Assessment B
A nurse is documenting information in a clients medical record. Which of the following entries should the nurse make?
"Client reports not pain while ambulating in the hallway."
A nure is teaching the parent of a 5-month-old infant who is breastfed about the introductions of complementary foods. Which of the following statements should the nurse make?
"Give your baby iron-fortified infant rice cereals before starting other foods."
A nurse at a mental health clinic is interviewing a client who has depressive disorder and identified as religious during intake. Which of the following client statements should the nurse identify as indicating spiritual distress?
"I am not even sure why I exist."
A nurse is providing teaching to a group of newly licensed nurses about hr legal scope of practice of nurses. Which of the following statements by a newly licensed nurse indicate an understanding of the teaching?
"I can reposition a client who has tetraplegia without a providers prescription."
A nurse is providing teaching to a client who has a prescription fir risedronate to treat postmenopausal osteoporosis. Which of the following client statements indicates an understanding of the teaching?
"I wont lie down for 30 minutes after I take my medication."
A nurse is teaching a client to self-administer 8 units of NPH insulin and 2 units of regular insulin in the same syringe. Which of the following client statements indicates an understanding of the teaching?
"I'll draw up regular insulin in the syringe before the NPH insulin."
A nurse is teaching a client who has chronic fatigue syndrome. Which of the following statements should the nurse include?
"Reduce stress bt taking tai chi classes."
A nurse is preparing to administer acetaminophen drops 60 mg PO to an infant who has a fever. The amount available is 160mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a training zero.)
1.8 mL
A nurse is monitoring a client who is 3 days postoperative following amputation and reports phantom limb pain (PLP). Which of the following actions should the nurse take first?
Ask the client to describe the pain sensations
A nurse is assessing a 10-month-old infant who has a urinary tract infection (UTI). which of the following findings should the nurse expect?
Decreased appetite
A nurse is applying a bed safety monitoring device for a client. Which of the following actions should the nurse take?
Connect the sensor pad to the call system
A nurse is irrigating a client's infected surgical wound to promote wound healing. Which of the following actions should the nurse take?
Continue irrigating until clear solution drains from the wound
A nurse is teaching a class about documenting client care in paper charts. Which of the following instructions should the nurse include in the teaching?
Correct charting errors as they occur.
A community health nurse is teaching a group of older adult clients at a senior center. Which of the following factors should the nurse include as an age-related changed that increases the risk for constipation in older adult clients?
Delayed gastric emptying
A nurse is preparing to calculate the medication dosage for andult client who has a prescription for a weight-based medication. Which of the following actions should the nurse plan to take?
Divide the client's weight in pounds by 2.2 to obtain their weight in kilograms
A nurse is planning to provide teaching for a client who has fibromyalgia and is experiencing chronic pain. The nurse should expect to teach the client about which of the following medications?
Duloxetine
A nurse is providing teaching to the parent of a school-age child who has juvenile idiopathic about pain management. Which og the following statements should hte nurse include?
Encourage the child to participate in physical play activities/
A nurse is caring for a client who reports nausea. Which of the following actions should the nurse take?
Encourage the client to suck on a spoon full of ice chips several times an hour
A nurse is teaching a client who has acute ulcerative colitis and is prescribed a low-fiber diet. Which of the following foods should the nurse instruct the client to eat?
Flavored gelatin
A nurse is teaching a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following actions should the nurse include as an example of PSDA compliance?
Informing clients they can decline any treatment the provider prescribes
A nurse is teaching a group of parents and guardians who have toddlers about home safety. Which of the following information should the nurse provide?
Install deadbolts toward the top of doors leading outside
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following manifestations should indicate to the nurse that the client is developing a catheter-acquired infection?
Low-back pain
A charge nurse is planning a presentation about electronic health records (EHR) for a group of newly licensed nurses. Which of the following information should the nurse include?
Maintaining security of client information is a concern with EHRs
A public health nurse is preparing to care for a community that has a large population of clients who practice the Islamic faith. Which of the following practices should the nurse anticipate when care for clients in this community?
Moving to the floor to pray
A nurse is reviewing the facility policy about occurrences that require an incident report with a newly licensed nurse. Which of the following examples should the nurse include?
Omission of a laboratory test
A home health nurse is planning care for an older adult who lives alone and reports having difficulty adhering to their medication regimen. The nurse should include with of the following interventions in the plan?
Organize using divided daily medication doses
A nurse is teaching a group about cultural competence related to clients who follow Islamic dietary laws. Which of the following images of food should the nurse include in the teaching as appropriate for a client who devoutly follows Islamic dietary practices?
Pizza
A nurse is teaching a client who has left-sided weakness and a history of falls to use a quad cane. In what order should the nurse provide the following instructions?
Place the cane on right side of the body Keep weight in both legs as you mire the cane forward Advance the can 6 to 12 inches forward Move your left leg forward until it is even with the cane
A public health nurse is planning care to meet Healthy People 2020 objectives. Which of the following interventions should the nurse include to promote clients' access to health care?
Set up workshops to help people who are uninsured sign up for health coverage
A nurse is teaching an assistive personnel (AP) about manifestations of dysphagia. Which of the following manifestations should the nurse include?
Storing food in the mouth after swallowing
A nurse is participating in a community health screening. Which of the following information should the nurse include about the risk factors for breast cancer?
The use of hormone replacement therapy increases the risk for breast cancer
A nurse is providing dietary teaching to a client who has diarrhea. Which of the following items should the nurse include in the teaching as an appropriate dietary choice?
Tomato juice
A nurse is a part of an informatics committee to improve safety with medications administration. Which of the following recommendations should the nurse make to decrease the risk of errors at the bedside?
Use an electronic medication administration record for documentation
A charge nurse is supervising a newly licensed nurse who is caring for a group of clients. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
Uses a square knot to attach a wrist restraint to a client
A nurse discovers a medication omission from the previous shift and notifies the charge nurse. which of the following statements should the charge nurse make?
You should monitor the client for injury.
A nurse is updating the plan of care for a client who is experiencing chemotherapy-induced nausea and vomiting. Which of the following interventions should the nurse include?
Provide the client with room-temperature foods
A nurse is teaching a client about carbon monoxide and home safety. The nurse should instruct the client that which of the following is a manifestation of carbon monoxide exposure?
Blurred vision
A nurse is discussing a wellness approach to preventing excessive nutrition intake with a group of clients. Which of the following statements should the nurse make?
Keep a record of cues that trigger a desire to eat."
A nurse is administering a liquid oral medication from a multi dose bottle to a client. The nurse calculates that the does to me administered id 4 mL. Which of the following actions should the nurse take?
Label the medication after measuring the dosage
A nurse is discussing informed consent with a group of newly licensed nurses. Which of the following actions is the responsibility of the nurses when obtaining informed consent?
Verify that the client voluntarily gave consent for the procedure
A nurse is performing a fall risk assessment for a client. Which of the following findings should the nurse identify as a fall risk?
the client has a history of urinary frequency
A nurse in a ;long-term care facility is performing an admission assessment on a client who reports that they are currently observing Lent. Which of the following questions should the nurse ask the client to identify ways to accommodate their religious practices in their plan of care?
"Would you like to abstain from meat on Fridays?"
A nurse is initiating droplet precautions for a newly admitted client. Which of the following actions should the nurse take?
-Place the client in a private room -Ensure the client wears a face mask for transport to x-ray
A nurse is obtaining signatures on informed consent forms from a group of clients who are schedules for surgery. Which of the following individuals should the nurse identify as legally unable to provide informed consent?
A young adult who received morphine for pain
A nurse is teaching a client about using nicotine gum for smoking cessation. Which of the following instructions should the nurse include?
Chew a piece of nicotine gum slowly and intermittently
A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?
Clean the client's perineal area with no-rinse cleanser
A nurse is reviewing the urinalysis report for a client who reports dysuria. Which of the following finding should the nurse identify as a manifestation of a urinary tract infection (UTI)?
Presence of crystals
A nurse is planning to teach a class about standard precautions and preventing puncture injuries. Which of the following information should the nurse include in the plan?
Recap needles using the one-handed scoop method
A nurse is planning care for a client who has dementia and continues to get out of bed without assistance. Which of the following actions should the nurse plan to take?
Apply the electronic safety device to the bed
A nurse is teaching about applying the National Patient Safety Goals to reduce health care-associated infections in clients. Which of the following information should the nurse include in the teaching?
Bathe clients using a chlorhexidine solution
A nurse is preparing an in-service on different types of pain. Which of the following information should the nurse plan to include as a characteristic of acute pain?
It is part of the body's attempt to protect itself
A nurse is conducting a cultural assessment on a client to understand the clients values and beliefs. Which of the following actions should the nurse take first?
Reflect in their own cultural values
A nurse is assessing a client who has a rash on their hands and forearms after working in a garden. The nurse should identify that which of the following findings indicates contact dermatitis?
Well-defined margins of the erythematous area
A nurse is care for a client who has a history of depressive disorder. The client states, "It feels pointless to get up in the morning." Which of the following responses should the nurse make?
"It sounds as if life seems meaningless to you now."
A nurse is caring for a group of client who had dark pigmented skin. For which of the following clients should the nurse notify the provider?
A child who has red pinpoint dots on the palms of their hands
home health nurse is teaching a client about fire extinguishers. Which of the following instructions should the nurse include in the teaching?
Call the fire department before using a fire extinguisher
A nurse is using the SOAP format to document in the electronic medical record of a client who is 2 days postoperative following an open cholecystectomy. Which of the following entries should the nurse practice in the "A" portion of the SOAP progress note?
"Ineffective airway clearance due to inadequate use of spiromimeter."
A nurse is assisting a client who is learning to use a walker following stroke. The client states, "I wasn't sure I could do this, but I talked to my friend who uses crutches and they think I can." Which of the following responses should the nurse make?
"It sounds like your friend's encouragement about using a walker was helpful."
A nurse is assessing a client who has urolithiasis and is experiencing acute pain. Which of the following manifestations should the nurse expect?
-Flank pain -Fever -Hematuria
A nurse is teaching a class about cultural and religious differences in values and beliefs related to death. Which of the following information should the nurse include in the teaching regarding postmortem clients who devoutly practiced Orthodox Judaism?
Clients's bodies should not be left alone until after the funeral
A nurse is submitting a dietary request for a client who devoutly follows Mormon dietary practices. The nurse should ask the client if they would like which of the following foods or beverages excluded from meals?
Coffee
A nurse is applying a belt restraint to a client. Which of the following actions should the nurse take?
Tie the restraint to a movable part of the clients bed frame.
A nurse is teaching a client who has a new diagnosis of obstructive sleep apnea. Which of the following statements should the nurse include?
"Obstructive sleep apnea occurs when you stop breathing for at least 10 seconds."
A nurse is talking with the parents of a school-aged child about managing enuresis. Which of the following parent statements indicates an understand of the information?
"We will have him help change the bed linens after he has an accident."
A nurse is providing teaching about infant nutrition to the guardian of a 1-month-old infant who is formula fed. Which of the following statements should the nurse include?
"Your baby should be consuming 18 to 21 ounces of formula per day."
A nurse is preparing to administer furosemide 35 mg IV to a client. The amount available is 10mg/mL. How many mL should the nurse administer? (round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
3.5 mL
A nurse is assessing a client who has received laboratory confirmation of a Clostridium difficle infection. Which of the following findings should the nurse expect?
Abdominal pain
A nurse is preparing to administer enoxaparin to a client via subcutaneous injection. Which of the following actions should the nurse take?
Administer the medication to the client's abdomen.
A nurse is providing change-of-shift report on a client using Situation Background Assessment Recommendation (SBAR) communication tool. The nure should identify which of the following information is included in the background step?
Admission diagnosis
A nurse is caring for a client who has a new diagnosis of diabetes mellitus and states that they cannot afford the prescribed insulin. The nurse offers to refer the client to the facility social worker. Which of the following principles is the nurse demonstrating?
Advocacy
A nurse is teaching a group of newly licensed nurses about providing emotional support to a client who has experienced a loss. Which of the following information should the nurse include in the teaching?
Allow the client to express a negative response
A home health nurse is making an initial visit to a client who reports fecal incontinence. Which of the following actions should the nurse take firsT?
Ask questions about the client's typical dietary intake
A charge nurse is providing an educational session to a group of newly licensed nurses about the purpose of the National Patient Safety Goals. Which of the following objectives should the nurse include as the component of the National Patient Safety Goals?
Decrease errors related to invasive procedures
A nurse is teaching a group of assertive personnel about expected physical changes associated with aging. Which of the following information should the nurse include?
Decrease in sense of taste
A nurse on a mental health unit is planning an in-service for a newly hired staff about the use of restraints. Which of the following information should the nurse include?
Document a client's condition every 15 while in restraints.
A nurse is teaching a group of newly licensed nurses about using abbreviations when transcribing prescriptions. Which of the following transcriptions should the nurse use as an example of the correct usage of abbreviations?
Docusate sodium 100 mg PO bid
A nurse is planning care for a client who is actively dying and has previously expressed a desire to adhere to Buddhist practices related to death. Which of the following actions should the nurse anticipate and confirm with the client to accommodate their preferences?
Ensure that there is a room for the family to stand at the head of the client's bed
A nurse is performing a health screening on a client. The nurse should identify that which of the following findings places the client at risk for type 2 diabetes mellitus?
History of a sedentary lifestyle
A nurse is performing a health screening assessment on a client. Which of the following findings should the nurse identify as a risk factor for developing colorectal cancer?
History of polyps
A nurse in a provider's office is caring for a client who has a new prescription for an opioid analgesic. the client states that they are concerned about developing constipation. Which of the following should the nurse take first?
Identify the client's usual bowel elimination pattern.
A nurse is reviewing the medical record of a client prior to medication administration. Which of the following actions should the nurse plan to take?
Instruct the client to refrain from taking St. John's wort
An operating room nurse is teaching an in-service about standardized procedures to reduce the risk for client injury during surgery. Which of the following information should the nurse include?
Mark the operative site prior to surgical procedure.
A nurse is providing teaching about a mechanically altered, or level 2, diet to the caregiver of a client who has dysphagia. Which of the following food selections should the nurse include?
Mashed bananas
A nurse is providing teaching about negative pressure wound therapy (NPWT) to a client who has a chronic pressure ulcer. Which of the following information should the nurse include?
NPWT promotes drainage of infectious materials from the wound.
A nurse in a provider's office is planning medications teaching for a client who has a urinary tract infection. The nurse should prepare teaching for which of the following medications?
Nitrofurantoin
A nurse is discussing the Healthy People 2020 initiative with a group if newly licensed nurses. The nurse should identify that which of the following nursing interventions meets one of the Healthy People 202 objectives?
Organizing an exercise program for a group of older adults in an independent living facility
A nurse is caring for a client who uses a fetanyl trans-dermal patch to treat chronic pain and is experiencing breakthrough pain following a surgical procedure. Which of the following medications should the nurse expect to administer?
Oxycodone
A nurse is providing teaching to the guardians of a of a preschooler about preventing contact dermatitis. Which of the following guardian statements indicted an understanding of the teaching?
Plants are among the most common cause of contact dermatitis.
A nurse is caring for a client who has a recent diagnosis of iron deficiency. The client asks the nurse for food suggestions to increase iron in their diet. Which of the following foods should the nurse recommend?
Raisins
A nurse is teaching an in-service about applying the National Patient Safety Goals when taking a verbal consent for a client. Which of the following instructions should the nurse include?
Read back the prescription to the provider
A nurse is caring for an unconscious client who was brought into the emergency department by a law enforcement agent. The law enforcement agent requests that the nurse obtain a blood sample for toxicity screening. Which of the following actions should the nurse take?
Refuse to provide a blood sample
A nurse is caring for a client who has a pressure ulcer and a prescription for a culture to evaluate the effect of antibiotic therapy on wound healing. Which of the following actions should the nurse take first when obtaining the culture?
Remove dressings covering the wound
A nurse is assessing a client who has coughing frequently during meals? The nurse should initiate a referral to which of the following members of the inter-professional care team to evaluate the client for dysphagia?
Speech-language pathologist
A nurse is caring for a client who has clostridium difficile. Th nurse should identify that C. difficile can be transmitted thought contact with which of the following?
Stool
A nurse is supervising a newly licensed nurse who is documenting care on four clients in the client's electronic medical records. Th nurse should identify that which of the following notations indicates accurate documentation?
The client is disoriented to place and date
A nurse is providing hand off report on a client. Which of the following information should the nurse include in the report?
The client is scheduled for a chest x-ray on the next shift
A nurse is reviewing the advance directives of a client who is being sustained on life support. The family disagrees regarding the continuation of life support measures. Which of the following individuals should the nurse identify as having the legal ability to determine the client's course f treatment?
The clients younger child, who is the client's health care proxy
An employee health nurse is providing an in-service on infection control procedures. Which of the following infections should the nurse identify as requiring contact isolation precautions?
Vancinycin-resistant enterococci (VRE) Methicillin-resistant Staphyloccus aureus (MRSA) Clostridium difficile
A nurse is teaching a group of parents and guardians about identifying substance use disorder among adolescents. Which of the following adolescent behaviors should the nurse include as a possible indications of substance use disorder?
Wearing dark glasses indoors
