfaces and requires small amount of body pressure over a large area, client need to use head to activate signal. Or device activated by blowing through a tube or moving the eyes 4. pushing small button

A client who is quadriplegic will have limited to no functional mobility in his arms and hands and will therefore be unable to use any device that requires pushing a small button (Options 1, 2, and 4). Instead, the nurse should provide a call device that requires application of a small amount of pressure over a large area, as the client will probably need to use the head to activate the signal (Option 3). Other call devices that this client would probably be able to activate include those activated by blowing through a tube or moving the eyes.

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

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 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 clinic nurses reviewing self care management of acne vulgaris with an adolescent client which client's statement indicates a need for further instruction

I have been scrubbing my face twice daily with antibacterial soap

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 prop 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 nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease which of the following client statements indicate appropriate understanding of teaching

I need to avoid taking medications like ibuprofen without a prescription I should avoid drinking SS coffee or cola I should enroll in a smoking cessation program I should reduce or eliminate my intake of alcoholic beverages

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

a client is in the cardiovascular clinic for a 3-month follow-up visit. at the first visit, the client was prescribed hydrochlorothiazide and amlodipine for hypertension which statement by the client would be concerning and should be reported to the registered nurse

I started taking licorice root for occasional heartburn

The nurse is reviewing teaching with the parents of the child who has tenia capitis ringworms of the scalp and is newly prescribed griseofulvin oral suspension and 1% selenium sulfide shampoo. which statement by the child's parents requires a nurse to intervene?

I will discontinue the grizzio folding once the ringworm stops itching and the scales go away

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 nurses reinforcing instructions about the use of regular and neutral protomine hagadorn insulin in pH. which statement by the client indicates that further instruction is needed?

I will use the sliding scale to determine my MPH dose four times a day

a client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spiralactone and reports some occasional dizziness. which statement by the client would warrant intervention by the nurse?

I've been trying to eat more fruits and vegetables. I discovered that I really like grapefruit

The nurse is reinforcing education on child abuse and neglect to a certified home health aide. The nurse will include which statements and identify the characteristics of the typical perpetrator of child abuse?

abusers often have a history of growing up in an environment of domestic violence abusers often have a history of substance abuse teenage parents are particularly vulnerable to abusing their children

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

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 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

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

a client suffering from chronic kidney disease is scheduled to receive recumbinant human erythropoietin and iron sucrose. The client's hemoglobin is 9.7 grams and hematocrit is 29%. what is the appropriate nursing action?

check blood pressure prior to administering the erythropoietin

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 home health nurse visits at 75-year-old client with mild Alzheimer's dementia who recently moved in with the caregiver. which observations would cause the nurse to suspect neglect?

client breaks eye contact when discussing caregiver Klein has lost 8 lb in the previous 4 weeks clients eyeglasses have been visibly broken for one month client's prescription medication is expired

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 registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. which instructions should the nurse include when discussing combined estrogen progesterone oral contraceptives?

consult the healthcare provider if you experience leg pain or swelling do not smoke while taking combined contraceptives seek immediate medical treatment if you experience vision loss

The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. which instructions should the nurse include when discussing combined estrogen progestin oral contraceptives?

consult the healthcare provider if you experience leg pain or swelling do not smoke while taking combined contraceptives seek immediate medical treatment if you experience vision loss

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 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? 1. contact the client's family and asl them to bring prepared food fron hone 2. inform client that tube feedings will be initiated if the client refuses to eat offer to taste the client's food and drinks while the client observes provide the client food in uopened single-sefving packages

provide the client food and unopened single-serving packages

a client at 9 weeks gestation arrives at the clinic for an initial obstetrics appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the healthcare provider immediately

doxycycline ISOtretinoin Lisinopril

a client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. which instruction should the nurse reinforce to reduce the risk of future episodes?

drink plenty of fluids exercise regularly include whole grains fruits and vegetables in the diet

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

a nurse is changing a sterile dressing for a client with an infected wound. while doing so, unlicensed assistive personnel report that a second client is requesting pain medication. what is a nurse's most appropriate action?

have the UAP till the second client that the nurse will be there soon and complete a sterile dressing change

a client with Ebola was just admitted to the unit. which actions by the nurse would represent appropriate care of this client

keeping the door of the client's room closed at all times maintaining a log of everyone in and out of the client's room restricting visitors from entering the client's room

The nurse is caring for a client who performs frequent urinary self-catherizations. which of the following client assessments would indicate a potential for latex allergy?

known allergy to avocados and bananas lip swelling when blowing up balloons

The nurse prepares equipment for insertion of a large bore nasal gastric NG tube for the hospitalized client which actions should the nurse take to measure and mark the tube

measure from tip of nose to earlobe to xiphoid process place a small piece of tape at the point of measurement

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

a home health nurses supervising a home health aide who is changing the dressing for a client with the chronic heel wound. which action by the aid indicate adherence to appropriate infection control procedures?

open asteroid container of 4x4s using the outermost corner to peel back the cover pool glove off over the soil dressing to in case it before disposal wash hands prior to putting on gloves and after removing them

a client would Alzheimer's disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse. I really want to take my mother home and continue care there. however, lately, my mother has become agitated and restless at night. I'm awake most of the night, feel exhausted, and do not know what to do. what is the best response by the nurse?

our social worker can discuss long-term care options with you

a nurse administers an intramuscular I am injection using the z-track technique. place the steps in chronological order

pull the skin 1-1.5 inches literally and away from the injection site hold the skin taught with non-dominant hand and insert needle at a 90° angle inject medication slowly with dominant hand while maintaining traction Wait 10 seconds after injecting the medication and withdrawal the needle release the hold on the skin, allowing the layers to slide back to the original position apply gentle pressure at the injection site but do not massage

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

a client is being discharged after having a stent placed in the left interior descending coronary artery. The client is prescribed clobital. which client data obtained by the nurse would be concerning in relation to this new medication

report ginkgo biloba use report peptic ulcer disease

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 with asthma exacerbation. blood pressure is 146 over 86, post is 110, respirations are 32. The respiratory therapist administers nebulize albuterol as prescribed. one hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect?

respirations of 24