Comp
A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective?
"I will use my cell phone on the ear opposite of my pacemaker."
A nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport which of the following should the nurse say?
"Let's talk about what happened to you."
A charge nurse is creating assignments for the next shift for several nurses and one of them is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? A. A 60-year-old client who is recovering from shingles B. A 20-year-old client who is HIV positive C. A 40-year-old client who is suspected of having tuberculosis D. An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo
A
A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? A. Shellfish allergy B. History of smoking C. Cardiac dysrhythmia D. Family history of malignant hyperthermia
A
A client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The client's sibling comes to visit but has obvious manifestations of an upper respiratory infection. Which of the following nursing actions is appropriate at this time? A. Allow the sibling to wave at the client through the window or door. B. Allow the sibling to visit after donning a sterile gown, mask and gloves, but prohibit physical contact
A
A nurse discovers that the wrong dosage was given to a client. When determining what action to take, the nurse should recognize that which of the following ethical principles should be applied? A. Veracity B. Paternalism C. Fidelity D. Utility
A
A nurse from the state health department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the centers for disease control and prevention? A. Lyme disease B. Herpes simplex virus 2 C. Staphylococcus aureus D. Candida albicans
A
A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex? A. Avocados B. Eggs C. Peanuts D. Shellfish
A
A nurse is assessing a client who has non-Hodgkin's lymphoma. Which of the following findings should indicate to the nurse that the clients might be experiencing syndrome of inappropriate antidiuretic hormone? a) diminished deep tendon reflexes b) hyperthermia c) weak, thready pulse d) weight loss
A
A nurse is assessing a client who has pericarditis. Which of the following findings is the priority? A. Paradoxical pulse B. Dependent edema C. Pericardial friction rub D. Substernal chest pain
A
A nurse is assessing a client who has pneumonia. Which of the following findings is priority for the nurse to report to the provider? A. Change in vocal tone after drinking liquids B. Nocturia with episodes of incontinence C. Oral temp of 100.4 F degree D. Weight loss 1.8 kg in a month
A
A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take? A. Monitor for abdominal ascites B. Implement a low-carbohydrate diet. C. Review serum amylase levels D. Place warm compresses on area of pruritus.
A
A nurse is caring for a client who is 2hr postoperative following an Ileal conduit procedures for bladder cancer. For which of the following findings should the nurse notify the provider? A. a dusky-colored stoma B. absence of bowel sounds C. serosanguineous drainage D. urinary output 40ml/hr
A
A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnosis as a contraindication to the administration of methylergonovine? A. Hypertension B. Diabetes mellitus C. Migraine headaches D. Hepatitis B
A
A nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? A. Infuse 0.9% sodium chloride IV. B. Administer an antipyretic. C. Decrease the infusion rate to 75 mL/hr. D. Place the client in a left lateral position
A
A nurse is caring for a client who is taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication? A. Uric acid level B. Serum chloride C. Serum albumin D. Magnesium level
A
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take? A. Use a designated stethoscope when caring for the toddler. B. Wear an N95 respiratory mask while caring for the toddler. C. Place the toddler in a room with negative air pressure. D. Remove the disposable gown after leaving the toddler's room
A
A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? A. Perform chest compressions during cardiac resuscitation. B. Perform a dressing change for a new amputee. C. Assess effectiveness of antiemetic medication. D. Provide discharge instructions
A
A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take? A. Apply the tourniquet 15cm (6 in) above the insertion site B. Check for pulsation at sited proximal to the tourniquet C. Anchor the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site D. Wipe the skin dry before inserting the catheter
A
A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? A. diaphoresis B. polyuria C. abdominal pain D. thirst
A
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? A. Place the newborn 45cm (18in) from the light source B. Clothe the newborn in light cotton. C. Check the newborn's temperature every 8 hr. D. Administer 120 mL (4 oz) of water between feedings
A
A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions should the nurse take? A. Occlude the IV tubing above the injection port. B. Use the injection port farther from the IV catheter insertion site. C. Check for blood return after medication administration. D. Flush the IV tubing with a heparinized solution
A
A nurse is preparing to provide education about electroconvulsive for a client who has major depressive disorder. Which of the following should the nurse include in the teaching? A. A general anesthetic is administered prior to ECT treatment B. ECT treatment are administered once every 6 months C. Oral antidepressants are discontinued after ECT treatment D. Implied consent is required prior to ECT treatment
A
A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? A. "I am thankful there are no serious complications from this type of surgery" B. "I wonder if the metal in my knee will show up in airport screenings" C. "The physical therapy has not been working, so I will need to have the surgery" D. "I look forward to being able to bend my knee again when I sit in a chair"
A
A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching? A. Hospice care improves quality of life through palliative care. B. Hospice care provides 24 hours, in home care. C. Hospice care is intended to postpone death. D. Hospice care encourages the family to coordinate health care services
A
A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? A. "Notify your provider if you experience muscle weakness." B. "Reports a weight gain of one-half pound per day." C. "Expect this medication to increase your blood pressure." D. "You will need to take a diuretic while taking this medication."
A
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? A. Notify the facility operator. B. Close the fire doors on the unit. C. Turn off oxygen sources. D. Put out the fire with the appropriate extinguisher
A
A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain on a scale of 0 to 10 B. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C (101F) C. A 60-year-old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an oxygen saturation of 89% D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void
A
A nurse is caring for a client who has a chest tube and notes continuous bubbling in the water-seal chamber. Which of the following actions should the nurse take? A. Turn down the wall suction B. Observe the system for an air leak C. Obtain a prescription to discontinue the chest tube D. Empty the drainage from the collection chamber
B
A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?
A client who has difficulty swallowing
A nurse is delegating tasks to an assistive personnel. For which of the following clients should the nurse have the AP measure vital signs?
A client who is requesting pain medication 2 days after surgery.
A (APT-M) - Right side of patient's chest
A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to your answer.)
A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included? Select all that apply. A. Newborn swallowing sounds are audible while breastfeeding B. Newborns stools are yellow and seedy after 7 days of breastfeeding C. Maternal breasts become soft following feedings
A, B ,C
A nurse is instructing a group of newly hired nurses about medication to promote fetal lung maturation. Which of the following medications should the nurse include in the instructions?
Betamethasone
A nurse is setting up a sterile field before preforming a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply) A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap B. Open the first flap of the sterile package toward the nurse's body C. Place a surgical pack with a sterile drape on the work surfaceel D. Select a work surface at the nurse's waist level E. Apply sterile gloves before opening the pack
A, C, D
A nurse is administering medications to a client who has dysphagia and a new prescription for divalproex sodium extended-release tablets. Which of the following actions should the nurse take?
Administer the medication with applesauce
A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? A. art therapist B. speech -language pathologist C. social worker D. recreational therapist
C
A nurse is planning care for a newborn who is receiving phototherapy. Which of the following actions should the nurse include the plan of care?
Assess the infant's eyes for corneal irritation Q4h
A client at 38 weeks of gestations enters the emergency department. the nurse should recognize that which of the following indications that the client is in the latent phase of labor? A. Contractions are 2 to 3 min apart. B. The cervix is dilated 2 cm C. The client reports nausea and vomiting. D. The client reports the urge to push
B
A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immuneglobulin. The client is gravid 2, para 2, and her blood type is AB negative. The newborn's blood type is B Positive. Which of the following statements is appropriate? A. "You only need to receive Rh immune globulin if you have a positive blood type. " B. "You should receive Rh immune globulin within 72 hours of delivery." C. "Both you and your baby should receive Rh immune globulin at your week appointment." D. "immune globulin is not necessary since this is your second pregnancy."
B
A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching? A. Place enough formula for 12 hr in the feeding container B. Allow the infant to suck on a pacifier during feedings C. Change the tube feeding setup every 36 hr D. Flush the tube with 30 ml of water between feedings
B
A nurse is assessing a client who is 8 hr postoperative following a right modified radical mastectomy. Which of the following should the nurse recognize as the priority finding? A. Urinary output of 100ml in 4 hr B. Coughing frothy, pink secretions C. Emesis of 110ml of thick yellow fluid D. Red drainage on the dressing
B
A nurse is assessing a client who is postoperative following abdominal surgery. The client states "I feel like my incision ripped open" the nurse notes dehiscence of the incision. which of the following actions should the nurse take? A. Extend the client's legs above heart level B. Place the client in low fowlers position. C. Instruct the client to perform the Valsalva maneuver D. Apply a dry gauze dressing to the incision
B
A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? A. INR 1.1 B. Hyperemesis C. HbA1c 5.6% D. Uncontrolled pain
B
A nurse is caring for a client who has a partial laryngectomy and is receiving continuous internal feeding at 65 ml/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? A. The gastric residual volume is 250 mL following two hours of infusion. B. The client is lying in a supine position. C. The infusion pump for administering continuous feeding is turned off. D. Interior feeding bag and tubing are not dated
B
A nurse is caring for a client who has schizophrenia. the client's states "run cats soon the rain throwing procedure mechanical paper lake." The nurse should document that the client is demonstrating which of the following speech alterations? A. Echolalia B. Word salad C. Neolgisms D. Clang association
B
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings medication toxicity? A. Blood glucose of 150 mg/dL B. Urine output of 20 mL per hour C. Systolic blood pressure at 140 mm Hg D. BUN 20 mg/dL
B
A nurse is caring for a client who is receiving systematic desensitization therapy to treat agoraphobia. Which of the following client statements should indicate to the nurse that the treatment has been effective? A. "I have been able to watch a church service on television without anxiety." B. "I was able to sit on a park bench for 30 minutes." C. "I enjoyed a visit from four of my work friends at my house." D. "I had a panic attack when driving by the grocery store."
B
A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage? A. aPTT 80 secs B. Troponin I 1.8ng/ml C. ESR 17MM/HR D. Human B type
B
A nurse is planning care for a child who is unresponsive and has increased intracranial pressure. Which of the following actions should the nurse take? (similar question but child is responsive and different answer options) A. Schedule routine oral suctioning B. Pad the side rails of the bed C. Obtain isolation supplies D. Place the child in the Trendelenburg position
B
A nurse is planning care for a client who has anew diagnosis of dysphagia. Which of the following foods should the nurse recommend? A. Apple juice B. Oatmeal C. Beef broth D. Toast
B
A nurse is planning care for a client who takes haloperidol for the treatment of schizophrenia. Which of the following should the nurse include in the plan of care? A. Monitor the client for hypothermia B. Screen the client for tardive dyskinesia C. Check the client's weekly potassium level D. Schedule the client for a 24hr urine collection
B
A nurse is planning to delegate a client assignments to an assist personnel. Which of the following tasks is appropriate for the nurses to delegate? A. Adjust the flow rate of the client's oxygen tank B. Collecting urine sample C. Measuring the clients pain level D. Monitoring blood glucose levels
B
A nurse is precepting a nursing student who brings the following client observations to the nurse's attention. Which of the following clients should the nurse assess first? A. A client who is 3hr post Foley catheter removal and has not voided B. A client who is 3days postoperative colectomy with a large, loose melena stool C. A client who is 1-day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago
B
A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? A. Beef liver B. Egg whites C. Steamed claims D. Broiled lobster
B
A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? A. Set up the sterile field 7.6 cm below waist level B. Hold the bottle of sterile solution with the palm over the label while pouring C. Place the sterile items within 1 cm of the edge of the sterile border D. Place the lid of a bottle of sterile solution within the sterile field
B -place the bottle cap face up on a clean (non-sterile) surface
A home health nurse is teaching the parents of a school-age child who has Legg-Calvé-Perthes disease. Which of the following information should the nurse include? A. "Your child will be contagious until the first round of antibiotics is complete." B. "Your child should perform weight-bearing exercises daily" C. "Your child should continue to attend school" D. "Your child will need to increase their daily caloric intake until they gain 5 pounds."
B or C?
A nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate nursing action? A. Administer chlorpromazine with a loop diuretic B. Check orthostatic blood pressure 1 hr after administration C. Administer once daily 30 min before breakfast D. Check weekly calcium levels
B?
A charge nurse overhears two assistive personnel in the unit lobby discussing the HIV status of a client. Which of the following response is the priority for the nurse to make? A. Do you understand HIPAA regulations? B. This discussion is only appropriate in a private area C. Please stop this discussion D. Did you know you can be liable if you breach confidentiality?
C
A nurse in a pediatric unit is caring for a group of clients. For which of the following disease should the nurse implement droplet precautions? A. Varicella-zoster B. Vancomycin-resistant enterococcus C. Pertussis D. Rotavirus
C
A nurse is admitting a client who has antisocial personality disorder. Which of the following client's behaviors should the nurse identify as consistent with this disorder? A. Compulsive attention to details B. Avoids interacting with others C. Uses others for personal gain D. Socially awkward in group situations
C
A nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears agitated and apprehensive. The nurse identifies that the client is in the alarm stage of general adaptation syndrome and should expect which of the following findings? a) pupillary constriction b) hypoglycemia c) tachycardia d) hypotension
C
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider? A. Respiratory rate 14/min B. Blood pressure 150/98 mm Hg C. Magnesium 9 mEq/L (level 1.3-2.1) D. 2+ deep tendon reflexes
C
A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate? A. ABG B. Total cholesterol C. Thyroid hormones D. Hemoglobin
C
A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurse to facilitate in the client's grief process? A. Overcoming feeling of guilt about the NB death B. Dealing with feelings of anger resulting from NB death C. Acknowledging the reality of NB death D. Understanding the reason for NB death
C
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personal requires the nurse to intervene? A. Encourages the client to use the incentive spirometer. B. Elevates the head of the client's bed. C. Offers oral fluids to the client. D. Checks the client's pulse oximetry
C
A nurse is caring for a client who has meningitis. Which of the following assessments should the nurse perform? A. Homans' sign (DVT) B. Trousseau's sign (Hypocalcemia) C. Brudzinski's sign D. Chvostek's sign (hypocalcemia)
C
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? A. Encourage the client to ambulate in the hallway 1 hr before bedtime B. Tell the client to avoid drinking fluids 1 hr before bedtime C. Schedule routine care tasks during hours when the client is awake D. Advise the client to leave the television in the room on when trying to fall asleep
C
A nurse is completing a dietary assessment for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors would the nurse expect to fine? A. Leavened bread maybe eaten during Passover B. Shellfish is commonly consumed in the diet. C. Meat and dairy products are eaten separately. D. Fasting from meat occurs during Hanukkah
C
A nurse is performing a vision screening for a client. Which of the following findings should the nurse identify as an indication that the client has cataracts? A. Report of a chronic dull ache in the eyes B. Bilateral redness of the sclerae C. Increased opacity of the lens of the eye D. Report of seeing halos around lights
C
A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care? A. Assist the client to a supine position. B. Recommend prophylactic acyclovir (Zovirax) for the client's family. C. Initiate droplet precautions for the client. D. Perform a Glasgow Coma Scale every 24 hr
C
A nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of the following actions should the nurse take? A. Maintain the child in a sitting position for 3 min following administration B. Administer the drops directly to the center of the eyeball C. Apply pressure to the lacrimal punctum for 1 min following administration D. Wipe excess medication from the outer canthus toward the nose
C
A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider? A. Constipation B. Blurred vision C. Fever D. Dry Mouth
C
A nurse is providing teaching to the parent of a 6-month-old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include? A. "Rub your child's gums with an aspirin tablet before bedtime." B. "Place an amber teething necklace on your child before bedtime." C. Administer" acetaminophen drops to your child before bedtime." D. "Apply a teething product containing benzocaine to your child's gums before bedtime."
C
A nurse is teaching a client about smoking cessation. Which of the following client statements should the nurse identify as an understanding of the teaching? A. If I stop abruptly I cannot use a nicotine replacement. B. After 6 months, my risk of heart disease is the same as that of a nonsmoker C. I will set a specific date to stop smoking D. I will use high carbohydrate snacks as a substitute for cigarette
C
A nurse received change of shift report on four clients. Based on the shift report information, which of the following clients would the nurse plan to assess first? A. A client who had a barium enema 2 days ago and reports abdominal pain B. A client who has anorexia and peripheral edema C. A client who had a hip arthroplasty reports pain and erythema in their calf D. A client who had Addison's disease and blood glucose level of 75mg/dL
C
A nurse in the PACU is caring for 4 postoperative clients. The nurse realizes that coughing poses a risk to which of the following clients?
Client who had a thyroidectomy
A nurse is caring for a client who is receiving a controlled epidural analgesia infusion. Which of the following nursing actions is appropriate?
Covering the insertion site with a transparent dressing
A nurse has been caring for a female client who has bruises on her arms that are a result of physical abuse by her partner. The client states, "I don't know how much longer I can take this, but I am afraid he'll really hurt me if I leave." Which of the following is an appropriate nursing intervention? A. Assist the client to identity personal behaviors that trigger abusive behavior B. Insist that the client report the abusive behavior to the proper authority C. Offer to speak to the client's partner regarding his abusive behavior D. Help the client to recognize the signs of escalation of abusive behavior
D
A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? A. Insist the client use direct eye contact during the interview. B. Seat the client at least 3.7 m (12 feet) from the nurse. C. Position the client's chair between the nurse's chair and the door. D. Lean in slightly when speaking to the client.
D
A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescent client who was admitted for treatment of anorexia nervosa. Which of the following is an appropriate short-term goal the nurse should set? A. The client will reach an appropriate body weight B. The client will gain 2 to 3 lb weekly C. The client will verbalize a realistic body image D. The client will develop a personalize meal plan
D
A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestations and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? A. Contractions are strong to palpation B. Cervix is dilating at 1 cm every 4 hr C. Consistent contractions last 80 seconds D. Contractions occur every 90 seconds
D
A nurse is caring for a client who is taking alprazolam. Which of the following prescriptions should the nurse clarify with the provider? A. Digoxin B. Lorazepam C. Atomoxetine D. Ceftriaxone
D
A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document? (Similar questions asked about advanced directives) A. It expresses my wishes about distribution of my belongings after death B. It designates a family member to make my health care decisions C. It is required for anyone undergoing surgery D. It communicates my wishes for end-of-life care
D
A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increases in their diet during lactation? A. Vitamin D B. Iron C. Vitamin A D. Calcium
D
A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? A. "Wear an underwire bra between feedings." B. "Cover your breasts immediately after feedings." C. "Apply cold compresses to your breasts before feedings." D. "Try to have your baby empty your breasts with each feeding."
D
An infection control nurse is reviewing the medical records of several clients. Which of the following infections should the nurse report to the centers for disease control and prevention? (Different diseases but same question) A. Candidiasis B. Pelvic inflammatory disease C. MRSA D. Syphilis
D
A nurse is caring for a client who will be receiving a transfusion of platelets. The nurse recognizes that the expected outcome of this treatment will be which of the following?
Decreases in bleeding from puncture sites
A nurse is preparing to discharge a client who is to be transferred to a long-term care facility. The nurse should recognize that which of the following actions is a breach of client confidentiality?
Discussing the client's reaction to the transfer with another staff nurse
A nurse is caring for a school-age child who has a blood pressure of 88/50 mmHg and develops septic shock. Which of the following medications should the nurse expect the provider to prescribe?
Dopamine
A nurse is caring for a client who has a femur fracture and is on bedrest with Buck's extension traction. Which of the following actions should the nurse take?
Inspect the client's skin under the device every 8 hours
A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of the following is appropriate for the nurses to offer as an evening snack?
Low Fat Yogurt
A nurse is caring for a client who is undergoing peritoneal dialysis and notes that the dialysate outflow has become cloudy. Which of the following complications of this procedure should the nurse suspect?
Peritonitis
A nurse is providing nutritional counseling to the parents of a toddler. Which of the following instructions should the nurse include in the teaching?
Offer snacks throughout the day
A nurse is caring for a client who has fractures ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time of 100 seconds. Which of the following actions should the nurse take first?
Turn off heparin drip
A nurse is caring for a client who is receiving radiation therapy through a sealed implant. Which of the following actions should the nurse take?
Wear a lead apron when providing care for the client Donot let family stay more than 30minutes
A nurse is teaching a client who has a low-literacy level about home management of diabetes mellitus. Which of the following actions is appropriate?
Show the client an educational video.
A nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1hr ago. Which of the following is an appropriate intervention?
Support the affected leg on a pillow/elevate the extremity
A nurse is preparing to administer an enteral feeding via NG tube for a client the day after verifying placement of the tube using a chest x-ray. Which of the following methods should the nurse use to confirm placement prior to initiating the feeding?
Test the pH level of the clients gastric aspirate
A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?
The tubing may be kinked.
