Comp 2020B

a nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. which of the following statements by a client indicates an understanding of cutaneous stimulation?

"i should use counterpressure for back pain during labor"

a nurse is reinforcing teaching about stress managment techniques with a client who has moderate anxiety disorder. which of the following responses by the client indicates an understanding of the teaching?

"i will imagine myself in a calm place when i cant concentrate"

a nurse is reinforcing teaching with the adult children of a client who is dying. which of the following statements should the nurse make?

"you can continue talking to your patient until they are gone"

a nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. which of the following instructions should the nurse reinforce with the client?

"you should depress the button on the handheld marker when you feel your baby move"

a nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. which of the following instructions should the nurse include in the teaching? -"You will need to take the medication for the rest of your life." "You should withhold the medication if you develop a low heart rate." "Take the medication just before bedtime." "Take the medication with meals."

"you will need to take the medication for the rest of your life" Hypothyroidism is a chronic disorder that requires lifelong thyroid hormone replacement therapy.

a nurse in a long term care facility is serving on the ethics committee.. which is addressing a client care dilema. which of the following strategies will facilitate resolving the dilemma? sata

-determine the facts related to the dilemma -identify possible solutions -consider the clients wishes

a nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes mellitus and inquires about information concerning oral antidiabetic agents. in addition to the provider; where should the nurse refer the client for information? sata

-pharmacist -package inserts -american diabtes association

a nurse is collecting data from a client who has a newly applied cast to the right lower extremity. which of the following findings should the nurse expect?

a capillary refill of 5 seconds to the clients toes

a nurse on a pediatric unit is collecting data from four newly admitted clients. which of the following clients should the nurse identify as being at risk for urinary retention?

a school age child who has allergic rhinitis and is taking diphenhydramine

a nurse is caring for a client who took an overdose of acetaminophen. which of the following medications should the nurse plan to administer to the client?

acetylcysteine

a charge nurse on a long term care unit is preparing to delegate taks to a licensed practial nurse and an ap. which of the following tasks can the charge nurse delegate to the LPN?

administering an intial NG tube feeding to a client who had a stroke

a nurse is reinforcing teaching with a client who has fluid volume deficit about selecting foods that have a high water content. the nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving?

cherry tomatoes

a nurse is assisting with a presentation at a community center about personal disaster preparedness. which of the following strategies should the nurse reccommend for preparing a home disaster kit?

have a supply of prescribed medications

a nurse is preparing to administer a medication to a client. the client states "im sick of all these medications, and im not taking anymore today" which of the following actions should the nurse take?

inform the client of the possible consequences of the medication refusal

a nurse is administering lorazepam to a client who is schudled for surgery within 1 hr. which of the following actions should the nurse take after administering the medication?

instruct the client not to get out of the bed

a nurse is performing vision testing for a client following a head injury. which of the following findings should t he nurse identify as a problem with pupil accomidation?

lack of change in pupil size when the client looks from a far to a near object

a nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. the nurse recognizes late decelerations on the fetal monitoring tracing. which of the following actions should the nurse take?

place the client in a lateral position

a nurse is transferring a client from a bed to a wheelchair. the client has right sided weakness following a recent stroke. which of the following actions should the nurse take?

place the wheelchair on the clients left side

a nurse is receiving change of shift report for a group of clients. the nurse should plan to implement which of the following time management strategies?

prepare a priority list of client needs for the shift

a nurse manager is providing an in service on hand hygiene to assistive personnel. which of the following information should the nurse manager include in the in service?

remove rings when washing hands with soap and water

a nurse is caring for a client who is scheduled for surgery in the morning. the nurse learns that the client has decided not to have surgery even though they already signed the informed consent form. which of the following actions should the nurse take?

report the situation to the provider who obtained informed consent

a nurse is reinforcing teaching with a client who has a prescription for nitroglycerin suglinigal tablets. which of the following instructions should the nurse include in the teaching?

take up to three tablets during an anginal episode

a nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. which of the following foods should the nurse reccomend as being high in vitamin c?

tomatoes

a nurse is caring for a client who requests information about advance directives. which of the following responses should the nurse make? -"Advance directives provide education on palliative care issues." "Advance directives require the provider's approval before changes can be implemented." "Advance directives are written instructions regarding end-of-life care." "Advance directives help determine legal competency."

"advance directives are written instructions regarding end of life care' The nurse should inform the client that advance directives allow the client to make decisions and provide written instructions regarding end-of-life care. These directives take effect if the client is unable to make their own health care decisions.

a nurse is collecting data from a client who has a multiple fractures following a motor-vehicle crash. for which of the following client statements should the nurse recommend a referral to an occupational therapist?

"i am so frustrated. i cannot even open my milk carton for breakfast"

a nurse is reinforcing teaching with a client about the clients recent diagnosis of multiple sclerosis. the client states :i am very upset and i want to be alone for a little while" which of the following responses should the nurse make?

"i see that you are feeling overwhelmed. i will come back when you are ready"

a nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I should apply sterile saline to lubricate the suction catheter." "I should wait 30 seconds between each suction pass." "I will repeat the suction procedure for up to 4 suction passes." "I will apply suction for 10 seconds as I insert the catheter."

"i should apply sterile saline to lubricate the suction catheter The nurse should lubricate the suction catheter with sterile saline prior to suctioning.

a nurse is reinforcing teaching with a client who has asthma and a new perscription for an ipratropium inhaler. which of the following statements by the client indicated an understanding of the teaching? -"I should wait 1 minute before taking a second puff of the medication." "This medication might cause me to have nose bleeds." "This medication can cause me to have increased saliva production." "I should use this inhaler as soon as I have trouble breathing."

"i should wait 1 minute before taking a second puff of the medication" The client should wait 1 min between puffs of medication to increase absorption.

a nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. which of the following statements by the parent indicates an understanding of the teaching?

"i will apply diaper cream to my babys skin during each diaper change"

a nurse is reinforcing teaching with a newborns parents about umbillical cord care. which of the following statements by a parent indicate an understanding of the instructions?

"i will give our baby sponge baths until the cord falls off"

a nurse is reinforcing teaching with a client who has acute diverticulitis. which of the following statements by the client indicates an understanding of the instructions? "I will receive the nutrients I need through my IV fluid." "I can eat sunflower seeds when I need a high-protein snack." "I should consume a diet that is high in fiber." "I must eat fresh fruits to increase my vitamin intake."

"i will recieve the nutrients i need through my iV fluid" During initial treatment of acute diverticulitis, the client is often kept NPO and receives parenteral nutrition to promote bowel rest. As the client's condition improves, they can progress to a soft, low-fiber diet. A high-fiber diet is prescribed once the client is fully recovered from the acute inflammation.

a nurse is reinforcing discharge teaching about car safety with guardian of a newborn. which of the following statements by guardian indicates an understanding of the teaching?

"i will secure the car seat in the car by using the seatbelt"

a nurse is reinforcing teaching with a female client who requests information about how to lose weight. which of the following statements should the nurse make?

"keep fat intake to no more than 30 percent of your daily caloric intake"

a nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. which of the following instructions should the nurse include in the teaching?

"perform kegel exercises daily"

a nurse is reinforcing home safety instructions with the parent of a newborn. which of the following statements should the nurse include in the instructions? "Cover your baby with a light blanket at bedtime." "Give your baby a bath once a day." "Keep your baby's umbilical cord stump covered with the diaper." "Place your baby's crib away from heat vents."

"place your babys crib away from the heat vents" The nurse should instruct the parent to position the newborn's crib or playpen away from windows, heat vents, and space heaters. Window blinds and curtains present a risk for strangulation. Heat vents and space heaters can cause the crib linens to catch fire.

a nurse is reinforcing teaching with a client who has TB.which of the following statements by the client indicates an understanding of the teaching?

"the people i live with should be tested for TB"

a nurse is reinforcing teaching with a client who is scheduled for a barium enema. which of the following statements should the nurse make?

"this procedure uses diagnostic imaging to locate an obstruction

a school nurse is having a convo with the parents of an adolescent. the nurse should identify which of the following situations as an ethical dilemma for the parents?

"we cant decide whether to homeschool our child or move them to a private school"

a nurse is reinforcing teaching with a client who has new prescription for prednisone for the treatment of addisons disease. which of the following instructions should the nurse include in the teaching?

"you will need to schedule a bone density test"

a nurse is reinforcing teaching with a group of clients about the heimlich maneuver during a first aid class. the nurse should include in the teaching that which of the following manifestations indicates the need for the heimlich maneuver

-difficulty breathing -coughing -presence of stridor

a nurse is reinforcing discharge teaching with a client who has coronary artery disease CAD and is taking a low dose asprin daily., the nurse should include that this medication has which of the following therapeutic effects?

antiplatelet

a nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. which of the following instructions should the nurse include in the teaching?

avoid foods with a high sugar content

a nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. which of the following actions should the nurse take?

avoid massaging the site after injecting the vaccine

a nurse is preparing to administer digoxin to a client who has heart failure. which of the following findings should indicate to the nurse that the medication has been effective? -Blood volume increases Heart rate increases Cardiac workload decreases Urinary output decreases

cardiac workload decreases Digoxin reduces the effects of heart failure and improves cardiac output by improving the conduction of the heart. This action allows the heart to work less to provide adequate perfusion, reducing the overall oxygen demand on the heart.

a nurse is caring for a clioent following a bronchoscopy. which of the following actions should the nurse take first?

check for gag reflex

a nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. which of the following findings is the nurses priority to report to the provider?

client reports burning on urination

a nurse is collecting data from a school age child who has sustained a skull fracture. which of the following is a manifestation of increased cranial pressure? -Glasgow Coma Scale score of 15 Headache when lying down Confusion about knowing their own name Tympanic temperature of 37.6° C (99.68° F)

confusion about knowing their name Confusion is a sign of a decreased level of consciousness and is an indication of increased intracranial pressure.

a nurse mamanger is preparing to complete a performance analysis for a group of assistve personal AP. the manager asks a staff nurse for feedback on each APs abilities. which of the following actions should the staff nurse take?

discuss how each AP actions measure against the job description

a charge nurse in a long term care facility notices an AP repeated failire to provide oral care for clients. which of the following actions should the charge nurse take?

discuss this behavior with the AP while reinforcing expecations

a nurse is collecting data from a client who has tourette syndrome. the client reports taking haloperidol 0.5 mL orall three times a day at home. which of the following comopnents of the prescription should the nurse question?

dosage

a nurse is preparing to administer purified protein derivative (ppd) to a client who has suspected tb. which of the following actions should the nurse plan to take? Ensure the injection produces a wheal on the skin. Insert the needle at a 45° angle. Inject with the bevel of the needle pointing down. Aspirate the syringe prior to injecting the medication.

ensure the injection produces a wheal on the skin. The nurse should ensure that the injection of the PPD produces a wheal, or bleb, on the skin. This indicates the medication has been injected into the dermis of the skin.

a nurse is working with an interpreter to assist the provider with explaining a diagnostic procedure to client who speaks a different language than the nurse. which of the following actions should the nurse take? Speak in a loud tone to the interpreter. Ensure the interpreter is culturally compatible with the client. Use technical terms when explaining the procedure. Make eye contact with the interpreter when explaining the procedure.

ensure the interpreter is culturally compatible with the client. The nurse should ensure that the interpreter and client speak the same dialect and share similar cultural norms and practices.

a nurse in a providers office is collecting data from a preschooler. which of the following findings should the nurse report to the provider?

heart rate 146/min

a nurse is assisting with the admission of an adolescent who has bulimia nervosa. which of the following manifestations should the nurse expect? -Hematemesis Lanugo Elevated liver enzyme levels Neuropathy

hematemesis The nurse should expect hematemesis, or vomiting blood, in a client who was recently diagnosed with bulimia nervosa. Hematemesis is a result of esophageal tears caused by purging.

a nurse is collecting data from a client who has post traumatic stress disorder PTSD. which of the following manofestations should the nurse expect?

hypervigilance

a nurse is assisting with the admission of a client who has a latex allergy. the nurse should identify that which of the following supplied has the potential to contain latex? -Indwelling urinary catheter Paper tape Nitrile gloves Gauze dressings

indwelling urinary catheter The nurse should identify that most indwelling urinary catheters are made of rubber, which is a form of latex. A rubber indwelling urinary catheter should not be used for a client who has a latex allergy. The nurse should obtain an indwelling urinary catheter made of silicone for a client who has a latex allergy.

a nurse in a long term care facility is assisting with an in service for newly hired AP about legal issues within the facility. which of the following should the nurse include as an example of assault? -Telling another nurse rumors about a client newly admitted to the unit Informing a client that the nurse is going to administer an injection even though the client refuses Telling a clergy member that one of their church members has been admitted to the facility without the client's permission Placing a restraint on a client to keep them in bed before trying alternative measures

informing a client that the nurse is going to administer an injection even though the client refuses. This is an example of assault, which is the threat of unlawful touching of an individual. The nurse should respect the client's right to refuse treatment and not administer an injection against the client's wishes.

a nurse is assisting in the plan of care for a female client who is to undergo a 12 lead ECG. which of the following actions should the nurse include in the plan of care?

instruct the client to remain still while the test is performed

a nurse is contributing to the plan of care for a client who is postop following a rhinoplasty. which of the following interventions should the nurse reccomend?

instruct the patient to avoid the valsalva manuver

a nurse is caring for a client who is 1 day post op and is unable to ambulate. which of the following actions should the nurse take to promote clients venous return?

maintain a sequential compression device

a nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system.. which of the following interventions should the nurse include? Maintain the drainage system below the level of the client's chest. Reposition the client every 4 hr. Report drainage greater than 30 mL/hr to the provider. Clamp the drainage system when transporting the client.

maintain the drainage system below the level of the clients chest The nurse should maintain the drainage system below the level of the client's chest to prevent the backflow of secretions and water from the system into the chest cavity.

a nurse is caring for an infant who is recieving IV fluids for dehydration. which of the following should the nurse recognize as a positive response to the therapy?

moist mucous membranes

a nurse is collecting data from a client who has hypokalemia. which of the following findings should the nurse expect?

muscle weakness

a nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. which of the following interventions should the nurse reccomend?

position the head of the bed at a 30 degree angle

a nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. after drawing up the medication, the nurse accidentially brushes the needle across the counter surface. which of the following actions should the nurse take? -Administer the insulin injection. Wipe the needle with an antiseptic swab. Transfer the insulin to a new syringe. Prepare a new dose of insulin for injection.

prepare a new dose of insulin for injection. Insulin is administered using an insulin syringe with a preattached needle. Therefore, to ensure the sterility of the needle, the nurse should prepare a new dose of insulin for injection using a new syringe and new dose of insulin.

a nurse in a long term care facility is reviewing information about health care associated infections with a newly licesned nurse. which of the following information should the nurse include?

prolonged use of cortiosteroids is a risk factor for infection

a nurse is caring for a client who has expressive aphasia following a stroke. which of the following methods should the nurse use when communicating with the client? -Ask open-ended questions. Speak slowly with a raised voice. Provide a picture board. Limit the use of gestures.

provide a picture board A client who has expressive aphasia has difficulty expressing needs or wants through verbalization or writing. The use of a picture board provides an alternative means of communication that might be less frustrating for the client.

a nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. which of the following instructions should the nurse include?

purchase beef that is a loin cut

a charge nurse is observing a newly licensed nurse apply sterile gloves. which of the following actions by the newly licensed nurse demonstrates sterile technique?

putting a glove on their dominant hand first

a nurse notices an AP taking a nap in the break room during meal time. the nurse notes that the ap is drowsy while performing routine tasks. Which of the following actions should the nurse take? -Keep a record of the AP's behavior over a period of time. -Report the observations about the AP to the unit's nurse manager. -Ask another unit staff member if they have observed the same behavior. -Determine if the AP is having problems at home.

report observations about the ap to the units nurse manager The nurse should report their observations to the unit's nurse manager because they have a duty to report any behavior that poses a risk to client safety.

a nurse on an acute care unit is collecting data from a school age child who has cystic fibrosis. which of the following findings is the priority for the nurse to report to the provider?

reports lack of appetite

a nurse is preparing to administer a clients morning medications. which of the following actions should the nurse take to verify the clients identity?

scan the clients facility identification band

a nurse is reinforcing teaching about home care for conjuctivitis with the parent of a school age child. which of the following info should the nurse incclude? Maintain a warm compress on the affected eye at bedtime. Clean the eye from the outer to the inner canthus. Separate the child's used washcloth from those of others. Instill ointment in the child's affected eye each morning.

separate the childs used washcloth from those of others Due to the contagious nature of the infection, it is necessary to separate the washcloth of a child who has conjunctivitis from those of others to prevent the spread of infection.

a nurse is reinforcing teaching with a client about how to use an incentive spirometer. which of the following The client attempts to elevate the cylinder by inhaling deeply. The client attempts to elevate the cylinder by exhaling forcefully. The client assumes the orthopnea position. The client assumes the low-Fowler's position.

the client attempts to elevate the cylinder by inhaling deeply This is the correct action by the client. The cylinder should be elevated by the client inhaling deeply.

a nurse has administered medications to a group of clients. for which of the following client situations should the nurse complete an incident report? -The nurse administered enalapril to a client who has a blood pressure of 162/90 mm Hg. A client who received morphine for postoperative pain becomes somnolent. The nurse administered insulin lispro to a client who has diabetes mellitus and is NPO. The nurse administered heparin to a client who has an aPTT of 60 seconds.

the nurse administered insulin lispro to a client who has diabetes mellitus and is NPO. Lispro is a rapid-acting insulin given with or just after meals because the onset of action is 15 to 30 min after administration. A client who is NPO will not receive a meal and can have a potentially serious drop in blood glucose levels. Therefore, the nurse should complete an incident report after ensuring the safety of the client and notifying the client's provider.

a nurse is maintaing droplet precautions for a client who has meningitis. which of the following actions should the nurse take?

wear a surgical mask within 3 feet of the client

a nurse at a long term care facility is caring for a client who requires oral suctioning. which of the following supplies should the nurse plan to use for this task?

yankaur catheter

a nurse in a long term care facility is contributing to the plan of care for a client who has a new ostomy. which of the following interventions should the nurse include?

change the appliance two times each week

a nurse is reviewing the clients electronic medical record and find the AP recorded the clients temp 95.5 f 2 hr earlier. which of the following actions should the nurse take first? -Check the client's temperature. Notify the client's provider. Instruct the AP to cover the client with a blanket. Review the procedure with the AP.

check the clients temperature According to the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should retake the client's temperature.

a nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. which of the following medications should the nurse expect the provider to prescribe for the client?

chloridiazepoxide

a nurse is assisting with an in service about hep A for a group of staff nurses. the nurse should include that hep A is transmitted through which of the following methods?

consumption of contaminated food

a nurse is reviewing lab reports for a client who has an e coli infection and is recieving gentamicin. which of the following results should the nurse report to the provider before administering the next dose?

creatinine 2.5 mg/dl

a nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. which of the following findings is the nurses priority?

lack of sleep

a nurse is reinforcing teaching with a client about cancer prevention. the nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer?

lamb

a nurse is positioning a client who is scheduled for a lumbar puncture. the nurse should assist the client into which of the following positions?

lateral recumbant

a nurse is caring for a client who is being discharged home following a cerebrovascular accident. which of the following documents should the nurse plan to include with the discharge report?

list of potentional complications to report

a nurse is preparing to administer medications to a client who is NPO and is recieving enteral feedings thru an NG tube. which of the following precrptions should the nurse clrify with the provider? -Clopidogrel 75 mg per NG tube daily Metoprolol ER 50 mg per NG tube BID Levetiracetam 500 mg oral solution per NG tube BID Lovastatin 20 mg per NG tube daily

metoprolol er 50 mg per NG tube BID The nurse should clarify the prescription for metoprolol ER with the provider because it is an extended-release tablet. The nurse should not crush extended-release medication because parts of the medication dissolve at variable rates and the client can receive an overdose of the medication in a short period of time.

a nurse on a medical surgical unit is delegating tasks to an AP. which of the following tasks should delegate to the AP?

obtaining a clients vital signs prior to discharge

a nurse is recieving report on 4 clients. which of the following clients should the nurse plan to see first?

a client who has pnemonia and a new onset of confusion

a nurse is receiving change of shift report for four clients. which of the following clients should the nurse see first? A client who requests to be moved to a room closer to the nurses' station A client who is postoperative and has received morphine twice during the last 8 hr A client whose urinary output was 100 mL for the past 12 hr A client who insists on speaking with a provider prior to discharge

a client whose urinary outpit was 100 ml for the past 12 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a urine output of less than 30 mL/hr due to the risk for fluid imbalance. Therefore, the nurse should see this client first.

a nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. which of the following information should the nurse include? -Limit carbohydrates early in the day. -Practice relaxation techniques. -Eat a bedtime snack. -Increase daily exercise.

Eat a bedtime snack The symptoms described by the client indicate hypoglycemia. Eating a snack at bedtime will help prevent hypoglycemic episodes during the night.

a nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. which of the following responses should the nurse make? -"Your weight gain should be the same as for someone without diabetes." "Weight gain should be 2 pounds during the first trimester and 2 pounds per week thereafter." "Weight reduction during pregnancy is often necessary for clients who have diabetes." "Your weight gain should average between 10 and 15 pounds."

"your weight gain should be the same as for someone without diabetes" A client who is pregnant and has diabetes mellitus should gain the same amount of weight as a client without diabetes mellitus.

a nurse is preparing a client for surgery. the client states "im sure this surgery will not help me get better" which of the following responses should the nurse make? "You're saying that you are doubtful that this procedure will benefit you." "Do you want to talk to your family before this surgery?" "Having a positive outlook will improve your chances for recovery." "Why do you feel this surgery will not help you to get better?"

"youre saying that you are doubtful that this procedure will benefit you" This response uses reflection as a therapeutic technique. This communication technique lets the client know that their concerns and feelings are heard and understood.

a nurse is reinforcing teaching with a client who is scheduled for a colonscopy. which of the following client statements indicates an understanding of the teaching? -"The colonoscopy examination is limited to the lower part of my colon." "I will undergo bowel cleansing prior to the procedure." "I can eat a low-residue diet up until 8 hours before the colonoscopy." "I will receive a general anesthetic for the procedure."

"i will undergo bowel cleansing prior to the procedure" The client will receive a bowel preparation prior to the procedure and an enema immediately before the procedure to ensure the bowel is free of stool to allow for visualization of the intestinal mucosa. Therefore, this statement indicates that the client understands the teaching.

a nurse is reinforcing teaching with a client about taking warfarin to treat a fib. which of the following statements by the client indicates an understanding of the teaching? "If I need to floss my teeth, I can use wax-coated floss twice a day." "I'll take ibuprofen if I get a headache." "I'll use a safety razor to shave each day." "If I forget to take a dose, I can take it later on the same day."

"if i forget to take a dose, i can take it later on the same day" If the client misses a dose of medication, they can take it later the same day but should not double the dose the next day.

a nurse is collecting data from an older adult client during a routine physical examination. which of the following client statements should the nurse identify as a possible indication of maltreatment?

"my son took my wallet so he can keep track of what i am spending"

a nurse is collecting data from a client who is in severe pain. which of the following questions should the nurse take first? -"How have you managed pain in the past?" "Does anything make your pain worse?" "Where is your pain located?" "Is the pain preventing you from performing any activities?"

"where is your pain located?" When using the urgent vs. nonurgent approach to collect data from a client who is having acute and severe pain, the nurse should first ask the client about location, severity, and quality to identify appropriate nursing interventions for pain relief. The nurse should collect more detailed data about the client's pain experiences after administering pain medication, when the client's pain level is tolerable.

a nurse is reinforcing teaching with a client who is at 20 weeks of gestation and will undergo routine abdominal ultrasonopraghy the following day. which of the following statements should the nurse include in the teaching? -"The doctor will insert a probe into your vagina." "The doctor will have to obtain a sample of amniotic fluid." "You will have a minimal amount of x-ray exposure." "You will need to have a full bladder for the procedure."

"you will need to have a full bladder for the procedure" A full bladder is necessary because it moves the uterus upward for optimal visualization of the fetus and stabilizes the uterus for optimal reflection of sound waves.

a nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. which of the following statements should the nurse make?

"your oncologist might prescribe you a cold cap to wear during treatment to reduce hairloss"

a nurse is talking with a client whose son died in a car crash 2 weeks ago. the client states "i really thoight id be back to my normal routines by now, but i cant think of anything else except that my son is gone" which of the following responses should the nurse make? "Perhaps you should try not to keep thinking about how your son died. Focus instead on your pleasant memories of him." "You should schedule a time with the provider to discuss your relationship with your son." "It might be better to let go of your daily routines and start creating new patterns in your daily life." "Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss."

"greiving for your son is hard work. it will take as much time as you need to come to terms with your loss" The nurse should encourage the client to take all the time they need to grieve. Although there is no specific timeline for working through the various stages of grief, it is common for it to take at least 1 year for people to learn to accept the loss of a loved one.

a nurse in a providers office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixer. which of the following statements by the client should indicate to the nurse an understanding of the teaching?

"i will rinse my mouth after taking this medication."

a nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerant. which of the following statements by the parent indicates an understanding of the teaching?

"I should offer my child yogurt that has a probiotic as a snack"

a nurse is speaking with the partner if a client who has alzheimers disease. the partner states"i love him. but caring for him is wearing me out" which of the following responses should the nurse make?

:lets discuss how caring for your partner is affecting your health"

a nurse is reinforcing teaching with a client regarding prescribed asthma medications. the nurse should instruct the client to use which of the following medications for treatment of an acute asthma attack?

albuterol

a nurse is caring for a client who is in bucks traction. which of the following actions should the nurse take? Allow the weights to hang freely. Inspect the skin every 24 hr. Remove the weights every 24 hr. Assist the client to the bedside commode.

allow the weights to hang freely -The nurse should ensure the weights hang freely to provide the appropriate counterweight to facilitate reduction and alignment of the client's fracture.

a nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. the provider report the clients cervix is dilated to 1 cm with an unengaged presenting part. which of the following actions should the nurse take?

apply the external fetal heart rate monitor

a nurse is reinforcing teaching with a client who has a new prosthesis for an above the knee amputation of the right leg. which of the following instructions should the nurse include? Adjust the prosthesis for comfort if there is an area of tenderness on the residual limb. Sleep with the affected leg elevated so that the hip is flexed. Apply the prosthesis immediately upon waking each day. Apply unscented lotion to the residual limb after bathing.

apply the prosthesis immediately upon walking each day The nurse should reinforce with the client the importance of applying the prosthesis immediately upon waking to prevent swelling of the residual limb.

a nurse is observing an AP apply antiembolic stockings for a client. which of the following actions by the AP demonstrates an understanding of how to perform this skill?

applying the stockings before the client gets out of bed

a nurse is delegating the collection of a sputum specimen to an AP. at which of the following times should the nurse instruct the AP to collect the specimen?

as soon as the client awakens in the morning

a nurse is collecting data from a client who has multple sclerosis. which of the following findings should the nurse expect? -Ptosis Photophobia Ataxia Bradykinesia

ataxia The nurse should expect a client who has multiple sclerosis to manifest ataxia, which is a lack of coordination and movement. Other manifestations include fatigue, impaired memory, diplopia, and bowel and bladder incontinence.

a nurse in a providers office is reinforcing teaching with a client who is post op following cataract removal from one eye. which of the following instructions should the nurse include?

avoid lying on the affected side

a nurse is checking a newborns vital signs. which of the following methods of temp measurment should the nurse use? -Rectal Axillary Temporal Tympanic

axillary The nurse should obtain the newborn's temperature using the axillary method because this method is accurate and safe for newborns. Axillary temperatures are expected to range from 36.5º to 37.5º C (97.7º to 99.5º F) in newborns.

a nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. which of the following foods should the nurse include in the plan as having the highest amount of iron? Cooked cabbage Plain yogurt Cooked white rice Boiled spinach

boiled spinach The nurse should determine that boiled spinach is the best food source to include in the plan because boiled spinach contains 6.43 mg of iron per cup.

a nurse is collecting data from a male client who is scheduled for left inguinal herniorrhaphy. which of the following findings is the priority for the nurse to report to the provider?

decreased bowel sounds

a nurse is reinforcing discharge teaching with a client who has dependent personality disorder. which of the following instructions should the nurse include in the discharge teaching?

demonstrate assertiveness

a nurse is collecting data from a client who is experiencing a situatuional crisis following the loss of a job. the client states "i dont think i can go through this again" which of the following actions is the nurses priority?

determine if the client is experiencing psyhchotic thinking

a home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. which of the following actions should the nurse take first? -Talk to the client about developing a family support system. Assist the client to develop attainable, short-term goals. Reinforce teaching with the client about how to care for a surgical wound. Determine the client's mobility status.

determine the clients mobility status The first action the nurse should take when using the nursing process is to determine the client's mobility status. The nurse should begin collecting data about the client's ability to move freely within their environment while preventing injury. The nurse should begin by placing the client in the position providing the most support, then moving in increments to positions requiring less support and higher levels of tolerance.

a nurse is collecting data from a client who has iron defieciency anemia. which of the following findings should the nurse expect?

difficulty concentrating

a nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. which of the following interventions should the nurse include? Administer diphenhydramine at bedtime. Increase the bedroom's temperature to 26.7º C (80º F). Establish a regular exercise routine 2 hr or more before bedtime. Turn on the television in the bedroom at bedtime.

establish a regular exercise routine 2 hr or more before bed time. The nurse should include in the plan to engage the client in moderate exercise activities during the day but at least 2 hr prior to bedtime to help promote a deep, restful sleep.

a nurse is reinforcing teaching with a client who is bottle feeding their full term newborn with formula. which of the following instructions should the nurse include in the teaching?

feed the newborn at least every 3 to 4 hr

a nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. the nurse should plan to monitor the client for which of the following adverse effects?

gastric ulcer formation

a nurse is performing postmortem care for a client prior to the arrival od the clients family for viewing the body. which of the actions should the nurse take? -Remove the client's dentures and place them in a container. Perform a complete bath for the client. Gently close the client's eyelids. Remove the pillow from under the client's head.

gently close the clients eyelids The nurse should hold the client's eyelids closed for a few seconds to ensure that they remain closed.

a nurse in a long term care facility is observing a newly licensed nurse who is providing trach care for a client. the nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula? -Distilled water Dakin's solution Povidone-iodine 1% Hydrogen peroxide

hydrogen peroxide -The nurse should identify that sterile hydrogen peroxide solution is used to loosen secretions from the inner cannula during cleansing. If the client's skin becomes irritated, the nurse should choose 9% sodium chloride solution.

a nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago and has a 4th degree perineal laceration. which of the following interventions should the nurse reccomend? Instruct the client to apply perineal pads from back to front. Administer a suppository to alleviate constipation. Encourage the client to sit on an inflatable donut cushion. Instruct the client to use a sitz bath at least twice a day.

instruct the client to use a sitz bath atleast twice a day. The nurse should instruct the client to use a sitz bath for at least 20 min twice per day. For the first 24 hr following delivery, the sitz bath should contain cool water to reduce edema and pain. After 24 hr following delivery, the sitz bath should contain warm water to promote circulation and reduce pain.

a nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (turp). which of the following interventions should the nurse include? -Discontinue the urinary catheter 24 hr after surgery. Adjust the bladder irrigation to keep the urine a bright yellow color. Use 50 mL of sterile water to clear the urinary catheter of obstruction. Irrigate the bladder using sterile technique

irrigate the bladder using sterile technique The nurse should irrigate the bladder using strict sterile technique and maintain the closed catheter drainage system to minimize the risk of infection.

a nurse is collecting data from newly admitted infant who is 3 months old and has diarrhea. which of the following findings should the nurse report to the provider?

irritability

a nurse is assisting with the admission of a client who has major depressive disorder. which of the following communication techniques should the nurse use to establish a trusting relationship with the client? -Giving approval Changing the subject Providing personal advice Offering general leads

offering general leads Offering general leads is therapeutic and will enhance positive interaction with the client because it demonstrates to the client that the nurse is listening and is interested in what the client is sharing.

a nurse is preparing to insert an indwelling cath for a female client. which of the following actions should the nurse take? Open the outer package flap of the catheterization kit away from their body. Place the tip of the catheter 1.3 cm (0.5 in) from the outer edge of the sterile field. Remove their nondominant hand from the labia prior to inserting the catheter. Apply the lubricating jelly into the catheter tray before donning sterile gloves.

open the outer package flap of the cath kit away from their body The nurse should open the outer package flap of the catheterization kit away from their body to prevent their arm from crossing over the sterile field when opening the remaining flaps.

a nurse is collecting data from a client from a client who delivered a full term newborn 16 hr ago. the nurse notes excessive lochia discharge. which of the following actions should the nurse take first?

perform a fundal massage for the client.

a nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. which of the following interventions should the nurse include? Place the client in a 30° lateral position. Limit time spent sitting in a chair to 4 hr at a time. Cleanse the client's skin twice daily with soap and hot water. Massage inflamed areas over bony prominences every 2 hr.

place the client in a 30 lateral position. The nurse should place the client in a 30° lateral position to alleviate pressure over bony prominences.

a nurse is reviewing the lab results for a client who is at 29 weeks of gestation. for which of the following results should the nurse notify the provider? -Platelet count 95,000 mm3 BUN 15 mg/dL Hgb 11.3 g/dL WBC count 10,000/mm3

platelet count 95000 The nurse should recognize that this platelet count is below the expected reference range for a client who is pregnant and might be indicative of HELLP syndrome. Other manifestations of HELLP syndrome include malaise and epigastric pain. The nurse should immediately notify the provider of this result.

a nurse is prearing the discharge a client who is immunocompromised. which of the following should the nurse plan to administer?

pneumococcal polysaccharide (PPSV)

a community health nurse is helping to reinforce teaching about hep A with a group of employees at a childcare facility. which of the following characterisitcs should the nurse identify as an external factor that can impede learning for the participants?

poor lighting in the learning setting

a nurse at a long term care facility is transcribing new prescriptions for four clients. which of the following prescriptions is accurately transcribed by the nurse?

potassium chloride 20 mEq PO every morning

a nurse in a pediatric clinic is collecting data from a school age child whose injuries are inconsistent with the parents stated cause. which of the following actions should the nurse take? -Interview the child with the parents in the room. Ask the provider to talk to the child and parents. Make a note in the chart to check the child during the next visit. Report the suspected abuse to the appropriate agency.

report the suspected abuse to the appropriate agency It is the nurse's legal and professional responsibility to immediately report suspected abuse to the proper child protective service agency.

a nurse is observing an AP caring for a client. for which of the following actions by the AP should the nurse intervene?

the AP reports client info to the

a nurse is contributing to an in service for newly licensed nurses about child maltreatment. the nurse should include that which of the following characteristics increases a childs risk of physical maltreatment? The child has 2 parents in the home The child is 13 years old The child has guardians who are unemployed The child was born at 34 weeks of gestation

the child was born at 34 weeks of gestation The nurse should identify that children born prematurely are at an increased risk for physical maltreatment. This increased risk is due to possible impairment of bonding during infancy and an increased need for care due to medical concerns as a result of their premature delivery.

a nurse at a long term care facility is part of a team preparing a report on the quality of care at the facility. which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality? Staff at the facility worked 23% more overtime than in the previous year. The facility increased nurse-to-patient ratio by 1 resident per nurse over the past month. The facility had 12% fewer urinary tract infections over the past 6 months. Central supply ordered twice the number of dressing supplies than the prior year.

the facility had 12% fewer uti over the past 6 months Quality improvement relates to improving outcomes for clients, staff, or the facility. The nurse should document a reduction in urinary tract infections as an improvement in care quality.

a nurse is preparing to administer a rectal suppository to a school age child. which of the following actions should the nurse plan to take? -Use one finger to insert the suppository past the anal sphincters. Place the child in a lithotomy position. Cut the suppository in half crosswise prior to insertion. Don sterile gloves prior to inserting the suppository.

use one finger to insert the suppository past the anal sphincters The nurse should apply clean gloves and use one finger to gently insert the suppository past both anal sphincters to ensure that the child does not expel the suppository after insertion.

a nurse is reinforcing teaching with a client who has undergone vein ligation and stripping to treat varicose veins. which of the following instructions should the nurse include in the teaching? Wrap the lower legs with an elastic bandage at bedtime. Remove the elastic bandages for 15 min daily. Avoid sitting in chairs that recline. Walk for 1 to 2 hr each day.

walk for 1 to 2 hr each day The nurse should instruct the client to walk for at least 1 to 2 hr per day after surgery to promote venous return.

a nurse is caring for a female client who has an indwelling urinary cath. which of the following actions should the nurse take?

wipe the drainage port with an antiseptic wipe after emptying urine from the bag.

a nurse is caring for a client who has an altered mental status and has become aggressive. which of the following prescriptions should the nurse clarify with the provider prior to administration? -Haloperidol Lorazepam Zolpidem Alprazolam

zolpidem Zolpidem is a sedative-hypnotic medication used to treat insomnia. It is not indicated for treatment of confusion and aggressive behavior. Zolpidem can cause agitation and should be used with caution for clients who have a history of mental illness. Therefore, the nurse should clarify this prescription with the provider prior to administration.