comprehensive 2023 A

A nurse is caring for a client who is in the fourth stage of Labor and is receiving oxytocin via continuous IV infusion. Which of the following assessment is a nurse's priority? Amount of vaginal bleeding Amount of urinary output Pain level Fundal height

Amount of vaginal bleeding The first action the nurse should take using the nursing process is to assess the amount of vaginal bleeding. A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vaginal bleeding is the nurse's priority.

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

Enter the plasma product number into the client's medical record. The nurse should complete documentation following blood product therapy, which includes recording the type of product, amount administered, product number, infusion time, and client response. The nurse should plan to administer each unit of plasma over 30 to 60 min. The nurse should slow the rate of infusion if the client shows indications of fluid overload. The nurse should transfuse the plasma immediately after obtaining it from the blood bank to maintain integrity of the clotting factors.

An RN is planning care for a group of clients and is working with a licensed practical nurse and an AP. Which of the following attached the RN delegate to the LPN? Collection of a stool specimen. Preparation of a client's postoperative bed. Preparation of a teaching plan about pneumonia. Insertion of a nasogastric tube.

Insertion of a nasogastric tube. The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the LPN's scope of practice.

A nurse is providing client teaching about the basal body temperature method of birth control period which of the following information should the nurse include in the teaching? "Your body temperature will drop approximately 1° one week after ovulation." "You should take your body temperature each evening prior to going to sleep." "Your body temperature might decrease slightly just prior to ovulation." "Your body temperature is at its highest during menstruation."

"Your body temperature might decrease slightly just prior to ovulation." The nurse should teach the client that a decrease in body temperature of approximately 0.5° C (1° F) commonly occurs immediately prior to ovulation. Body temperature rises about 0.4° to 0.8° C (0. 7° to 1.4° F) after ovulation. The temperature remains elevated until 2 to 4 days prior to the start of menstruation. The client should measure their body temperature upon waking each morning prior to getting out of bed. Body temperature rises 1 to 2 days after ovulation and remains elevated until 2 to 4 days prior to the onset of menstruation.

A nurse on a pediatric unit has received change of shift report for a four children. What do the following children should their nurse assess first? A 6-month-old infant who has croup and an O2 saturation of 92% on room air. A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication. A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain.

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain. Using the urgent vs. nonurgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. The nurse should notify the provider immediately. An O2 saturation of 92% on room air is an expected finding for a child who has croup. Therefore, the nurse should assess another client first. A request for pain medication is an expected finding for a client following an open reduction and internal fixation. Therefore, the nurse should assess another client first. Two loose bowel movements over the past 24 hr is an expected finding for a child who has gastroenteritis. Therefore, the nurse should assess another client first.

A nurse is caring for a client in the emergency department (ED). Nurses' Notes 0600: Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke this morning on the living room floor trembling and flushed; remembers having intense dreams and was afraid they had a seizure so they called a family member to bring them to the ED.Client reports their average alcohol intake has been "two or three beers" after work each day and "more on the weekends" for the past 6 months.Client reports headache, nausea, agitation, and is noted to be diaphoretic.0800: Client states "I've got bugs crawling on me. Get them off me!" Client tremulous and diaphoretic. The nurse is planning care for the client. Select the 5 actions the nurse should plan to take. Administer thiamine. Perform a Cli

Administer thiamine. Perform a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Administer chlordiazepoxide. Maintain a low-stimulation environment. Initiate seizure precautions. When generating solutions and planning care for a client who is experiencing alcohol withdrawal, the nurse should plan interventions that keep the client safe and treat the physical manifestations of alcohol withdrawal. The nurse should use the CIWA-Ar screening tool to determine the severity of withdrawal. Withdrawal seizures can occur 12 to 24 hr after cessation of alcohol use; therefore, the nurse should initiate seizure precautions to prevent client injury. The nurse should plan to administer chlordiazepoxide, a benzodiazepine, to decrease agitation, hallucinations, and tremors. The nurse should place the client in a quiet environment with minimal stimuli to decrease agitation and the risk for seizures. The nurse should administer thiamine to prevent Wernicke syndrome.

A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition? A client who is pregnant and has cytomegalovirus (CMV). An adolescent client who has foodborne botulism. A child who has erythema infectiosum. A young adult client who has herpes simplex virus type 1 (HSV-1).

An adolescent client who has foodborne botulism. The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Clients who ingest the botulism toxin can develop dysphasia, drooping 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 on a mental health unit is caring for a client. Nurses' Notes Day 1, 1300: Client admitted following a suicide attempt. Client's family reports client has not left bedroom in 1 week. Client previously diagnosed with bipolar disorder.Client reports feeling excessively tired and light-headed.Allergies: Client's family reports allergy to SSRIs (angioedema) and penicillin (anaphylaxis).1600: Client has been sleeping in their room since admission. Flat affect noted. Laboratory Results: Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 11 mg/dl (10 to 20 mg/dL) Magnesium 1.3 mEq/L (1.3 to 2.1 mEq/L) Total calcium 10.1 mg/dL (9.0 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3.0 to 4.5 mg/dL) Glucose 75 mg/dL (74 to 106 mg/dL) For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the cl

Anticipated -- Initiate suicide precautions, Potassium 40 mEq PO daily. Contraindicated -- Fluoxetine 20 mg PO daily, Low-sodium diet. When generating solutions for a client who has bipolar disorder, the nurse should anticipate prescriptions for potassium and suicide precautions. The client has hypokalemia which is treated with a potassium supplement. The client has a recent suicide attempt and is exhibiting manifestations of depression. Therefore, the nurse should anticipate that the client will be placed on suicide precautions, which include continuous monitoring. The nurse should identify that a low-sodium diet and fluoxetine are contraindicated for this client. A low-sodium diet increases their risk for lithium toxicity. The client has a history of severe allergic reaction to SSRIs, so fluoxetine should not be administered.

A nurse is assessing for correct placement of the clients an NG feeding tube prior to administering a bolus feeding. which of the following actions should the nurse take? Insert air in the tube and listen for gurgling sounds in the epigastric area. Aspirate contents from the tube and verify the pH level. Review the medical record for previous x-ray verification of placement. Auscultate the lungs for adventitious breath sounds.

Aspirate contents from the tube and verify the pH level. The nurse should verify that the pH level of the client's gastric aspirate is less than 5 to determine proper placement of a client's NG feeding tube prior to administering a bolus feeding. This method is unreliable because the nurse can still hear a gurgling sound if the tube is in the lung or the esophagus. Absence of adventitious breath sounds does not validate correct placement of the NG tube.

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

Assess the client for functional limitations. When using the nursing process, the first action the nurse should take is to assess the client's functional limitations to determine how much the client can assist with the transfer.

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

Clear objects from the client's walking area. The nurse should plan to clear objects from the client's walking area because CN II is the optic nerve and a deficit can result in visual impairment, which can lead to falls. The nurse should plan to ask clients to restate directions if they have a CN VIII deficit because CN VIII affects hearing. The nurse should plan to evaluate the swallowing ability of clients who have a CN IX deficit because it can impair swallowing.

A nurse is caring for a client who has a new prescription for Clonidine. The nurse should inform the client that which the following findings is an adverse effect of this medication? Diarrhea Dry mouth Photophobia Bruising

Dry mouth Clonidine is an indirect-acting antiadrenergic agent used for hypertension, severe pain, and attention deficit disorder. The nurse should inform the client that dry mouth, or xerostomia, is a common adverse effect of clonidine. constipation common AE. medication can dry eyes. Transdermal clonidine patches can cause localized skin reactions.

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

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

A home health care nurse is developing and teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include? Limit intake of fluids to 1,000 mL daily. Take a laxative if no stool has passed after 12 hr. Empty the appliance when it is one-third to one-half full. Change the entire pouch system every 1 to 2 days.

Empty the appliance when it is one-third to one-half full. The ileostomy pouch should be emptied when it is one-third to one-half full to prevent stool leakage and skin irritation. Fluid volume deficit is common in clients who have an ileostomy due to liquid stools. A fluid intake of at least 1,920 mL is recommended daily. If no stool has passed after 6 to 12 hr, then the client should contact their provider. The appliance should be changed every 3 to 7 days to prevent skin irritation around the stoma.

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

Gather more information about the staff nurse's actions. The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action.

A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provided? Hypotension Headaches Bruising Oliguria

Headaches The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. The nurse should instruct the client to monitor for and report hypertension. The nurse should instruct the client to monitor for swelling and tenderness of an extremity or fluid retention. Bruising is not an adverse effect of this medication. The nurse should instruct the client to monitor for the development of genitourinary candidiasis. Oliguria is not an adverse effect of this medication.

A nurse's associate client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso occlusive crisis? Diminished reflexes Hematuria Hyperglycemia Hearing loss

Hematuria The nurse should identify hematuria as a manifestation of vaso-occlusive sickle cell crisis resulting from ischemia of the kidneys. Painful swelling of the hands and feet, rather than diminished reflexes, is a manifestation of vaso-occlusive sickle cell crisis. Visual disturbances, rather than hearing loss, are manifestations of vaso-occlusive sickle cell crisis.

A nurse is assessing a client who is scheduled for surgery. Vital Signs 0630:Temperature 36.9° C (98.4° F)Heart rate 74/minRespiratory rate 20/minBlood pressure 122/76 mm HgOxygen saturation 96% on room air0730:Temperature 36.9° C (98.4° F)Heart rate 76/minRespiratory rate 20/minBlood pressure 128/78 mm HgOxygen saturation 95% on room air. 0630:Client reports restlessness and inability to sleep more than 3 to 4 hr per night for the last week.Client reports pain in the right upper quadrant as 2 on a 0 to 10 pain scale, constant for 2 weeks and increases after meals. Oxygen saturation Creatinine level Hemoglobin level Allergies Family history Insomnia Pain level

Hemoglobin level Allergies Family history When obtaining the preoperative assessment and analyzing cues, the nurse should determine that the provider should be notified about the client's hemoglobin level, latex allergy, and family history of malignant hyperthermia. When the client's hemoglobin level is below the expected reference range, the client might require blood products during the intraoperative phase. The client's allergy to avocados and bananas can indicate an allergy to latex products and should be reported to the provider. The surgical team will need to remove all latex products from the operating room. During the intraoperative phase, the nurses must be diligent in monitoring the client's vital signs and laboratory values, especially in a client who has a family history of malignant hyperthermia.

A nurse in an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? Implement fall precautions for the client. Monitor the client's thyroid function. Place the client on a fluid restriction. Discontinue the medication if hallucinations occur.

Implement fall precautions for the client. Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore, the nurse should initiate fall precautions for the client. Risperidone does not affect thyroid function. The nurse should monitor the client's CBC for anemia, thrombocytopenia, leukocytosis, and leukopenia, as well as the client's liver function for elevated AST or ALT levels. Risperidone can cause constipation, diarrhea, or dry mouth. Therefore, the nurse should encourage increased intake of fluids. Hallucinations are an expected manifestation of schizophrenia. Risperidone is an antipsychotic medication used to treat manifestations of schizophrenia, including positive symptoms such as hallucinations. Therefore, the nurse should not discontinue the medication.

A nurse is planning care for a client who has RA. Which of the following interventions with the nurse include in the plan? Encourage the client to take a cool sponge bath each morning. Administer opioid analgesia. Increase the client's dietary iron intake. Restrict the client's intake of foods high in purines.

Increase the client's dietary iron intake. Clients who have rheumatoid arthritis require foods high in protein, vitamins, and iron to promote tissue repair. The nurse should encourage the client to increase their intake of dietary iron. Encouraged to take hot showers to help relieve morning stiffness rather than sponge baths or tub baths. NSAIDs Rather than opioid analgesic medication used to relieve the pain and inflammation of RA. Patients who have gout should avoid foods high in purines.

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

Initiate oral rehydration therapy for the toddler. Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed. 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, inadequate amounts of protein and electrolytes, and is high in simple carbohydrates. It is contraindicated for a child who has acute diarrhea. The nurse should identify that chicken and beef broths contain excessive amounts of sodium and very few carbohydrates.

Abdominal assessment.

Inspection, auscultation, percussion, palpitation

A nurse is assessing infant who has hydrocephalus and is 6 hour postoperative following placement of a ventriculoperitoneal shunt. Which of the following findings should the nurse report to the provider? Heart rate 122/min Irritability when being held Hypoactive bowel sounds Urine specific gravity 1.018

Irritability when being held The nurse should recognize that irritability is a manifestation of increased intracranial pressure, which is an indication that the VP shunt is malfunctioning. This finding should be reported to the provider immediately. A heart rate of 122/min is within the expected reference range for an infant. Hypoactive bowel sounds is an expected finding 6 hr postoperative following the insertion of a VP shunt. A urine specific gravity of 1.018 is within the expected reference range for an infant.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as a priority? Organizing the work environment. Delegating assigned tasks appropriately. Making a list of activities to complete. Rewarding oneself for accomplishing goals.

Making a list of activities to complete. According to evidence-based practice, planning is the most important step in managing time effectively. Therefore, the nurse manager should include making a list of activities to complete as the priority. Other planning activities include setting goals, establishing priorities, and scheduling activities.

a nurse is caring for a client who has a closed head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce ICP? Propranolol Phenytoin Lorazepam Mannitol

Mannitol The client should receive mannitol, an osmotic diuretic, to reduce intracranial pressure caused by cerebral edema. lorazepam, a short-acting sedative, to manage discomfort and agitation. phenytoin, an antiepileptic, to prevent seizures. propranolol, a beta blocker, to decrease blood pressure.

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

Massage the uterus to expel clots. Using the evidence-based practice approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding.

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

Move the client to a quiet place away from others. The client's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other clients by moving the client to a quiet place away from others.

A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following action takes place first when implementing an emergency preparedness plan? Contact the triage officer. Implement the client tracking system. Ask the communications officer to release a press statement. Notify the incident commander.

Notify the incident commander. The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order.

A nurse is caring for a client who has hearing loss period which of the following actions should the nurse take to improve communication? Reduce environmental stimuli. Provide written material at an 8th grade reading level. Provide interpretation services over the telephone. Use exaggerated lip movements when speaking.

Reduce environmental stimuli. When caring for a client who has hearing loss the nurse should reduce background noise to improve communication. Excessive stimuli in the environment can increase sensory alterations. The nurse should provide written materials that are a 5th grade reading level or lower to the client, to ensure information is presented clearly. The nurse should provide face-to-face interpretation services for a client who has hearing loss. Clients who have hearing loss may have difficulty understanding interpretation services that are provided via telephone. Should not use exaggerated lip movements when communicating with a client with hearing loss.

A nurse is providing teaching to a client who is scheduled for ECT. The nurse should inform the client that which of the following findings is an adverse effect of ECT? Agitation. Short-term memory loss. Post-treatment seizures. Incontinence of the bowel and bladder.

Short-term memory loss The nurse should inform the client that short-term memory loss is a common adverse effect of ECT.

A nurse is reviewing the lab report of a client who has end stage kidney disease and received hemodialysis 24 hours ago. Which of the following lab values should the nurse report to the provider? Platelets 268,000/mm³ (150,000 to 400,000/mm³) Calcium 9.2 mg/dL (9 to 10.5 mg/dL) WBC count 5,200/mm³ (5,000 to 10,000/mm³) Sodium 148 mEq/L (136 to 145 mEq/L)

Sodium 148 mEq/L (136 to 145 mEq/L) The nurse should report this sodium level because it is above the expected reference range of 136 to 145 mEq/L, indicating hypernatremia. Clients who have kidney disease often retain sodium and require sodium-restricted diets.

A nurse in an outpatient mental health facility is assessing a child who has autism. Which of the following manifestation should the nurse expect? Strict adherence to routines. Difficulty paying attention to tasks. Disobedience to authority figures. Excessive anxiety when separated from parents.

Strict adherence to routines. The nurse should identify that a child who has autism spectrum disorder can exhibit strict adherence to routines or rituals, a fixation to specific objects, and resistance to change. A child who exhibits difficulty paying attention to tasks might have attention-deficit hyperactivity disorder. A child who exhibits disobedience to authority figures might have oppositional defiant disorder. A child who exhibits excessive anxiety when separated from parents might have separation anxiety disorder.

A nurse is assessing A preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hour period which of the following findings should the nurse identify as an indication that the client has developed oxygen toxicity? Wheezes Tachycardia Restlessness Substernal pain

Substernal pain. The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased work of breathing, such as in a preschooler who has cystic fibrosis. Restlessness indicates the client has hypoxemia, is working hard to obtain oxygen, and requires oxygen therapy. Tachycardia indicates the client has hypoxemia, is working hard to obtain oxygen, and requires oxygen therapy. Clients who develop oxygen toxicity are more likely to have crackles and substernal chest pain than wheezes.

A nurse is creating a plan of care for a client who has left sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Massage bony prominences on the client's left side. Support the client's left arm on a pillow while sitting. Position the bedside table on the client's left side. Place the client's cane on their left side while ambulating.

Support the client's left arm on a pillow while sitting. The nurse should support the client's affected arm to prevent the extremity from hanging freely because this can cause shoulder subluxation.

A charge nurse overhears 2 staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? Apologize to the client for the nurses' actions. Advise the nurses that they are being insubordinate. Tell the nurses to stop the discussion. Document the incident in the client's medical record.

Tell the nurses to stop the discussion. The nurses are violating client confidentiality by having the discussion in a public hallway. The charge nurse should tell the nurses to stop the discussion to prevent any further breach of confidentiality. The nurses are not committing insubordination because insubordination occurs when an employee disobeys a person in authority such as a manager or supervisor.

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

Tells the hospital chaplain a client's diagnosis. Discussing a client's diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPAA. The nurse has a legal responsibility to report chlamydia, syphilis, gonorrhea, chancroid, and HIV/AIDS to the local health department.

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. Nurses' Notes Client arrived today for follow up. Client reports worsening gastrointestinal symptoms. Client was last seen 2 months ago and reported abdominal pain and bloating. Today, the client reports worsening abdominal pain in the right lower quadrant and abdominal bloating. Client reports frequent soft to loose stools today and denies tarry stools. Client also states that they have been experiencing a loss of appetite and some weight loss. For each assessment finding, click to specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis. Each finding may support more than one disease process.

Temperature is consistent with Crohn's disease, ulcerative colitis, and peritonitis. The client's temperature is elevated. This can occur with all three of the above disease processes due to inflammation and infection. Weight is consistent with Crohn's disease and ulcerative colitis. The client has lost weight since their initial appointment 2 months ago. Unintended weight loss can occur with Crohn's disease and ulcerative colitis due to malabsorption in the gastrointestinal tract. Bowel pattern is consistent with Crohn's disease. The client reports frequent soft, loose stools without the presence of blood. This is most consistent with Crohn's disease. Clients who has ulcerative colitis often have liquid, bloody stools. WBC is consistent with Crohn's disease, ulcerative colitis, and peritonitis. The client's WBC is elevated, which can occur with all three of the above disease processes because of inflammation and infection. Heart rate is consistent with peritonitis. The client's heart rate is elevated, which may occur with peritonitis due to inflammation, infection, and dehydration. Albumin level is consistent with Crohn's disease and ulcerative colitis. The client has a decreased albumin level. Unintended weight loss can occur with Crohn's disease and ulcerative colitis due to malabsorption in the gastrointestinal tract. Abdominal pain location is consistent with Crohn's disease. The client reports abdominal pain in the right lower quadrant, which occurs with Crohn's disease. Clients experiencing peritonitis often experience generalized abdominal pain that can radiate to the shoulder and back.

Then RN is observing a LPN and a AP move a client up in bed. For which of the following situations should the nurse intervene? The LPN and AP lower the side rails before lifting the client up in bed. Prior to lifting the client, the LPN and AP raise the bed to waist level. The LPN and the AP grasp the client under their arms to lift him up in bed. The LPN and the AP ask the client to flex their knees and push their heels into the bed as they lift.

The LPN and the AP grasp the client under their arms to lift him up in bed. The LPN and AP should not grasp the client under the arms when lifting, as this can result in shoulder dislocation or other injury to the client. Therefore, the RN should intervene and instruct the nurses to use a draw sheet or friction-reducing device to lift the client. The client can assist with the move by flexing the knees and pushing the heels into the bed when the LPN and the AP are lifting.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? Maintain a flexible daily schedule for the child. Use a reward system to modify the child's behavior. Provide a variety of family members to care for the child. Administer alprazolam as needed to reduce the child's anxiety.

Use a reward system to modify the child's behavior. Children who have autism spectrum disorder respond well to a reward system, which can provide structure and expectations for behavior. Children who have autism spectrum disorder respond better to a familiar daily schedule that includes a minimal amount of change. Children who have autism spectrum disorder respond better by developing trust with one person and can have difficulty communicating with a variety of caregivers. Administer alprazolam as needed to reduce the child's anxiety. MY ANSWER Children who have autism spectrum disorder might be prescribed SSRIs, rather than benzodiazepines, to improve mood and reduce anxiety.

A nurse's teaching a group of guardians about child safety measures. Which of the following statements by guardian indicates understanding of the teaching? "I will make sure my 4-year-old child wears a helmet when using a skateboard." "I should have my child avoid sun exposure between 10 am and 2 pm." "I can give my 2-year-old child a whole hotdog on a bun." "When my infant is in the carrier, I will place it on a raised, flat surface whenever possible."

"I should have my child avoid sun exposure between 10 am and 2 pm." To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400. Guardians should prevent children who are younger than 5 years old from skateboarding because they are not able to adequately protect themselves from skateboard-related injuries. The guardians should cut a hotdog lengthwise for toddlers to prevent choking. Guardians should avoid placing carriers on raised surfaces to reduce the risk for falls.

A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I will decrease my intake of high-fiber foods." "I will apply hydrocortisone cream if I develop a rash on my face." "I will sleep flat on my back if I develop back pain." "I will wear a supportive bra overnight."

"I will wear a supportive bra overnight." The nurse should teach the client that wearing a supportive bra even while sleeping can promote comfort by providing support to enlarged breasts during pregnancy. The nurse should teach the client to relieve back pain with moderate exercise, sleeping on a firm mattress, and wearing low-heeled shoes. The nurse should also teach the client to sleep on their side to promote placental perfusion. "I will apply hydrocortisone cream if I develop a rash on my face." The nurse should teach the client that hormonal changes during pregnancy can result in increased pigmentation of the face, but hydrocortisone cream will not resolve hyperpigmentation. The nurse should teach the client to increase, rather than decrease, their intake of high-fiber foods to prevent constipation.

A nurse is caring for a client who has end stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make? "Your mother might still know you are here." "Why do you feel that way?" "It seems like you feel your visits are a waste of time." "Are you sure you would not want to see your mother again?"

"It seems like you feel your visits are a waste of time." The nurse is using a clarifying technique that facilitates the nurse's understanding of the adult child's feelings.

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

"Secure the retainer clip at the level of your baby's armpits." The nurse should instruct the parent to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cage and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs. newborn's car seat at a 45° angle. Newborns' heads are large in proportion to their body, and they do not have the muscle strength to hold their heads upright. remain rear-facing in the back seat of the vehicle until the age of 2 or until reaching the age and weight the car seat manufacturer recommends. The nurse should instruct the parent to place a blanket over the newborn, once secure in the car seat. Blankets, coats, or heavy clothing can make it difficult to secure the shoulder harnesses tightly, leading to injury in the event of a collision.

A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make? "I understand this is a difficult decision." "Tell me more about your understanding of the options." "You will make the right choice." "I will ask your provider to talk with you further."

"Tell me more about your understanding of the options." This response by the nurse is therapeutic because it is offering a general lead that facilitates communication between the nurse and the client and will help the nurse to explore the client's feelings about the treatment options.

A nurse's assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? "It's natural for you to feel this way now, but things will get better with time." "You seem to be having a difficult time right now." "Why do you feel like your life isn't worth living?" "You'd be surprised how many people experience these feelings."

"You seem to be having a difficult time right now." This statement makes an observation, which is a therapeutic response by the nurse. It encourages the client to express their thoughts and feelings.

A nurse is reviewing the laboratory results of a toddler who has hemophilia a period which of the following aPPT (30 to 40 seconds) values should the nurse expect? 11 seconds 22 seconds 30 seconds 45 seconds

45 seconds This value is above the expected reference range of 30 to 40 seconds and indicates a risk for spontaneous bleeding, which is a manifestation of hemophilia A. <30 = risk for developing blood clot

A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following client is effectively using sublimation as a defense mechanism? A client who transfers their anger about their job onto their family and then apologizes. A client who misses provider appointments because they say they are too busy. A client who channels their energy into a new hobby following the loss of their job. A client whose partner died 4 years ago sets a place for them at dinner each night.

A client who channels their energy into a new hobby following the loss of their job. The nurse should identify that this client is using the defense mechanism of sublimation by channeling negative feelings over the loss of their job into a new hobby. The nurse should identify that a client transferring the anger that they feel about their job to a less threatening source, their family, is using the defense mechanism of displacement. The nurse should identify that a client who justifies not keeping appointments with their provider by saying they are too busy is using the defense mechanism of rationalization. The nurse should identify that a client who is avoiding feelings of loss from the death of a partner is using the defense mechanism of denial.

A nurse in the Community Center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? Diarrhea Urinary retention Purulent discharge Abdominal bloating

Abdominal bloating The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. Constipation, urinary urgency and frequency are manifestations of ovarian cancer. Presence of purulent vaginal discharge are manifestations of STI's.

A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factors should the nurse recognize as being the greatest barrier to the client's ability to be compliant? A detailed plan of care. Absence of symptoms. Dietary salt restriction. Addition of a new medication.

Absence of symptoms A client without symptoms might not understand the need for treatment, which would indicate the greatest barrier for adherence. A plan of care that is too detailed can be confusing for the client, but this does not indicate the greatest barrier for adherence. The need for dietary salt restriction does not indicate the greatest barrier for adherence. Adding a new medication does not indicate the greatest barrier for adherence.

A rural community health nurse is developing a plan to improve health care delivery for migrant farm workers period to identify health services data for this minority group, the nurse should gather information from which of the following sources? Agency for Healthcare Research and Quality. National Institutes of Health. Department of Agriculture. World Health Organization.

Agency for Healthcare Research and Quality The nurse should gather data from the Agency for Healthcare Research and Quality (AHRQ) regarding health care services for migrant farmworkers. The goal of AHRQ is to improve the quality of health care services for all populations, including low-income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations. The National Institutes of Health focuses on biomedical research to improve the prevention, diagnosis, and treatment of specific diseases. Department of Agriculture focuses on the availability of food and nutrition services for U.S. citizens. orld Health Organization focuses on improving the health of the world's global population by developing initiatives and conducting research that benefit all countries.

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following action should the nurse plan to take? Perform ADLs for the client to promote rest. Allow for frequent rest periods throughout the day. Use heat to reduce joint inflammation. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain.

Allow for frequent rest periods throughout the day. The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion. The nurse should use ice to reduce joint inflammation and heat to alleviate joint discomfort. The nurse should not administer more than 3 g of acetaminophen to the client each day to reduce the risk of injury to the client.

A charge nurse assigns A newly licensed nurse to care for a client who has a chest tube. The nurse expresses concerns about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? Refer the nurse to the procedure manual. Use a diagram to explain the procedure to the nurse. Demonstrate the procedure to the nurse. Ask the nurse about their knowledge of the procedure.

Ask the nurse about their knowledge of the procedure. The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs.

A nurse is caring for a newborn whose parents asked why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? Bleeding Potassium deficiency Infection Hyperbilirubinemia

Bleeding The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding.

A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions should the nurse implement? Airborne Droplet Contact Protective environment

Contact The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA.

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 decelerations on the monitor tracing. Which of the following actions should the nurse take? Continue observing the fetal heart rate. Assist the client to a knee-chest position. Prepare the client for continuous internal monitoring. Prepare for an emergency cesarean birth.

Continue observing the fetal heart rate. Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing. The nurse should assist the client into a knee-chest position if the umbilical cord prolapses. There is no indication for the client to have internal monitoring. The nurse should prepare for an emergency cesarean birth if the monitor indicates late or variable decelerations despite interventions.

24. A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? Increased intraocular pressure Floating dark spots Decreased central vision Double vision

Decreased central vision The nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina. Double vision is a manifestation of cataracts. Floating dark spots are a manifestation of retinal detachment. An increase in intraocular pressure is a manifestation of glaucoma.

A nurse is caring for a client who has a potassium level of 3 (3.5-5). For which of the following manifestations should the nurse monitor? Increased bowel sounds. Dry, sticky mucous membranes. Decreased deep tendon reflexes. Numbness and tingling of the extremities.

Decreased deep tendon reflexes A client who has hypokalemia can have muscle weakness and decreased deep tendon reflexes. A client who has hypokalemia is likely to have hypoactive bowel sounds due to decreased gastrointestinal mobility. hyponatremia - dry, sticky mucous membranes. A client who has hypocalcemia is likely to have numbness and tingling of the extremities and around the mouth.

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication of the medication is effective? Decreased blood pressure Decreased hallucinations Decreased cholesterol Decreased esophageal reflux

Decreased hallucinations The nurse should recognize that chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia. ortho hypo - adverse effect of chlor.

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? Popcorn Diced steamed carrots Whole celery sticks Marshmallows

Diced steamed carrots Diced steamed carrots are a safe food choice for toddlers because they are soft and do not present a choking hazard.

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

Fever unresponsive to antipyretics. The nurse should expect a child who has acute Kawasaki disease to have a high fever that is unresponsive to antibiotics or antipyretics. The nurse should expect the child to report pain in the weight-bearing joints during the subacute phase of Kawasaki disease. Expect tachycardia during the acute phase of Kawasaki disease. Expect peeling of the palms of the hands and soles of the child's feet during the subacute phase of Kawasaki disease.

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? Calories Protein Potassium Fiber

Fiber The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation.

A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/minutes and a BP of 90 / 44. Which of the following medications should the nurse anticipate in administering? Naloxone Flumazenil Acetylcysteine Atropine

Flumazenil The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to support the client's respirations with a bag-valve mask. atropine -> neostigmine (cholinesterase inhibitor OD)

A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify which of the following physiological changes is the cause for the client's visual loss? An increase in the intraocular pressure Deterioration of the macula Increased opacity of the lens Vitreous hemorrhage

Increased opacity of the lens A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration. Glaucoma leads to an increase in intraocular pressure, causing mild headaches and foggy vision. Macular degeneration is caused by deterioration of the macula, resulting in decreased central vision. Vitreous hemorrhage is bleeding following damage of retinal blood vessels, which can occur due to elevated blood pressure or uncontrolled diabetes mellitus.

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? Place the client in the lithotomy position. Elicit a vagal response by performing gentle rectal stimulation. Administer oral bisacodyl 30 min prior to the procedure. Insert a lubricated gloved finger and advance along the rectal wall.

Insert a lubricated gloved finger and advance along the rectal wall. The nurse should insert a lubricated gloved finger and advance it along the rectal wall when digitally evacuating stool. The nurse should place the client in a side-lying position with the knees flexed. Eliciting a vagal response by performing rectal stimulation is unsafe because it can cause cardiac dysrhythmias. A fecal impaction is a contraindication for administering a laxative, such as bisacodyl. Instead, the nurse should plan to administer an oil retention enema prior to the procedure.

The nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? Ketonuria Fecal impaction Latex allergy Tachycardia

Latex allergy The nurse should assess the client for a latex allergy prior to the insertion of an indwelling urinary catheter due to the risk of an allergic reaction. Ketonuria is the presence of ketones in the urine and occurs due to fatty acid catabolism caused by hyperglycemia, starvation, high-protein diets, and alcohol use disorder. Although this condition will require intervention, it is not necessary for the nurse to assess for ketonuria prior to inserting an indwelling urinary catheter.

A nurse is administering cyclophosphamide orally to a school each child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? Give an antiemetic 30 min after medication administration. Monitor blood glucose levels. Maintain hydration with liberal fluid intake. Monitor for tumor lysis syndrome.

Maintain hydration with liberal fluid intake. The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication. The nurse should administer an antiemetic 30 min before administration of the medication to decrease gastrointestinal effects. Tumor lysis syndrome can occur in clients who are diagnosed with acute lymphoblastic leukemia, not neuroblastoma.

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? Assess the client's IV site every 8 hr. Check the client's WBC count every 48 hr. Monitor the client's mouth every 8 hr. Change the client's IV tubing every 48 hr.

Monitor the client's mouth every 8 hr. The nurse should monitor the client's mouth at least every 8 hr for manifestations of an infection, such as sores or lesions. Monitor IV site for manifestations of infection Q4hr. WBC Q24hr. Change IV tubing Q 24 hours for patients who are immunosuppressed.

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

Nausea The nurse should instruct the client to monitor for and report manifestations of digoxin toxicity, such as nausea, anorexia, abdominal pain, bradycardia, and visual changes. Diarrhea and muscle weakness are manifestations of toxicity. The nurse should inform the client that wheezing is a manifestation of anaphylaxis, not digoxin toxicity.

A nurse is caring for a client in the inpatient psychiatric unit. An adult client is admitted to the inpatient psychiatric unit for evaluation, monitoring, and treatment of major depressive disorder. Client has been treated in the outpatient setting, but depressive symptoms have worsened. Client has significant insomnia (only sleeping 1 to 2 hr each night), has been unable to concentrate long enough to complete daily tasks, such as paying the bills, and developed a markedly diminished interest in any activities, including meeting ADL tasks and hygiene needs. Based on the assessment findings, which of the following actions should the nurse take? Select all that apply. Remind the client that everything is going to be fine. Ensure client is assigned to a private room. Observe the client swallow all prescribed medications. Provide one-on-one observation. Assess the client's method of lethality. Discuss with the client

Observe the client swallow all prescribed medications. Provide one-on-one observation. Assess the client's method of lethality. Ensure that the client does not have access to sharp objects. When taking actions, the nurse's primary concern should be the client's safety. The nurse should observe the client swallowing all prescribed medications to confirm they are not hoarding pills; provide one-on-one observation; assess the client's method of lethality by discussing the client's suicide plan; ensure the client does not have access to sharp objects, including silverware; and also ensuring that all windows and exit doors are locked.

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

Partial-thickness skin loss The nurse should expect to see partial-thickness skin loss or blister formation in a client who has a stage II pressure injury. stage IV = muscle damage & tendon exposure. stage III = visible subcutaneous tissue.

A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging? Sudden drop in heart rate. Rapid decrease in blood pressure. Client reports a feeling of abdominal fullness. Client reports pain as 8 on a scale of 0 to 10.

Rapid decrease in blood pressure. A rapid decrease in blood pressure is an indication of hemorrhage. increased heart rate can indicate a possible hemorrhage. Pain could be an indication of a bowel perforation and does not indicate hemorrhage.

A nurse in the emergency department is assessing A preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child's sexual maltreatment? The child exhibits discomfort while walking. The child has thin extremities. The child has bruises on the upper back. The child is wearing a stained shirt.

The child exhibits discomfort while walking. The nurse should identify this finding as a potential indication of child sexual maltreatment. Thin extremity = child's physical neglect. Bruising on upper back = child physical maltreatment. Stain shirt = child physical neglect.

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

The client needs assistance when transferring from the bed to a wheelchair. The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers.

A charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. Which of the following information should the nurse plan to include? Choosing to donate organs can delay the timing of the child's funeral. The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. The family should understand that an autopsy is mandatory prior to organ donation. The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death.

The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body. Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral. The nurse should discuss organ donation with the parents separately from discussions about the child's impending death.

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in a change of shift report? The time of the client's last dose of pain medication. The client's most recent ventilator settings. The last time the provider evaluated the client. The frequency in which the client presses the call button.

The time of the client's last dose of pain medication The nurse should recognize that an effective change-of-shift report provides a baseline of the client's status for comparison and should include any recent changes or priority situations affecting the client's condition. Therefore, the time of the client's last dose of pain medication is important to include so the receiving nurse can anticipate what time to give the next dose.

A nurse is assisting a client who is taking Propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to propranolol? Weight loss Wheezing Blood pressure 146/92 mm Hg Heart rate 110/min

Wheezing The nurse should recognize that wheezing can indicate the client is experiencing an adverse reaction to the medication. The client might gain weight as a result of taking a beta blocker and should be monitored for heart failure. Elevated BP and HR = med not working

A nurse is caring for a client who is receiving continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? aPTT PT INR WBC count

aPTT Prior to adjusting the client's continuous heparin infusion, the nurse should review the client's activated partial thromboplastin time (aPTT). The expected reference range for the aPTT is 40 seconds. Clients who are receiving continuous heparin therapy should have an aPTT of 60 to 80 seconds, which is 1.5 to 2 times the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value. The nurse should review the WBC count if the client has a fever, infection, or is immunocompromised.

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

"I should pull the top of the ear upward and back while instilling the medication." The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back. The nurse should instruct the parent to allow otic medication stored in the refrigerator to warm to room temperature prior to administration to prevent dizziness and pain. The nurse should instruct the parent to gently massage the tragus on the area anterior to the ear to allow the medication to reach the entire canal. The nurse should instruct the parent to have the child remain lying on the unaffected side for a few minutes after instilling the medication to allow the medication to remain in the ear canal.

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

"I will bend at my knees when picking an object up off the floor." The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object. The client should avoid lifting anything that weighs 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 a terminal illness and requests no life saving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? "You will need to draft a health care surrogate so a designee can make this decision for you." "I will make sure that no one performs any lifesaving measures if your heart stops." "Your provider determines if you should have lifesaving measures if your heart stops." "I will provide you with information about medical treatment to include in your living will."

"I will provide you with information about medical treatment to include in your living will." The nurse's responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themselves by providing information about what end-of-life preferences to document.

A home health nurse is providing teaching about an infection prevention to a client who has cancer and receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? "I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature." "I will clean my toothbrush in my dishwasher once each month." "I will take my temperature once each week and let my doctor know if it is high." "I will walk for short distances throughout the day."

"I will walk for short distances throughout the day." The client should ambulate for short distances as tolerated throughout the day. This will help to reduce pulmonary stasis and prevent the development of respiratory infections. The client should take their temperature once each day to monitor for infection and notify the provider if the temperature is greater than 37.8° C (100° F). Early intervention for an infection will increase the likelihood of the client's recovery. Clients can reduce the risk for oral infections by cleaning their toothbrushes in a dishwasher once per week. This reduces the risk for transmission of bacteria from the toothbrush to the oral cavity. Consuming water, or other liquids, that have been standing at room temperature for longer than 1 hr increases the client's risk for infection due to contamination with bacteria.

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

"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, but the client has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the client with access to the medical record.

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

"You will receive fingersticks for blood glucose testing." A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring. The client should receive oral or enteral nutrition whenever possible because it enhances the immune system and maintains intestinal motility. However, the client should receive TPN when nutritional needs are greater than oral or enteral nutrition can provide, such as in a client who has burn injuries. TPN provides calories to clients who are unable to eat or who do not have a functioning gastrointestinal tract. A client who has a burn injury is in a hypermetabolic state and requires additional calories, carbohydrates, proteins, and fats. The nurse should check the client for an egg allergy because this can result in an intolerance of the lipid solution and many lipids are composed of egg phospholipids.

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an AP? Arrange the lunch tray for a client who has a hip fracture. Measure the vital signs of a client who just returned from the PACU. Evaluate dietary intake for a client who has anorexia. Assess I&O for a client who is receiving dialysis.

Arrange the lunch tray for a client who has a hip fracture. Assisting a client with meals is within the range of function of the AP. Although an AP can measure vital signs, this client is postoperative and requires close assessment, which is not within the range of function of the AP. Postoperative clients are not considered medically stable and are often fragile, so the nurse should not delegate this task to the AP.

A client who is 24 hour postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? Ask the client to rate their pain level. Assist the client in changing positions. Administer a PRN analgesic medication. Explain the importance of early ambulation.

Ask the client to rate their pain level. Using the nursing process, the first action the nurse should take is to assess the client's level of pain. If indicated, the nurse should administer an analgesic, then wait 30 to 45 min to allow the analgesic to take effect before encouraging the client to ambulate. Management of the client's pain is a priority for encouraging postoperative activity.

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care period which of the following actions should the charge nurse take first to resolve the situation? Evaluate the changes the partner requests. Review the client's plan of care. Analyze other reports of poor care to look for trends. Ask the partner to list specific concerns.

Ask the partner to list specific concerns. The first action the nurse should take using the nursing process is to assess the situation by asking the partner to list specific concerns.

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted births? Constipation Urinary urgency Cervical laceration Retained placenta

Cervical laceration The nurse should assess the client for complications associated with a vacuum-assisted birth such as perineal, vaginal, or cervical lacerations. Constipation is a common discomfort of pregnancy and is not associated with a vacuum-assisted birth. Urinary urgency is a manifestation of a UTI, which is not a complication associated with a vacuum-assisted birth. Retained placenta Abnormal adherence of the placenta to the myometrium or the incomplete separation of the placenta from the uterus can lead to retained placental fragments. This is not a possible complication of a vacuum-assisted birth.

A nurse is preparing to administer a long acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? Teach the client reportable adverse effects from the medication. Check the insulin dose with another licensed nurse. Administer the insulin at a 90° angle. Clean the insertion site.

Check the insulin dose with another licensed nurse. The greatest risk to the client is injury due to a medication error. Therefore, the priority action is for the nurse to validate the correct dose of insulin with another licensed nurse prior to administration. Insulin is a high-alert medication and incorrect dosages can be fatal for the client. The nurse should administer the insulin at a 90° angle to ensure subcutaneous administration; however, there is another action the nurse should take first. The nurse should clean the insertion site before injecting the medication to prevent an infection; however, there is another action the nurse should take first.

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

Decreased lung expansion Older adult clients are more likely to have decreased lung expansion due to decreased mobility of the ribs. Older adults have decreased oral temperature, decreased cardiac output, increase systolic blood pressure with a diastolic pressure that does not change. Older adults also have increased incidence of orthostatic hypotension.

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? Apply an over-the-counter cream if the wound becomes infected. Clean the wound twice a day with povidone-iodine. Apply heat to the wound for 10 min, four times per day. Double-bag soiled dressings in plastic bags for disposal.

Double-bag soiled dressings in plastic bags for disposal. The client should double-bag soiled dressings in plastic bags to prevent the spread of micro-organisms to other household members. The family should not use povidone-iodine to clean the wound, because it is toxic. Povidone-iodine should be used to clean equipment and intact skin. The client should not use over-the-counter products without consulting with their provider. Heat is contraindicated for wound therapy.

A nurse manager is reviewing unit records and discovers that clients falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? Investigate environmental factors that might be contributing to client injury during these hours. Review the performance evaluations of nurses who work during these hours. Implement a plan to transition from team nursing to primary care nursing during these hours. Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours.

Investigate environmental factors that might be contributing to client injury during these hours. When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can include environmental factors that might be causing the problem. When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the problem.

A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect? Abdominal striae Masklike face Nystagmus Ptosis

Nystagmus Nystagmus is involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis. Abdominal striae are a manifestation of Cushing's syndrome. Masklike face is caused by rigidity of the facial muscles and is a manifestation of Parkinson's disease. Ptosis is the drooping of the upper eyelids due to a decreased level of acetylcholine and is a manifestation of myasthenia gravis.

A nurse is caring for a client who is becoming agitated. While attempting to deescalate which of the following actions should the nurse take first? Observe the client and the situation. Respect the client's personal space. Give the client several clear options. Select a quiet location to talk to the client while remaining visible to staff members.

Observe the client and the situation. When using the nursing process priority framework, the first action the nurse should take is to assess and observe the client and situation. This action affords the nurse the opportunity to implement the best deescalation techniques and practice principles.

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

Place ice packs on the breasts for 15 min several times per day. The client should place ice packs on the breasts to reduce swelling and relieve the pain caused by engorgement. nurse should instruct the client to avoid nipple stimulation, because it increases milk production, leading to engorgement. avoid expressing milk to prevent further milk production, because this can lead to engorgement. the client should wear a tight-fitting, supportive bra or breast binder to decrease the discomfort caused by engorgement.

A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? Remove the client's restraints while sleeping. Document the client's status every 60 min. Check for a new prescription every 6 hr. Provide a staff member to stay with the client continuously.

Provide a staff member to stay with the client continuously. A staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment, if necessary, due to the risk of injury. don't remove restraints until pt is calm, in control, and able to follow simple commands. Nurse should assess patient for physical needs, safety, and comfort every 15 to 30 minutes and document the findings. Provider must renew prescription for restraints every 4 hours for clients 18 years or older, every 2 hours for children ages 9 to 17 years, and every 1 hour for children <9 years old.

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? Completion of the incident report. Time the medication was given. Reason for the medication error. Notification of the pharmacist.

Time the medication was given. The nurse should document the time, the name of the medication, the dose, and the route in which the medication was given on the client's medication administration record immediately after it was administered. The nurse should also document the time that the incorrect medication was administered to the client in the incident report, as this is a fact directly related to the occurrence. The nurse should complete an incident report for legal protection of the facility but should not document anything concerning the completion of the report in the client's medical record.

A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and a NG tube in place. Which of the following actions should the nurse take? Instill chilled lavage solution into the client's NG tube. Attach the client's NG tube to low intermittent suction. Use 0.9% sodium chloride for irrigation of the NG tube. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time.

Use 0.9% sodium chloride for irrigation of the NG tube. The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube. The nurse should use lavage solution that is at room temperature to reduce the risk of injury to the client. After instilling the lavage solution, the nurse should manually withdraw the solution and blood from the client's NG tube. The nurse should instill the solution in volumes of 200 to 300 mL at a time to reduce the risk of injury to the client.

a Hospice nurses consulting with the client and their family about receiving home services. Which of the following statements should the nurse identify as an indication of the family understands home Hospice care? "We can expect the hospice nurse to provide support for us after our mother's death." "A hospice nurse will come to the house each time our mother needs pain medication." "Now that my mother is receiving hospice services, we will not be able to get respite care." "Hospice care focuses on arranging treatment that will prolong our mother's life."

"We can expect the hospice nurse to provide support for us after our mother's death." Hospice care includes bereavement services after a family member's death. The hospice nurse will teach the family how to administer pain medication but is also available on call 24 hr every day if the family has questions. Hospice services include providing respite care for family members. Hospice care focuses on providing palliative, psychosocial, and spiritual care to the client and the client's family without the intent of prolonging the client's life.

A nurse is preparing A sterile field to perform a sterile dressing change period which of the following interventions should the nurse use to maintain surgical sterile technique? Hold hands folded below the waist after donning sterile gloves. Pick up and pour solutions with the palm of the hand covering bottle labels. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. Maintain sterile objects within the line of vision.

Maintain sterile objects within the line of vision. Objects out of the line of vision are not considered sterile. Therefore, the nurse should keep sterile objects in direct sight to maintain surgical asepsis. The nurse should use this technique to prevent the solution from running down the label and obscuring the writing, but this action does not maintain sterile technique.

A nurse is caring for a school aged child who is taking valproic acid. The nurse should expect the client to order which of the following diagnostic test? Chest x-ray Serum liver enzyme levels ABGs Urine culture and sensitivity

Serum liver enzyme levels Valproic acid can cause hepatic toxicity. Therefore, the nurse should expect the provider to prescribe laboratory tests to assess the child's liver function prior to and periodically during therapy.