ATI Comprehensive Test A

Disaster management

- The nurse should assist in the organization and implementation of an immunization campaign to prevent, treat, or contain disease during the prevention stage of a disaster management plan. - identify the specific roles of disaster workers during the preparedness stage of a disaster management plan - conduct home visits to identify health hazards such as a lack of safe shelter, clean water, and potential hazards that result from the disaster during the recovery stage

disaster triage tag system

- green tag on a client who is alert and has a 2.5 cm (1 in) laceration on the forehead because this client has an injury that is nonurgent. - a yellow tag on a client who has an open fracture of the right forearm because this client has a major injury that requires attention within 30 min to 2 hr. - a red tag on a client who is unconscious and has a rapid, thready radial pulse because this client has a life-threatening injury and requires immediate treatment.

A nurse in a prenatal clinical teaching a client about foods to avoid during pregnancy to decrease the risk of listeriosis. Which should nurse include in teaching?

- salami and other luncheon meats can harbor the bacteria Listeria monocytogenes, which crosses the placental barrier and is harmful to the developing fetus - Other foods that can contain L. monocytogenes are raw milk, soft cheeses, raw or undercooked poultry, raw vegetables, and ice cream. Listeriosis during pregnancy can lead to spontaneous abortion or stillbirth. Newborns who survive intrauterine infection can have sepsis and meningitis.

nonpharmacological therapy

- touch therapies are helpful for inducing relaxation in general, therapeutic touch specifically addresses pain, depression, healing of body tissues, and physiologic needs such as reducing blood pressure, fever, and nausea. - acupuncture requires special training. Needle placement can alter and improve immune, neurologic, cardiac, and endocrine function. It can help relieve pain and assist with substance withdrawal. - Spinal manipulation involves adjusting and aligning the spine, which can help with back pain, asthma, and allergies.

A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? A. "I should report a change in the color of my stools." B. "I can take acetaminophen to treat a headache." C. "I will take a calcium supplement while taking this medication." D. "I will return in a month to have my blood tested."

A. "I should report a change in the color of my stools." - red, black, or tarry stools can indicate bleeding, an adverse effect of warfarin, - instruct the client that using acetaminophen can increase the risk for bleeding. - daily blood draws for the first 5 days to establish appropriate warfarin dosage.

A nurse is providing teaching about improving nutrition for a client who has myasthenia graves. Which of the following instructions should the nurse include? A. "Cut food into small bites and eat slowly." B. "Lie flat for 1 hour following each meal of the day." C. "Monitor your weight once each week." D. "Take your anticholinesterase medication 20 minutes before meals." E. "Choose snacks that are high in calories."

A. "Cut food into small bites and eat slowly." E. "Choose snacks that are high in calories."

A nurse is teaching a female client about preventing recurrent bladder infections. which statements should nurse make? A. "Empty your bladder before and after sexual intercourse." B. "Limit your fluid intake to 1 liter per day." C. "Use a feminine hygiene spray after each urination." D. "Take a bubble bath to clean your perineum."

A. "Empty your bladder before and after sexual intercourse." - to reduce the risk of introducing bacteria into the urinary tract. - drink as much as 2 to 3 L of fluid per day to reduce the risk of urinary tract infections. - avoid using feminine hygiene spray, which can cause irritation to the perineum. - avoid taking bubble baths, which can cause irritation to the perineum.

A nurse is providing teaching to a client about newborn safety. Which of following statements should the nurse include in the teaching? A. "Set your hot water heater temperature at or below 120 degrees Fahrenheit." B. "Cover your baby with a light blanket when she is sleeping." C. "Make sure the slats on the baby's crib are no more than 3 inches apart." D. "Place your baby's car seat rear-facing until she is 1 year old."

A. "Set your hot water heater temperature at or below 120 degrees Fahrenheit." - set the maximum hot water temperature to no more than 49° C (120° F). to test the temperature of the newborn's bath water with her elbow - crib slats should be no more than 5.7 cm (2.25 in) apart. Slats that are further apart increase the risk of the injury. - the newborn's car seat should remain rear-facing until she is 2 years old

A client tells a nurse that she wants to review the information in her medical record. Which of the following responses should the nurse give? A. "There's a protocol for reviewing your medical record, and I can initiate the process." B. "The medical record has a lot of medical terminology, and it might be difficult for you to understand." C. "You should really talk to your provider if you have any questions about your treatment." D. "Some parts of your medical record are restricted, but I can show you the parts that you are allowed to see."

A. "There's a protocol for reviewing your medical record, and I can initiate the process." - The client's record is the legal property of the facility; however, the client has a right to access the information. HIPAA ensures that clients have access to their records, can obtain a copy of the record, and request corrections to the document. The nurse is responsible for providing the client with access to the medical record according to the facility's policy.

A nurse is counseling a couple who have been unsuccessful at conceiving for more than a year. Which of the following statements should the nurse make to help couple cope with prolonged infertility? A. "Would you like information regarding some support groups?" B. "Couples usually get pregnant when they stop trying." C. "Have you considered adoption?" D. "In time, the treatments you receive here will be effective."

A. "Would you like information regarding some support groups?"

A nurse is providing dietary teaching to a client who has celiac disease. What should the nurse include in teaching? A. "You will need to eat a gluten-free diet." B. "You will need to take a glucocorticoid when you have an exacerbation." C. "You should avoid taking enteric-coated medications." D. "You will need to follow a low-lactose diet."

A. "You will need to eat a gluten-free diet." - ulcerative colitis should take a glucocorticoid, such as prednisone, to decrease inflammation during an exacerbation. - ileostomy should avoid taking enteric-coated medications to ensure absorption in the small bowel.

A nurse is teaching a client about foods high in vitamin A. Which of the following should nurse recommend the highest amount? A. 1 medium raw carrot B. 1/2 cup cooked spinach C. 1/2 cup cooked butternut squash D. 1 cup sliced cantaloupe

A. 1 medium raw carrot - 1 medium raw carrot contains 2,025 mcg/dL of vitamin A.

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan? A. Avoid including raw fruits in the client's diet. B. Restrict visits from young children to 2 hr per day. C. Measure the client's temperature once per shift. D. Use disposable gloves from a box outside the client's room.

A. Avoid including raw fruits in the client's diet. - measure the client's temperature every 4 hr.

A nurse is assessing a client who has schizophrenia. The nurse should identify the following alterations in speech? A. Clang association B. Echolalia C. Neologisms D. Word salad

A. Clang association - in which the client chooses words that he bases on their sound, rather than their meaning. - Echolalia is an alteration in speech in which the client repeats back - Neologisms are made-up words that have no meaning - Word salad is an alteration in speech in which the client jumbles words

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early declarations on the monitor. Which of the following actions should the nurse do? A. Continue observing the fetal heart rate. B. Assist the client to a knee-chest position. C. Prepare the client for continuous internal monitoring. D. Prepare for an emergency cesarean birth.

A. Continue observing the fetal heart rate. - Early decelerations indicate the progression of labor and are a benign finding. The nurse should continue to observe the fetal heart rate. - assist the client into a knee-chest position if she notes a prolapsed cord. - no indication for the client to have internal monitoring. - prepare for an emergency cesarean birth if the monitor indicates late or variable decelerations despite interventions.

A nurse on a mental health unit is caring who tells the nurse that he does not want to receive a dose of lorazepam IM. Which of the following actions should the nurse take? A. Document the client's refusal of the medication. B. Administer the medication that the provider prescribed. C. Request consent from the client's family to administer the medication. D. Administer an oral dose of the medication.

A. Document the client's refusal of the medication.

A nurse in the delivery room is caring for a newborn after birth. Which of the following actions should the nurse take first? A. Dry the newborn. B. Assign the first Apgar score to the newborn. C. Place an identification bracelet on the newborn. D. Obtain the newborn's weight.

A. Dry the newborn. - greatest risk to the newborn is cold stress.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. What should nurse expect? A. Fever unresponsive to antipyretics B. Pain in weight-bearing joints C. Decreased heart rate D. Peeling of the soles of the feet

A. Fever unresponsive to antipyretics - expect pain in the child's weight-bearing joints during the subacute phase of Kawasaki disease. - expect tachycardia during the acute phase of Kawasaki disease. - expect peeling of the palms and soles of the child's hands and feet during the subacute phase of Kawasaki disease.

A community health nurse receives funding from a local charitable organization to develop a health education program for the local community. Which of the following actions should the nurse take first? A. Identify current health problems in the community. B. Develop program goals. C. Choose educational strategies for the program. D. Enlist community volunteers to promote the program.

A. Identify current health problems in the community.

A nurse is preparing to administer 15 units of regular insulin with 20 units of NPH insulin. Which of the following actions should the nurse take? A. Inject 20 units of air into the NPH insulin vial. B. Shake the NPH insulin vial vigorously to mix the insulin. C. Use a new needle to draw up the insulin from the second vial. D. Draw the longer-acting insulin into the syringe first.

A. Inject 20 units of air into the NPH insulin vial. - inject 20 units of air into the NPH insulin vial and withdraw the needle without touching the insulin, then proceed to inject 15 units of air into the regular insulin vial. - should roll the NPH insulin between the palms of the hands to mix the cloudy solution. Shaking the NPH insulin can make the solution frothy and difficult to measure an accurate dose. - draw the short-acting (regular) insulin into the syringe first. This prevents the longer-acting (NPH) insulin from contaminating the short-acting insulin.

A nurse is assessing a client who has antisocial personality disorder. Which on following manifestations should the nurse expect? A. Lack of remorse B. Sensitivity to rejection C. Extreme mood swings D. Self-mutilating behavior

A. Lack of remorse - narcissistic personality disorder is more likely to show sensitivity to rejection. - bipolar disorder is more likely to exhibit extreme mood swings. - borderline personality disorder is more likely to exhibit self-mutilating behaviors.

A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the followings signs should nurse expect? A. Persistent uterine contractions B. Painless vaginal bleeding C. Hyperactive deep-tendon reflexes D. Fundal height of 40 cm

A. Persistent uterine contractions - experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding. - placenta previa to experience a relaxed uterus and painless vaginal bleeding. - preeclampsia to have hyperactive deep-tendon reflexes. - placenta previa to have a fundal height that is greater than expected gestational age.

A nurse is caring for a client who vomits on a reusable BP cuff. Which should nurse do? A. Place the BP cuff in a labeled bag to send it for decontamination. B. Immediately rinse the BP cuff in hot running water. C. Dispose of the contaminated BP cuff in the bag lining the trash can. D. Clean the BP cuff with a chlorine bleach solution.

A. Place the BP cuff in a labeled bag to send it for decontamination. - should rinse the BP cuff in cold running water prior to sending it for decontamination. Hot water can cause the vomitus to coagulate and stick to the cuff making it difficult to remove. - should use a chlorine bleach solution to clean blood spills.

A nurse is caring for a client who is at risk for diabetes insipidus. The nurse should plan to monitor the client for which of the following? A. Polyuria B. Hyperglycemia C. Bradycardia D. Hypothermia

A. Polyuria - increased urine output, often in amounts greater than 4 L/day, resulting from a deficiency of antidiuretic hormone. - monitor the client for tachycardia, an attempt of the body to maintain cardiac perfusion despite fluid losses. - monitor the client for hyperthermia, which often occurs in clients who have dehydration, a complication of diabetes insipidus.

A nurse is assessing a client who is schizophrenia and taking chlorpromazine. What signs is a priority for the nurse to report? A. Temperature 39.4° C (103° F) B. Headache C. Constipation D. Vomiting

A. Temperature 39.4° C (103° F) - neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine in which the client can have a high temperature, dysrhythmia, decreased level of consciousness, and a labile blood pressure. Therefore, the priority finding for the nurse report to the provider is hyperpyrexia. - Headache, Constipation, Vomiting is a common adverse effect of chlorpromazine.

A night shift nurse is giving change of shift report on a client who is ready for discharge. Which of the following info is the priority for the nurse to communicate? A. The client needs assistance when transferring from the bed to a wheelchair. B. The client will have a visit by a home health nurse tomorrow. C. The client's partner will bring clothes for him to change into prior to discharge. D. The client often needs encouragement to engage in personal hygiene activities.

A. The client needs assistance when transferring from the bed to a wheelchair. - The greatest risk to this client is injury due to a fall.

A nurse is assessing a client who is 18hr post op following a cessation birth and is breastfeeding her newborn. Which of the following signs is the priority? A. Unilateral tenderness of the left lower extremity B. Oral temperature 37.7° C (99.8° F) C. Uterine contractions when breastfeeding D. Abdominal guarding when assessing the fundus

A. Unilateral tenderness of the left lower extremity - which can indicate the client is developing deep-vein thrombosis.

A nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? A. Use a chlorine bleach solution to clean kitchen surfaces. B. Seal nonwashable items in a plastic bag for 2 weeks. C. Wear a surgical mask when in public. D. Limit family visits to 30 min periods.

A. Use a chlorine bleach solution to clean kitchen surfaces. - to prevent transmission by killing the virus. - pediculosis capitis should seal nonwashable items in a plastic bag for 2 weeks. - does not need to wear a surgical mask because hepatitis A is not an airborne infection. - encourage safe food handling and appropriate hand hygiene techniques.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following should indicate to the nurse the client is having a hemolytic transfusion reaction? A. Bradycardia B. Low back pain C. Hypertension D. Distended jugular veins

B. Low back pain - expect to assess tachycardia, - Hypotension, - expect a finding of distended jugular veins in a client who has circulatory overload,

A nurse is teaching the parent of a school age child about administering ear drops. Which of the following responses by the parent indicates an understanding of teaching? A. "I should administer the ear drops as soon as I remove them from the refrigerator." B. "I should pull the top of her ear upward and back while instilling the medication." C. "I should massage behind her ear after I instill the drops." D. "I should have her lie on the affected side for a few minutes after I put the drops in her ear."

B. "I should pull the top of her ear upward and back while instilling the medication." - instruct the parent to pull the pinna upward and back in children older than 3 years of age. For children younger than 3 years of age the parent should gently pull the pinna downward and back. - allow otic medication she stores in the refrigerator to warm to room temperature prior to administration to prevent dizziness and pain.

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following statements indicate understanding. A. "I should avoid eating smoked meat, cheeses, and ripe avocados while taking this type of medication." B. "I should watch for common reactions like dry mouth and constipation." C. "I will avoid getting chilled because I am at risk for hypothermia." D. "I will take my daily dose of this medication every morning before breakfast."

B. "I should watch for common reactions like dry mouth and constipation." - reinforce that increasing dietary fiber, fluid intake, and chewing sugar free gum can alleviate the anticholinergic effects of dry mouth and constipation. - an MAOI should avoid foods that contain tyramine. - avoid overheating because of the lack of an ability to sweat while taking this medication. - take a daily dose of amitriptyline, a tricyclic antidepressant, at bedtime to promote sleep and minimize drowsiness during the day.

A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if he experiences cardiac arrest. Which of the following statements should the nurse make? A. "You will need to draft a health care proxy so a designee can make this decision for you." B. "I will provide you with information about medical treatment to include in your living will." C. "Your provider determines if you should have lifesaving measures if your heart stops." D. "I will make sure that no one performs any lifesaving measures if your heart stops."

B. "I will provide you with information about medical treatment to include in your living will." - A health care proxy is not necessary if the client is alert and able to document his own wishes in a living will. - the client decides and documents these decisions in a living will or verbally informs the provider.

A nurse is providing discharge teaching a client who has completed treatment following a suicide attempt and his partner. The client's partner asks to speak to the nurse privately. Which of the following concerns of there concerns of the client's partner is the priority for the nurse to report to the provider? A. "Will my husband be able to continue as the executor of his parents' estate?" B. "My husband doesn't know that I've already moved out of the house and filed for a divorce." C. "Do you think it is necessary to postpone our daughter's wedding until my husband is feeling better?" D. "One of my husband's friends visited last week to tell me that the union where he works is considering a strike."

B. "My husband doesn't know that I've already moved out of the house and filed for a divorce." - A lack of social support and isolation indicates the client is at greatest risk for another suicide attempt. - a strike can lead to unemployment, which is a risk factor for attempting suicide.

The parents of a preschool age child tell the nurse that their child is demonstrating reluctance in going to bed at night and reports that he is not tired. What should nurse recognize that the teaching has been effective when? A. "We will let him watch his favorite video before bed." B. "We should read him a story every night before bedtime." C. "We can let him fall asleep in our room, and then move him to his bed." D. "We should change his bedtime to be an hour later."

B. "We should read him a story every night before bedtime." - a child who is preschool age, is approximately 12 hr each night. A lack of sleep can lead to problems such as altered behavior, hyperactivity, and poor impulse control.

A nurse is teaching an adolescent who has tunneled central venous catheter. Which of the following information should the nurse include in the teaching? A. "You should flush the catheter with 0.9% sodium chloride solution daily when not using it regularly." B. "You should keep the catheter clamped when not in use." C. "You should swim twice weekly to prevent tissue from adhering to the cuff." D. "You should change your dressing every 10 days."

B. "You should keep the catheter clamped when not in use." - instruct the adolescent to flush the catheter daily with heparin when not using it regularly. - instruct the adolescent to restrict physical activities until the tissue adheres to the cuff. The adolescent should not participate in water sports because of the risk of infection. - instruct the adolescent to change the dressing at least every 5 to 7 days.

A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? A. "This type of nutrition is more effective than eating by mouth." B. "You will receive fingersticks for blood glucose testing." C. "TPN is a way to provide vitamins and minerals without increased calories." D. "Taking TPN can increase the risk of developing a latex allergy."

B. "You will receive fingersticks for blood glucose testing." - at risk for hyperglycemia due to the dextrose in the TPN solution, which will require blood glucose monitoring. - a burn injury is in a hypermetabolic state and requires additional calories, carbohydrates, proteins, and fats. - check the client for egg allergy, as this may result in an intolerance of the lipid solution because many lipids are composed of egg phospholipids.

A community health nurse is performing disaster triage tagging following a disaster. On which of the following clients should the nurse place a black tag? A. A client who is alert and has a 2.5 cm (1 in) laceration on the forehead B. A client who has significant head trauma and agonal respirations C. A client who has an open fracture of the right forearm D. A client who is unconscious and has a rapid, thready radial pulse

B. A client who has significant head trauma and agonal respirations - because this client is likely not to recover or will require extensive resources for care.

A nurse is performing a tracheostomy care for a client who is post op following a laryngectomy. Which of the following actions should the nurse take when suctioning the airway? A. Withdraw the catheter if the client begins coughing. B. Apply suction for 10 seconds. C. Advance the catheter 2 cm (0.8 in) after resistance is met. D. Use medical asepsis when performing the procedure.

B. Apply suction for 10 seconds. - apply suction for only 5 to 10 seconds to minimize oxygen loss. - Suctioning can initiate the cough reflex as it opens the airway further and allows for more effective removal of mucus. - use surgical asepsis when suctioning a newly created tracheostomy. - Once resistance is met, the nurse should withdraw the catheter 1 to 2 cm (0.4 in to 0.8 in) to prevent damaging bronchial tissue

A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about her limited experience with monitoring chest tubes. Which actions should the charge nurse do first to provide teaching? A. Refer the nurse to the procedure manual. B. Ask the nurse about her knowledge of the procedure. C. Demonstrate the procedure to the nurse. D. Use a diagram to explain the procedure to the nurse.

B. Ask the nurse about her knowledge of the procedure.

A nurse is caring for an older client who has generalized anxiety disorder and it to begin taking alprazolam. Which of the following should the nurse do? A. Check temperature every 4 hr. B. Initiate fall precautions. C. Monitor urine for discoloration. D. Limit fluid intake to 1 L per day.

B. Initiate fall precautions. - because this medication can cause orthostatic hypotension, dizziness, drowsiness, and fainting upon rising. - increase fluid intake as alprazolam can cause diarrhea or constipation.

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following findings should be a priority? A. Headache B. Confusion C. Polyuria D. Hyperglycemia

B. Confusion - additional indications of lithium toxicity, including coarse hand tremors, confusion, ECG changes, and sedation. - Headache, Polyuria, Hyperglycemia are nonurgent finding.

A nurse is providing discharge instructions to a school age child and his parent about caring for a fiberglass cast on the right tibia. Which of the following instructions should the nurse include? A. Apply heat below the injury for 24 hr. B. Cover the cast with plastic when bathing. C. Expect loss of sensation of the toes. D. Keep the leg in a dependent position for 60 min each day.

B. Cover the cast with plastic when bathing. - should not apply heat for the first 24 hr after the injury because it increases bleeding and swelling. - report any loss of sensation, numbness, tingling, and paralysis, which can indicate ischemia. - Keeping the leg in a dependent position for more than 30 min can lead to swelling and circulation impairment.

A nurse is an emergency department is preparing to discharge a young client who has experienced intimate partner abuse. Which of the following actions should the nurse take first? A. Offer a referral to the client for social services. B. Develop a safety plan with the client. C. Encourage the client to reach out to family and friends. D. Provide the client with a list of support groups.

B. Develop a safety plan with the client.

A nurse is caring for a female client who is to start taking misoprostol and taking NSAIDs for arthritis. The nurse should provide info? A. Increase intake of fluids and fiber to prevent constipation. B. Have a serum pregnancy test completed before taking the medication. C. This medication coats stomach ulcers so that they can heal. D. Take a magnesium-containing antacid along with this medication.

B. Have a serum pregnancy test completed before taking the medication. - Misoprostol can induce uterine contractions. Women of childbearing age must rule out pregnancy first. - Misoprostol tends to cause diarrhea - Magnesium-containing antacids increase the risk of diarrhea and the client should avoid - Misoprostol does not coat the stomach. Misoprostol reduces gastric acid secretion so that ulcers can heal and reduces the risk of new ulcer development.

A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects should nurse instruct to client? A. Hypotension B. Headaches C. Bruising D. Oliguria

B. Headaches - can cause a thromboembolism which can result in a stroke. - report hypertension. - monitor for swelling and tenderness of the calf. Bruising is not an adverse effect of this medication. - monitor for the development of genitourinary candidiasis. Oliguria is not an adverse effect of this medication.

A nurse is assessing an adolescent who has sickle cell anemia. The nurse should identify which of the following signs as an indication of vasoocclusive crisis? A. Diminished reflexes B. Hematuria C. Hyperglycemia D. Hearing loss

B. Hematuria - Painful swelling of the hands and feet, - Visual disturbances,

A nurse manger is reviewing a newly licensed nurse's performance appraisal. Which of following methods should the nurse manager use to evaluate the nurse's time management skills? A. Compare the nurse's time management skills to the skills of his coworkers. B. Maintain regular notes about the nurse's time management skills. C. Ask another staff nurse to evaluate the nurse's time management skills. D. Review client satisfaction reports about the nurse's performance.

B. Maintain regular notes about the nurse's time management skills. - Maintaining notes over a period of time provides a comprehensive view of the nurse's abilities.

A nurse is caring for a client who has bipolar disorder. The nurse observes the client is becoming increasingly restless. She is pacing the unit and speaking rapidly, frequently using profanities and sexual preferences references. Which of the following should nurse do first? A. Provide an opportunity for the client to express her feelings. B. Move the client to a quiet place away from others. C. State expectations that set limits on the client's behavior. D. Administer a PRN dose of haloperidol to calm the client.

B. Move the client to a quiet place away from others. - client's behavior indicates the greatest risk is injury to others.

A nurse is teaching a client who has a new prescription for digoxin about signs of toxicity. Which of the following signs should the nurse include in the teaching? A. Constipation B. Nausea C. Wheezing D. Muscle rigidity

B. Nausea - nausea, diarrhea, muscle weakness is a manifestation of digoxin toxicity and instruct the client to notify the provide - wheezing is a manifestation of anaphylaxis,

A nurse is assessing a client who is 2hr post op following a cardiac cauterization. Which go the following info should the nurse report? A. Pain level B. Neurologic status C. Laboratory results D. Urinary output

B. Neurologic status - indications of a stroke, a potential complication of cardiac catheterization.

A nurse is planning teaching about allowable food for a client who has a history of uric acid based urinary calculi formation. Which of the following foods should the nurse recommend in the diet? A. Liver B. Oranges C. Chicken D. Red wine

B. Oranges - avoid eating chicken. - avoid eating organ meats. - avoid consuming alcohol.

A nurse is assessing a client who has stage 2 pressure ulcer. which of the following wound characteristics should the nurse expect? A. Muscle damage B. Partial-thickness skin loss C. Visible subcutaneous tissue D. Tendon exposure

B. Partial-thickness skin loss - expect to see a partial-thickness skin loss or blister formation - a stage IV pressure ulcer is more likely to have muscle damage. - a stage III pressure ulcer is more likely to have visible subcutaneous tissue. - a stage IV pressure ulcer is more likely to have tendon exposure.

The nurse is caring for a child who begins experiencing a tonic clonic seizure. Which of the following actions should the nurse take? A. Ask the child's parents to step into the hallway. B. Place the child in a side-lying position. C. Administer rescue breaths until the seizure subsides. D. Obtain an ECG during the seizure.

B. Place the child in a side-lying position. - to maintain a patent airway, decrease the risk of aspiration, and facilitate drainage of oral secretions.

A nurse is initiating discharge planning for a client who had a stroke and is experiencing right sided weakness. Which of the following actions should nurse take first? A. Ask a social worker to identify the client's insurance eligibility for rehabilitation services. B. Request a referral for the client to occupational therapy. C. Arrange for delivery of medical equipment to the client's home. D. Provide the client with a list of community resources.

B. Request a referral for the client to occupational therapy.

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? A. Popcorn B. Steamed carrots C. Celery sticks D. Marshmallows

B. Steamed carrots - a safe food choice for toddlers because they are soft and do not present a choking hazard. - Popcorn, Celery sticks and Marshmallows are risk for choking.

A nurse in an acute mental health facility is planning care for adolescent who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care? A. Give the client a choice of foods and beverages. B. Supervise the client during and after eating. C. Encourage casual conversation about food during meal times. D. Provide opportunities for the client to choose her own meal times.

B. Supervise the client during and after eating. - to prevent the client from hiding food or purging. - establish specific meal times as part of a structured milieu.

A charge nurse is teaching a newly licensed nurse how to identify true labor. A. Contractions will be felt primarily in the upper abdomen. B. The cervix transitions to an anterior position. C. Contraction intensity decreases with ambulation. D. The cervix progressively thickens.

B. The cervix transitions to an anterior position. - contraction intensity increases with ambulation. - the cervix progressively shortens and thins. - feel contractions primarily in the lower abdomen and back.

A charge nurse on a pediatric unit is planning an educational session for staff nurses to teach them about working with parents whose children are candidates for organ donation. Which of the following information should the nurse plan to include? A. A child who has had an illness requiring an antibiotic over the last 30 days is not a candidate for organ donation. B. The family may have the child in an open casket if they wish because organ donation does not disfigure the child's body. C. The family should understand that an autopsy is mandatory prior to organ donation. D. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death.

B. The family may have the child in an open casket if they wish because organ donation does not disfigure the child's body.

A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates the charge nurse should intervene? A. While performing a breast examination, the newly licensed nurse discusses techniques of breast self-examination with the client. B. The newly licensed nurse writes detailed notes while performing the head-to-toe assessment. C. The newly licensed nurse uses a penlight to assess for changes in the contour of the body. D. The newly licensed nurse uses the dorsal surface of her hand to assess skin temperature.

B. The newly licensed nurse writes detailed notes while performing the head-to-toe assessment.

A nurse is reviewing the lab findings of a client who is experiencing chest pain. An elevation in which of the following lab values indicates cellular injury of the myocardial tissue? A. Amylase B. Troponin T C. Low-density lipoprotein (LDL) D. Homocysteine

B. Troponin T - The nurse should expect increases in the client's troponin level within 2 to 3 hr of myocardial injury. - Elevated LDL values indicate coronary artery disease and peripheral vascular disease which can increases the client's risk for development of a myocardial infarction. - Elevated homocysteine levels indicate the client is at risk for the development of ischemic heart disease, cerebrovascular disease, and peripheral vascular disease. - amylase can indicate acute pancreatitis, cholecystitis, or renal failure.

A nurse is reviewing the ABG results of a client who has COPD. The results are pH: 7.30, PaO2: 56, PaCO2: 54, HCO3: 26. A. Uncompensated metabolic acidosis B. Uncompensated respiratory acidosis C. Compensated respiratory acidosis D. Compensated metabolic acidosis

B. Uncompensated respiratory acidosis

A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client? A. BP 150/87 mm Hg B. WBC 2,800/mm3 C. Auditory hallucinations D. Nausea

B. WBC 2,800/mm3 - a WBC count of less than 3,000/mm3 is a contraindication

A nurse is providing discharge teaching to a client following a cataract extraction. Which statement indicates an understanding of the teaching? A. "I can resume my daily aspirin therapy." B. "I will contact my provider if my eye feels itchy." C. "I will bend at my knees when picking an object up off the floor." D. "It's okay for me to pick up my grandchild who weighs 20 pounds."

C. "I will bend at my knees when picking an object up off the floor." - avoid bending at his waist because this movement increases intraocular pressure - recommend the use of a cool compress to ease the discomfort of the itching. - avoid taking aspirin because of its anticoagulant effect. - avoid lifting objects that weigh more than 4.5 kg (10 lb) because it can increase intraocular pressure and damage the suture of the new lens.

A nurse is caring for a client who has end stage Alzheimer's disease. The daughter states "Idk why I bother to come here". What should the nurse say? A. "Your mother might still know you are here." B. "Why do you feel that way?" C. "It seems like you feel your visits are a waste of time." D. "Are you sure you would not want to see your mother again?"

C. "It seems like you feel your visits are a waste of time."

A nurse is teaching a female client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? A. "If you suspect you are pregnant, stop taking this medication." B. "You cannot become physically dependent on this medication." C. "Sedation is a common adverse effect of this medication." D. "If you forget a dose, you can double your next dose."

C. "Sedation is a common adverse effect of this medication." - Sedation and drowsiness are common adverse effects of methadone. Sedation most frequently occurs at the beginning of treatment or during dosage increases. - Methadone can cause respiratory depression. - can develop physical dependency with long-term use of methadone. - can take methadone to treat opioid withdrawal symptoms during pregnancy.

A nurse is caring for a client whose fetus has anencephaly. The client asks the nurse, "Do you think I should terminate the pregnancy?" Which of the following responses should the nurse make? A. "Why don't you talk with your family and see what they think is best." B. "My religious beliefs would prevent me from terminating a pregnancy." C. "Tell me how you are feeling about your available options." D. "Your provider is the best person to help you make that decision."

C. "Tell me how you are feeling about your available options."

A nurse is caring for an older client who reports that he is taking herbal supplement saw palmetto along with other meds. Which of the following responses should the nurse make? A. "This herb can cause gastrointestinal upset such as bloating and abdominal pain." B. "This herb can interact with caffeine and cause irritability." C. "This herb can result in a false low prostate-specific antigen level." D. "This herb can lower your blood pressure."

C. "This herb can result in a false low prostate-specific antigen level." - which can delay diagnosis of prostate cancer. - herbal supplement flaxseed, which clients can use for migraine prophylaxis, can lead to gastrointestinal symptoms such as bloating, abdominal pain and flatulence. - herbal supplement ginseng, which clients can use to stimulate mental activity and increase the appetite, can interact with caffeine and cause irritability. - herbal supplement valerian, which clients can use as a tranquilizer or sedative, can lower blood pressure.

A nurse enters the room of a client who is receiving oxygen and finds that a fire has started in the wiring of the client's bedside lamp. After removing the client which of the following actions should the nurse take next? A. Obtain a fire extinguisher. B. Turn off the oxygen equipment. C. Activate the fire alarm. D. Close doors and windows in the room.

C. Activate the fire alarm. - Using the RACE mnemonic, the next action the nurse should take is to activate the fire alarm to call for additional assistance and alert others of the danger. - the third action the nurse should take is to contain the fire by taking actions such as closing the doors and windows in the room. - the third action the nurse should take is to contain the fire by taking actions such as turning off the oxygen equipment. - the fourth action the nurse should take is to obtain a fire extinguisher to extinguish the fire.

A nurse in an emergency department is reviewing the prescriptions of an older client who has type 1 diabetes. The client reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse verify with the provider? A. Obtain capillary blood glucose level every 2 hr. B. Assess the neurovascular status of the client's lower extremities every hour. C. Apply a cold pack to the edematous area on the client's ankle for 30 min every other hour. D. Administer fentanyl 50 mcg IV bolus every 2 hr for pain.

C. Apply a cold pack to the edematous area on the client's ankle for 30 min every other hour. - a contraindication for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. - should administer an opioid medication, such as fentanyl, hydromorphone, or morphine, orally or intravenously to manage the client's pain. - should check the neurovascular status of the client's lower extremities every hour - monitor the client's blood glucose level every 2 to 4 hr to monitor for hyperglycemia due to stress on the body.

A charge nurse hears two nurse in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following should the charge nurse take? A. Inform the client of the nurses' actions. B. Tell the nurses they are committing insubordination. C. Ask the nurses to stop the discussion. D. Document the incident in the client's progress notes.

C. Ask the nurses to stop the discussion. - violating client confidentiality by having the discussion in a public hallway

A nurse is caring for an older client in the PACU following general anesthesia. Which of the following findings should the nurse report to provider? A. Urine output 120 mL in 4 hr B. Systolic blood pressure 12 mm Hg lower than the preoperative level C. Audible stridor D. Normal sinus rhythm with an occasional premature ventricular contraction

C. Audible stridor - report blood pressure changes that are greater than a 15 to 20 mm Hg difference from the client's baseline blood pressure. - Anesthesia medications and surgery, especially in older adult clients, are a common cause of premature ventricular contractions.

A nurse is assessing a newborn who was admitted and is sleeping. For which of the findings should the nurse intervene? A. A pink body and slightly blue hands and feet B. Respiratory rate 40/min C. Axillary temperature 36.2° C (97.2° F) D. Apical pulse 136/min

C. Axillary temperature 36.2° C (97.2° F) - The expected reference range for the axillary temperature of a newborn is between 36.5° C and 37.5° C (97.7° F and 100° F). An axillary temperature of 36.2° C (97.2° F) or below requires the nurse to intervene to prevent cold stress.

A nurse is assessing a client who has Raynaud's disease. What should nurse expect? A. Butterfly rash over the cheeks and nose B. Report of pain in the joints of the lower extremities C. Blanching of the fingers and toes D. Scaly patches over the knees and elbows

C. Blanching of the fingers and toes - in response to exposure to cold or emotional stress. - systemic lupus erythematosus is more likely to have a butterfly rash over the cheeks and nose. - arthritis is more likely to have pain in the joints of the lower extremities. - psoriasis is more likely to have scaly patches over the knees and elbows.

When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain med. Which strategies incorporates visualization techniques to help decrease the discomfort? A. Coloring with crayons in a coloring book B. Deep breathing and "going limp as a rag doll" C. Blowing bubbles with liquid soap to "blow the hurt away" D. Taking a warm bath and playing with a bath toy

C. Blowing bubbles with liquid soap to "blow the hurt away"

A nurse is caring for a client who has a deficit with cranial nerve 2. Which of following actions should the nurse plan? A. Keep the client resting in bed. B. Ask the client to restate directions. C. Clear objects from the client's walking area. D. Evaluate the client's ability to swallow.

C. Clear objects from the client's walking area. - CN II deficit can result in visual impairment and lead to falls. - CN VIII deficit, which causes hearing loss, to restate directions. - CN IX deficit because it can impair swallowing.

A nurse is assessing an older adult client for macular generation. Which of the following findings should the nurse expect? A. Increased intraocular pressure B. Floating dark spots C. Decreased central vision D. Double vision

C. Decreased central vision - due to bleeding into the macula or yellow spots under the retina. - An increase in intraocular pressure is a manifestation of glaucoma. - Floating dark spots are a manifestation of retinal detachment. - Double vision is a manifestation of cataracts.

A nurse is caring for a client who has a K level of 3, which clinical sign should the nurse monitor? A. Increased bowel sounds B. Dry sticky mucous membranes C. Decreased deep tendon reflexes D. Numbness and tingling of the extremities

C. Decreased deep tendon reflexes - hypokalemia can have muscle weakness and decreased deep tendon reflexes. - hypocalcemia is likely to have numbness and tingling of the extremities and around the mouth. - hypernatremia is likely to have dry sticky mucous membranes. - hypokalemia is more likely to have hypoactive bowel sounds due to decreased gastrointestinal mobility.

A nurse is teaching a client who is post op following a knee arthroplasty and is to receive enoxaparin. The nurse should explain that the purpose of the medication is to prevent which of the following complications? A. Paralytic ileus B. Atelectasis C. Deep-vein thrombosis D. Anemia

C. Deep-vein thrombosis

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following clinical signs should the nurse expect? A. Hypersensitivity to criticism B. Feelings of emptiness C. Grandiose thoughts D. Reclusive behavior

C. Grandiose thoughts - manic phase of bipolar disorder usually exhibit behaviors that appear to be euphoric. They often have abrupt mood changes, expansiveness, unlimited energy, poor impulse control, and grandiose thoughts. - borderline personality disorder have feelings of emptiness. - avoidant personality disorder are hypersensitive to criticism. - schizoid personality disorder demonstrate reclusive behavior.

A nurse is providing client education to a postpartum client who has decided to bottle feed her newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? A. Allow the newborn to breastfeed temporarily. B. Relieve pressure by expressing milk daily. C. Place ice packs on the breasts for 15 min several times per day. D. Sleep with a loose-fitting bra to prevent nipple stimulation.

C. Place ice packs on the breasts for 15 min several times per day. - should wear a tight-fitting, supportive bra or wear a breast binder to decrease discomfort. - should instruct the client to avoid nipple stimulation to prevent further milk production. - avoid expressing milk to prevent further milk production.

An AP and nurse are turning a client onto her right side. Which of the following actions by AP requires the nurse to intervene? A. Uses a draw sheet to move the client to the left side of the bed B. Raises the height of the bed to waist level C. Places a pillow under the client's right arm D. Lowers the side rails on the left side of the bed

C. Places a pillow under the client's right arm - to prevent internal rotation of the left shoulder.

A nurse is an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? A. Carotid bruit B. Tracheal deviation C. Pulsus paradoxus D. Heart murmur

C. Pulsus paradoxus - a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distention, bradycardia, and hypotension. - to assess tracheal deviation in a client who has a pneumothorax. - to hear a carotid bruit for a client who has atherosclerosis. - auscultate muffled heart sounds, which are an expected finding of cardiac tamponade, along with fatigue and dyspnea.

A nurse is assessing an older adult client who has delirium. Which of the following manifestations should the nurse expect? A. Projecting blame B. Excessive clinging C. Rapid speech D. Social awkwardness

C. Rapid speech - exhibit rapid, inappropriate, incoherent, and rambling speech patterns. - paranoid personality disorder project blame. - dependent personality disorder demonstrate excessively clinging behavior. - schizotypal personality disorder exhibit social awkwardness.

A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following signs should be a priority? A. Muscle spasms of the affected extremity B. A pain rating of 6 on a scale from 0 to 10 C. Upper chest petechiae D. Ecchymosis over the fractured area

C. Upper chest petechiae - Upper chest petechiae indicate that the client is at greatest risk for fat embolism syndrome, a life-threatening complication of fractures.

A nurse us caring for a client who has heart failure and asks the nurse for information regarding advance directives. Which of the following responses should the nurse make? A. "You don't need advance directives now because you are competent and can make decisions for yourself." B. "You must wait for a period of 6 months before changing the provisions in your advance directives." C. "You will have to speak to an expert who works in the social service department." D. "Advance directives are important because they guide health care decisions in the event you cannot express your own wishes."

D. "Advance directives are important because they guide health care decisions in the event you cannot express your own wishes."

A nurse is speaking with the partner who has a terminal illness. The partner states "Idk what I will do when he is gone". What should the nurse say? A. "Things will be better with time." B. "If I were you, I would be upset too." C. "I will call a friend to sit with you." D. "I am here to listen if you would like to talk."

D. "I am here to listen if you would like to talk."

A client who is in the first trimester of pregnancy is being seen in a clinic for her monthly visit. She has been using acupressure bands on her wrists. Which of the following statements by the client indicates that this therapy is having desired effect? A. "I have not had any food cravings." B. "The spotting I was having has stopped." C. "I don't feel depressed anymore." D. "I have not vomited for the past 2 weeks."

D. "I have not vomited for the past 2 weeks." - a type of complementary and alternative therapy that applies pressure to a specific part of the body the client can use to alleviate nausea and vomiting.

A nurse is education a client about the goals of hospice care. Which of the following statements should the nurse identity as an indication that the client understands the teaching? A. "I will be eligible to receive experimental therapy in hopes of overcoming my disease." B. "Care will include approved medications that might cure my disease." C. "If the suffering gets too bad, I will be able to take medication to help me end my life." D. "I will receive treatment to control my symptoms and keep me comfortable."

D. "I will receive treatment to control my symptoms and keep me comfortable."

A nurse is providing discharge teaching to a new mother about car safety. Which of the following statements should the nurse include in the teaching? A. "Place your baby's car seat at a 30-degree angle." B. "Your baby's car seat should be rear-facing until he is 6 months old." C. "Swaddle your baby in a light blanket before placing him in the car seat." D. "Secure the retainer clip at the level of your baby's armpits."

D. "Secure the retainer clip at the level of your baby's armpits." - to place the newborn's car seat at a 45° angle. - remain rear-facing in the back seat of the vehicle until he is 2 years old

A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? A. "Estrogen levels decrease during pregnancy, causing the stool to become hardened." B. "Decreased water absorption in the intestine during pregnancy causes constipation." C. "The intestine absorbs iron less efficiently during pregnancy, leading to constipation." D. "The enlarged uterus compresses the intestines and causes constipation."

D. "The enlarged uterus compresses the intestines and causes constipation." - During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation. - The small intestine absorbs iron more readily during pregnancy due to increased maternal needs leading to constipation. - intestine absorbs more water from the stool during pregnancy leading to constipation. - Estrogen and progesterone levels increase during pregnancy leading to decreased peristalsis and relaxation of the smooth muscles of the intestine, which can result in constipation.

A nurse is caring for 4 clients at the beginning of shift. Who should the nurse see first? A. A client who has a temperature of 38.2° C (100.8° F) and requests a cup of ice chips B. A client who is postoperative and reports a pain level of 5 on a scale from 0 to 10 C. A client who has voided and is ready for a bladder scan D. A client who is confused and has been attempting to get out of bed

D. A client who is confused and has been attempting to get out of bed

A home health nurse is caring for a group of older clients. The nurse should initiate a referral to the Program of All Inclusive Care for the Elderly (PACE) for which of the following clients? A. A client whose family requests hospital-based hospice care B. A client who requires transfer to a skilled care facility C. A client who qualifies for telehealth for pacemaker diagnostics D. A client whose caregiver requests adult day care services

D. A client whose caregiver requests adult day care services - PACE provides adult day care services along with in-home assessments and supportive services.

A nurse is caring for a client who is 12hr post op, is receiving PCA for pain control and requires a BP check in 10 min. Which of the following staff members should the nurse assign to collect? A. An RN who is monitoring a client who started receiving a blood transfusion 5 min ago B. An assistive personnel (AP) who is feeding a client a meal C. A licensed practical nurse (LPN) who is reinforcing discharge instructions with a client D. An assistive personnel (AP) who is assisting a client to return to bed

D. An assistive personnel (AP) who is assisting a client to return to bed

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36hr. Which of following signs should the nurse that the client developed O2 toxicity? A. Wheezes B. Tachycardia C. Restlessness D. Bradypnea

D. Bradypnea - due to the depression of the respiratory drive in a client who has chronic hypoxia, such as a preschooler who has cystic fibrosis. - Restlessness indicates the client has hypoxemia, is working harder to obtain oxygen, and requires oxygen therapy. - Tachycardia indicates the client has hypoxemia, is working harder to obtain oxygen, and requires oxygen therapy. - more likely to have crackles and substernal chest pain rather than wheezes.

A nurse is caring for an older client. Which of the following should the nurse recognize as a physiological change associated with age? A. Decreased blood pressure B. Increased cardiac output C. Increased oral temperature D. Decreased lung expansion

D. Decreased lung expansion - decreased lung expansion due to decreased mobility of the ribs. - more likely to have an increased systolic blood pressure, with a diastolic pressure that does not change. - have decreased cardiac output. - have decreased oral temperature.

A nurse interviewing a client who has just lost her home due to a natural disaster. After ensuring client's safety, which of the following actions should the nurse take first? A. Assist the client with contacting individuals from the client's support system. B. Give the client information about available community resources for shelter. C. Suggest the client obtain mental health counseling. D. Determine the client's perception of the personal impact of the crisis.

D. Determine the client's perception of the personal impact of the crisis.

A nurse is planning care for a client who is receiving heparin to treat a DVT of the left lower leg. Which of the following interventions should the nurse include in the plan of care? A. Maintain the client on bed rest. B. Restrict the client to 1 L of fluid per day. C. Place cool compresses on the edematous area. D. Elevate the affected leg.

D. Elevate the affected leg. - elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency. - encourage the client to ambulate, as walking does not increase the risk for pulmonary emboli nor does it worsen the deep-vein thrombosis - encourage the client to drink 2 to 3 L of fluid daily to decrease platelet aggregation and prevent dehydration. - place warm compresses on the affected area to reduce swelling and promote comfort.

A charge nurse observes a staff nurse document a dressing change in a client's chart that he did not perform. Which of the following actions should the charge nurse take first? A. Ensure that the staff nurse changes the dressing. B. Notify the nurse manager. C. Complete an incident report. D. Gather more information about the staff nurse's actions.

D. Gather more information about the staff nurse's actions.

A PTSD client asks nurse to recommend a nonpharmacological therapy. Which of the following should nurse teach client to help distress? A. Spinal manipulation B. Acupuncture C. Therapeutic touch D. Guided imagery

D. Guided imagery - useful therapy for anxiety and pain that the client can learn how to use to relieve his symptoms.

A charge nurse is preparing to administer meds at 9AM and told by pharmacy that the meds are not available and previously discussed this issue beforehand. What should the charge nurse do first? A. Document the actual time of medication administration. B. Notify the risk manager. C. Complete an incident report. D. Inform the nurse manager of the issue.

D. Inform the nurse manager of the issue. - the priority intervention the charge nurse should take is to follow the chain of command and contact the nurse manager who is her supervisor.

A nurse is caring for a client who requires physical therapy following discharge. Which of the following should nurse take? A. Initiate the referral at the time of discharge. B. Have the client contact a physical therapist when she feels ready to begin therapy. C. Verify that insurance will pay for outpatient physical therapy. D. Involve the client in selection of a physical therapy provider.

D. Involve the client in selection of a physical therapy provider. - responsibility of the social services department includes determining if the client's insurance will pay for outpatient therapies.

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Instills 100 mL of air into the NG tube after checking for residual. B. Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr. C. Adds 20 mL of blue dye to each feeding to help detect aspiration. D. Keeps the head of the bed elevated to 45° for 1 hr after feedings.

D. Keeps the head of the bed elevated to 45° for 1 hr after feedings. - avoid adding dye to the feeding to detect aspiration because using dye can increase the risk of death. - use 20 mL of tap water to flush the NG tube before and after each feeding. Using 0.9% sodium chloride irrigation can lead to hypernatremia. - inject 10 to 30 mL of air into the NG tube before checking residual to clear the tube of any feeding. Instilling excessive air into the tube can cause abdominal distention and discomfort.

A nurse is assessing a fetus that is in the left occiput anterior (LOA) position. In which of the following locations should the nurse assess for fetal heart tone? A. Midline above symphysis pubis B. Midline at level of umbilicus C. Right lower quadrant D. Left lower quadrant

D. Left lower quadrant - can hear fetal heart sounds best over the fetal back. In the LOA position, the position of the fetal back is in the mother's left lower quadrant. - hear fetal heart tones best in the right lower quadrant for a fetus in the right occiput position. - For fetuses in breech presentations, the nurse usually can auscultate the fetal heart tones above the mother's umbilicus.

A nurse manger is on planning committee to develop an emergency preparedness plan. The nurse should recommend that which go the following actions takes place first when implementing an emergency preparedness plan. A. Contact the triage officer. B. Implement the client tracking system. C. Request the communications officer to release a press statement. D. Notify the incident commander.

D. Notify the incident commander. - notify the incident commander to initiate the command hierarchy and maintain order.

A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The nurse should identify which of the following findings as an indication of FVD.? A. Shortness of breath B. Visual disturbances C. Decreased BUN levels D. Orthostatic hypotension

D. Orthostatic hypotension - as a result of decreased blood volume. - Increased BUN levels should indicate - visual disturbances, such as blurred vision, indicate fluid overload - shortness of breath as an indication of fluid volume excess because extra fluid interferes with oxygen exchange at the alveolar level.

A nurse is caring for a client who had a stroke 6hr ago, which of the following interventions should the nurse implement to lower the risk of ICP? A. Elevate the head of the client's bed to 45°. B. Group several nursing activities to be completed at one time. C. Perform tracheopharyngeal suctioning every 2 hr. D. Place the client in a quiet environment.

D. Place the client in a quiet environment. - should elevate the head of the client's bed no more than 25° to reduce the risk of increasing ICP from hip flexion.

A nurse on a mental health unit is planning care for a client who is a threat to herself and others and has a prescription for mechanical restraints and seclusion. Which of the following interventions should the nurse include in the plan? A. Remove the client's restraints while she is sleeping. B. Document the client's status every 60 min. C. Check for a new prescription every 6 hr. D. Provide a staff member to stay with the client continuously.

D. Provide a staff member to stay with the client continuously. - must renew a prescription for restraints every 4 hr for clients 18 years or older, every 2 hr for children ages 9 to 17 years, and every 1 hr for children under the age of 9 years. - assess the client for physical needs, safety, and comfort every 15 to 30 min and document the findings.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 ml/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? A. Administer the TPN solution at the same rate using manual drip tubing. B. Offer the client oral fluids in place of the TPN solution. C. Infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr. D. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr.

D. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr. - to prevent hypoglycemia - infuse an IV solution that will maintain adequate blood glucose levels.

A nurse working in a long term care facility is assessing an older client. Which of the following findings places the client at risk for developing a pressure ulcer? A. Report of persistent constipation B. Hgb 14 g/dL C. Albumin 4.2 g/dL D. Recent weight loss

D. Recent weight loss - A client who has recently lost 5% of total body weight or 4.5 kg (10 lb) is at risk for developing a pressure ulcer. - Albumin 4.2 : This value is within the expected reference range for an older adult client. - Diarrhea and exposure to stool place the client at risk for developing a pressure ulcer.

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse rewires the nurse manager to intervene? A. Informs the provider about a client's suicide plan B. Notifies the health department of a client's diagnosis of chlamydia C. Reports suspected child abuse to social services D. Tells the hospital chaplain a client's diagnosis

D. Tells the hospital chaplain a client's diagnosis

A nurse on a medical surgical unit is caring for a client prior to a surgical procedure. Which of the following should indicate to the nurse that the client has the ability to sign the informed consent? A. The client's partner tells the nurse that the client understands the procedure. B. The nurse locates the provider's prescription for the surgical procedure. C. The nurse witnesses the provider's explanation of the procedure. D. The client is able to accurately describe the upcoming procedure.

D. The client is able to accurately describe the upcoming procedure. - the nurse cannot assume that the client understands the information the provider gave.

A nurse is caring for a client who has a fracture femur and has a long leg fiberglass cylinder cast for 24 hr. which of the following assessment findings should the nurse as the priority? A. The client reports his leg itches under the cast around the mid-upper thigh area. B. The client reports increased pain when he lowers his leg below the level of his heart. C. The client's cast became wet during a sponge bath. D. The client's heel is reddened and tender.

D. The client's heel is reddened and tender. - greatest risk to this client is injury from a pressure ulcer - A fiberglass cast is waterproof and water will not affect the integrity of the cast. -

McBurney's point

Pain in RLQ with appendicitis, right lower quadrant between the umbilicus and the anterior iliac crest. - experiencing diverticulitis will most likely experience pain in the left lower quadrant at the site of the diverticula. - experiencing cholelithiasis, also known as gallstones, will experience pain in the right upper quadrant at the site of the gallbladder.

Identify the sequence steps to perform tracheostomy care

When teaching the parent to provide tracheostomy care; - the nurse should instruct the parent to first remove the inner cannula. - Next, the nurse should instruct the parent to remove the soiled dressing - and then clean the stoma with sterile saline. - Finally, the nurse should instruct the parent to change the tracheostomy collar.

CMV

can cause mild influenza-like symptoms or no symptoms in adults. Women who are pregnant can transmit a primary infection to the fetus in utero and during vaginal delivery.

Parvovirus

is the cause of erythema infectiosum resulting in a red facial rash that spreads over the body.

A nurse is assuming care for a client who is 4hr post op following a total vaginal hysterectomy. Which of the following actions should the nurse take first? A. Measure the client's vital signs. B. Reposition the client. C. Encourage the client to use an incentive spirometer. D. Administer pain medication.

A. Measure the client's vital signs. - assess for respiratory depression and hypotension resulting from anesthesia. - should reposition the client to prevent postoperative complications such as atelectasis - should encourage the client to use an incentive spirometer to increase lung expansion - should administer pain medication around the clock on a regular schedule for the first 48 hr

A nurse is caring foe a group of clients, which of the following clients should the nurse identify is in need of an interdisciplinary care conference? A. A client who has type 1 diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis B. A client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings C. A client who has sickle cell anemia and avoids contact sports D. A client who has a history of two prior miscarriages and has ruptured membranes at 38 weeks of gestation

A. A client who has type 1 diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis - this client is not managing his disease and is having repeated episodes of a life-threatening complication. Members of an interdisciplinary team can address his needs and provide necessary support from different disciplines.

A nurse is caring for a group of clients, for which of the following events should the nurse complete an incident report A. An IV pump delivers an inadequate dose of medication. B. A nurse discontinues a client's enteral feedings according to her advance directives. C. A nurse discards unused bags of IV fluids because they are expired. D. A client refuses an IV bolus of pain medication.

A. An IV pump delivers an inadequate dose of medication.

A nurse is caring for for a client who is to start taking captopril for a new diagnosis of hypertension. Which of the following tasks should the nurse delegate to assistive personal? A. Obtain blood pressure before and after medication administration. B. Request a dietary referral. C. Review the client's medication administration record. D. Teach the client to use salt substitutes.

A. Obtain blood pressure before and after medication administration.

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? A. Performing a rapid needs assessment B. Organizing an immunization campaign C. Identifying the specific roles of disaster workers D. Conducting home visits to identify health hazards

A. Performing a rapid needs assessment - Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response stage of a disaster management plan. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage.

A nurse is caring for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse take to provide comfort to this client? A. Perform ADLs in the morning. B. Allow for frequent rest periods throughout the day. C. Encourage the client to take warm tub baths when joints are inflamed. D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain.

B. Allow for frequent rest periods throughout the day. - should balance rest with exercise to maintain muscle strength, joint function, and range of motion. - Clients who have inflamed joints can use moist heat to enhance comfort. - Pain, stiffness, and swelling are worse in the morning for clients who have rheumatoid arthritis. The nurse should postpone assisting the client to perform ADLs

A community health nurse is reviewing the medical records of 4 clients. The nurse should report which client to CDC? A. A client who is pregnant and has cytomegalovirus (CMV) B. An adolescent client who has foodborne botulism C. A child who has erythema infectiosum D. A young adult client who has herpes simplex virus type 1 (HSV-1)

B. An adolescent client who has foodborne botulism - Clients who ingest the botulism toxin can develop dysphasia, dropping eyelids, and vision changes, and in 12 to 36 hr can develop neurologic symptoms such as symmetric, flaccid paralysis, and cranial nerve impairment.

A nurse is caring for a client who had a recent stroke. Prior to transferring the client to beside commode, which of the following actions should the nurse take first? A. Ask for help with a two-person assist transfer. B. Assess the client for functional limitations. C. Request a mechanical lift device. D. Medicate the client for pain.

B. Assess the client for functional limitations.

A nurse is an emergency department is assessing a client who reports taking methlenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect? A. Lethargy B. Diaphoresis C. Nausea D. Cough

B. Diaphoresis - might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects.

A nurse is assessing a client who is experiencing automatic dysreflexia. Which of the following findings should the nurse expect? Select all that apply A. Nystagmus B. Facial flushing C. Diplopia D. Nasal congestion E. Headache

B. Facial flushing D. Nasal congestion E. Headache - expect blurred vision

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with her parents, the nurse should recognize which of the following responses by the parents as an example of rationalization. A. "Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner." B. "Let's go on that family vacation we've got planned. We will deal with this when we return." C. "Maybe this is better for our child because we don't want her to suffer through chemotherapy treatments." D. "This isn't possible. Just last week the doctor said that she was responding well to treatment."

C. "Maybe this is better for our child because we don't want her to suffer through chemotherapy treatments." - By focusing on disbelieving the news about the adolescent's prognosis, the parent is using the defense mechanism of denial. - By exhibiting a conscious denial of the adolescent's prognosis until the family returns from vacation, the parent is using the defense mechanism of suppression. - By attributing the cause of the adolescent's prognosis to the provider's failure to diagnose the illness sooner, the parent is using the defense mechanism of displacement.

A nurse is preparing to administer 2 units of fresh frozen plasma to older client. Which of the following actions should the nurse plan to take? A. Allow the plasma to warm for 30 min before transfusion. B. Confirm the client's identification by checking the room number. C. Enter the plasma product number into the client's medical record. D. Administer each unit of plasma over 4 hr.

C. Enter the plasma product number into the client's medical record. - should plan to administer each unit of plasma over 30 to 60 min. - should transfuse the plasma immediately after obtaining it from the blood bank.

A nurse is teaching a newly hired nurse about inserting an indwelling urinary catheter for a client. The nurse should identify which of the following infectious organisms as the most common cause of a urinary tract infection? A. Proteus B. Klebsiella pneumoniae C. Escherichia coli D. Staphylococcus saprophyticus

C. Escherichia coli - greatest risk for a urinary tract infection from the E. coli bacteria. E. coli is responsible for 90% of urinary tract infections.

A nurse is administering meds to several clients and has to discard a portion of med dose. For which of the following meds should the nurse ask a second nurse to observe and cosign disposal of a portion of the dose? A. Sumatriptan B. Insulin lispro C. Fentanyl D. Dexamethasone

C. Fentanyl - Fentanyl is an opioid analgesic, which has the risk of abuse; therefore, the nurse has a legal responsibility - Dexamethasone is an anti-inflammatory, - Insulin is an antidiabetic medication - Sumatriptan is an anti-migraine medication,

An RN is planning care for a group of clients and is working with a LPN and AP. Which of the following tasks should the RN delegate to LPN. A. Collection of a stool specimen B. Preparation of a client's postoperative bed C. Administration of a unit of packed RBCs D. Insertion of a nasogastric tube

D. Insertion of a nasogastric tube

HSV-1

It causes painful blisters to form on the mouth or the genitals. Transmission can occur during sexual contact.

A nurse is caring for four clients, which of the following clients should the nurse assign an AP to assist with meals? A. A client who has Alzheimer's disease and is demonstrating aphasia B. A client who has asthma and an increased respiratory rate C. A client who had a stroke and is to start oral intake D. A client who had diabetic ketoacidosis and is difficult to arouse

A. A client who has Alzheimer's disease and is demonstrating aphasia - Aphasia impairs the client's ability to communicate, but does not interfere with nutritional intake or place the client at a safety risk while eating.

Discharge teaching for a client who has colorectal cancer and is post op following a new colostomy. The client states "I have no health insurance and cannot pay for the ostomy supplies" What should the nurse do? A. Arrange for a referral to social services. B. Initiate a consult with an enterostomal therapist. C. Provide the client with information about the American Cancer Society. D. Postpone the client's discharge. E. Give the client information about local support groups.

A. Arrange for a referral to social services. B. Initiate a consult with an enterostomal therapist. C. Provide the client with information about the American Cancer Society. E. Give the client information about local support groups.

A client who is 24hr post op following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? A. Ask the client to rate his pain level. B. Assist the client in changing positions. C. Administer a PRN analgesic medication. D. Explain the importance of early ambulation.

A. Ask the client to rate his pain level.

A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the care of plan? A. Avoid venipunctures when possible. B. Restrict visitors to family members. C. Limit oral fluid intake to between meals. D. Prohibit fresh flowers in the client's room.

A. Avoid venipunctures when possible. - thrombocytopenia have a decreased platelet count. To prevent the risk for bleeding, the nurse should avoid venipunctures. - Restricting visitors to family members and Prohibiting fresh flowers in the client's room is appropriate for clients who have neutropenia

A nurse is caring for a newborn whose parent asks why her baby is receiving vitamin K. The nurse should explain to the parents about prevention? A. Bleeding B. Potassium deficiency C. Infection D. Hyperbilirubinemia

A. Bleeding - should receive vitamin K at birth because they have low levels of vitamin K, which can lead to bleeding.

A nurse is providing discharge instructions to older client following a total hip arthroplasty. Which of the following instructions should the nurse indicate? A. Install a raised toilet seat at home. B. Maintain the hip at an angle greater than 90°. C. Minimize the use of a walker. D. Place a pillow under the knees when lying down.

A. Install a raised toilet seat at home. - To minimize hip flexion and prevent hip dislocation, - maintain the hip at an angle less than 90° to minimize hip flexion and prevent hip dislocation. - use a walker to minimize the risk of falls or injury. - should not have a pillow under the knees when lying down because it can impede circulation and result in flexion contractures.

A nurse manger is reviewing unit records and discovers that client falls occurs most frequently during the hours of 5:30-7:30. Which of the following actions should the nurse take when conducting a root cause analysis? A. Investigate environmental factors that might be contributing to client injury during these hours. B. Review the performance evaluations of nurses who work during these hours. C. Implement a plan to transition from team nursing to primary care nursing during these hours. D. Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours.

A. Investigate environmental factors that might be contributing to client injury during these hours. - conducting a root cause analysis, the nurse focuses on identifying the cause of a problem, not potential solutions to the problem.

A nurse is caring for an older client who has limited mobility. The client asks why he has a hand roll in each hand. The nurse explains which of the following as being the purpose of the client's hand rolls? A. Maintains a functional position B. Decreases muscle spasticity C. Increases joint mobility D. Improves hand and grip strength

A. Maintains a functional position - A hand roll keeps the thumb pulled slightly inward towards the fingers, maintaining a functional position. - can administer a muscle relaxant, such as cyclobenzaprine, to manage muscle spasms. - can use active and passive range of motion to increase a client's joint mobility and prevent contractures. - can use hand and wrist exercises to improve hand and grip strength.

A nurse is caring for a toddler who is postoperative following a tonsillectomy. Which of the following actions should nurse take? A. Position the client so the head is lower than the chest. B. Have the child cough and deep breathe every hour while awake. C. Administer liquids through a straw. D. Administer analgesics to the child every 8 hr.

A. Position the client so the head is lower than the chest. - place the client in a lateral or prone position with the head lower than the chest to avoid aspiration of saliva or blood from the surgical site. - avoid coughing and clearing her throat because these activities can aggravate the throat and cause pain and bleeding prior to surgery. - A straw can cause damage to the surgical site and result in bleeding. - should administer analgesics to the child every 4 hr for the first 24 to 48 hr to reduce pain and promote comfort.

A nurse manager is planning to make changes to the current scheduling system to the unit. To facilitate the staff's acceptance of this change. Which of the following actions should nurse manager take first? A. Provide information about scheduling issues to the staff. B. Ask staff members to participate in a trial of the new scheduling system. C. Encourage staff to offer alternate scheduling solutions. D. Develop goals to implement the new scheduling system.

A. Provide information about scheduling issues to the staff. - first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current issues. This can increase their understanding of why changes are necessary. - Participating in a trial implementation of the new scheduling system is a component of the moving stage of change. - Including staff members in the change by encouraging them to offer alternate scheduling solutions will make them feel included and less resistant to the new schedule, and is a component of the moving stage of change. - Developing goals and objectives to implement the new scheduling system is a component of the moving stage of change.

A nurse is assessing a 2 month old infant during a well baby exam. Which of the following is infant rooting reflex? A. Stroke the infant's cheek. B. Depress the infant's tongue. C. Turn the infant's head to one side. D. Tap on the bridge of the infant's nose.

A. Stroke the infant's cheek. - should depress the infant's tongue to assess the extrusion reflex, which will cause the infant to stick her tongue out. - should turn the infant's head to one side to assess the asymmetric tonic neck reflex, - should tap on the bridge of the infant's nose to assess the glabellar reflex, which will cause the infant to close her eyes tightly.

A nurse receives a telephone call from a person who identifies herself as a client's mother. The caller asks for information about the client but it is the unable to provide a security password. Which of the following should the nurse take? A. Tell the caller that she cannot give out client information. B. Give the caller limited information about the client. C. Transfer the phone call to the client's room. D. Inform the caller that she must obtain permission from the client's provider.

A. Tell the caller that she cannot give out client information. - HIPPA

A client is receiving lorazepam IV for panic attacks and develops a RR of 6/min and BP of 90/44. Which of the following signs should the nurse anticipate administering? A. Naloxone B. Flumazenil C. Acetylcysteine D. Atropine

B. Flumazenil - a competitive benzodiazepine receptor antagonist, to reverse the sedative effects of lorazepam, support the client's respirations with a bag-valve mask. - administer acetylcysteine to counteract an acetaminophen overdose. - administer atropine to counteract a cholinesterase inhibitor overdose, such as neostigmine.

A nurse is assessing a school age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to provider? A. Decreased activity B. Hemoptysis 275 mL/ 24hr C. Fever D. Weight loss 2.3 kg (5 lb)

B. Hemoptysis 275 mL/ 24hr - Hemoptysis greater than 250 mL/24 hr indicates that this client is at greatest risk for hemorrhage. - should report decreased activity, fever, anorexia and weight loss to the provider because it is an indication of pulmonary infection.

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor? A. Weight loss B. Urinary retention C. Hypertension D. Hypoglycemia

C. Hypertension - a complication of obstructive sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias. - assess the client for hyperglycemia because the client can develop type 2 diabetes resulting from the weight gain of obstructive sleep apnea. - expect the client to develop enuresis, rather than urinary retention, as an expected finding - identify weight gain as a complication of obstructive sleep apnea

A nurse is caring for a toddler who has infectious gastroeneteristis. Which of the following actions should nurse do? A. Include chicken broth in the toddler's diet. B. Feed the toddler the BRAT diet. C. Initiate oral rehydration therapy for the toddler. D. Offer the toddler flavored gelatin.

C. Initiate oral rehydration therapy for the toddler. - Diarrhea causes dehydration, which results in fluid volume deficit - Gelatin is high in carbohydrates, low in electrolytes, and high in osmolality which can prolong diarrhea and electrolyte imbalance. - The BRAT diet (bananas, rice, applesauce, and toast) contains little nutritional value, containing inadequate amounts of protein and electrolytes but is high in simple carbohydrates. - chicken and beef broths contain excessive amounts of sodium and too little carbohydrates.

A nurse is developing a care plan for a client who is immobile. Which of the following interventions should the nurse include? A. Promote the consumption of 1,000 mL of fluid per day. B. Massage the lower extremities with lotion daily. C. Maintain correct body alignment with use of trochanter rolls. D. Elevate the lower extremities with a pillow behind the knees while in bed.

C. Maintain correct body alignment with use of trochanter rolls. - to prevent external rotation and abduction of the hips which will maintain correct body alignment - should consume 2 to 3 L of fluids daily to prevent renal calculi and urinary tract infections.

A nurse is caring for a client who is 4hr postpartum and has a boggy uterus with heavy lochia. Which of the following should nurse do first? A. Administer oxygen. B. Initiate an infusion of oxytocin. C. Massage the uterus to expel clots. D. Obtain a CBC.

C. Massage the uterus to expel clots. - Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding.

A nurse is preparing to administer 2 units of RBCs to a client who has anemia. Which of the following actions should the nurse take prior to initiating the blood transfusion? A. Ensure that the client has been NPO for 4 hr. B. Initiate lactated Ringer's solution to infuse with the blood product. C. Obtain venous access using a 20-gauge needle. D. Collect both units of blood from the blood bank.

C. Obtain venous access using a 20-gauge needle. - The large size needle allows the blood cells to flow more easily through the IV catheter without occluding the lumen. - should only use 0.9% sodium chloride solution when transfusing blood because other solutions can cause clotting or hemolysis of the blood cells. - should collect 1 unit of blood at a time. The nurse should initiate the blood transfusion within 30 min of removing it from the blood bank refrigerator to prevent bacterial growth in the blood. - does not need to restrict food intake prior to receiving a blood transfusion. The nurse should encourage oral intake due to the client's anemia.

A nurse is planning to teach a client who is start a new prescription for fluoxetine. Which of the following findings should the nurse instruct the client to monitor and report? A. Jaundice B. Constipation C. Tremors D. Weight loss

C. Tremors - Fluoxetine can cause serotonin syndrome within 2 to 72 hr after starting treatment. The client can experience tremors, agitation, confusion, anxiety, and hallucinations. - weight gain is an adverse effect of fluoxetine. - report dark or tarry stools, because fluoxetine can cause gastrointestinal bleeding. - can cause a rash

A nurse in a community center is providing an educational session to a group of women about ovarian cancer. For which of the following signs should the nurse instruct the women to contact their providers? A. Back pain B. Postcoital bleeding C. Purulent discharge D. Abdominal bloating

D. Abdominal bloating - an early indication of ovarian cancer as well as other manifestations which include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. - presence of purulent vaginal discharge as an indication of a sexually transmitted infection. - presence of postcoital bleeding and back pain as an indication of cervical cancer.

A nurse is preparing a sterile field in order to insert an indwelling catheter for a male client. Which of the following techniques should the the nurse use to maintain surgical aseptic technique A. Open the top outer flap of the package toward the body. B. Clean the penis with the nondominant hand. C. Don sterile gloves after opening the lubricant packet. D. Set the catheter tray on the overbed table at waist height.

D. Set the catheter tray on the overbed table at waist height. - don sterile gloves before touching any of the items in the sterile field. - clean the penis with the dominant hand. - open the top outer flap away from the body to prevent contamination of the sterile field by reaching over it when opening the remaining flaps.