Comprehensive B

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?

"A client who requires airborne precautions should be placed in a negative pressure airflow room"

A nurse is admitting a client to the mental health unit after an attempted suicide. The client states, "my family does not care whether I live or die." Which of the following responses should the nurse make?

"How does this make you feel?"

A nurse is providing teaching about advance directives to a middle adult client. Which of the following clients responses indicates an understanding of the teaching?

"I can designate my partner as my healthcare surrogate"

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect?

"I have not vomited as much recently."

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates an understanding of the teaching?

"I should watch for common reactions like dry mouth and constipation"

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?

"I told my doctor that I would like to start a support group for other women who are sick in my community" reaching out and helping others

A nurse is providing information to a client immediately before their scheduled Romberg test. Which of the following statement should the nurse make?

"I will be checking you once with your eyes open and once with them closed"

A nurse is caring for an older adult client who is experiencing chronic anorexia is receiving enteral tube feedings. Which of the following laboratory values indicates the client needs additional nutrients added to the feeding?

Albumin 2.8 g/dL (3.5-5g/dL)

A nurse is caring for a client who has become aggressive and potentially violent. Which of the following actions should the nurse take?

Allow the client time for reflection and decision making

A nurse is planning care for a client who is receiving hemodialysis via an established arteriovenous(AV) fistula in the right arm. Which of the following intervention should the nurse include in the clients plan of care?

Auscultate the affected extremity for a bruit

A nurse is assessing a newborn's heart rate. Which of the following action should the nurse take?

Auscultate the apical pulse at least 1 min

A mental health nurse is conducting the first of several meetings with a client whose partner recently died. The nurse should perform which of the following actions to establish trust during the orientation phase of the nurse-client relationship?

Establish the termination date of therapy. Rationale: This task occurs in the orientation phase of a therapeutic relationship.

* the client returns to the providers office three days later. Which of the following assessment findings should the nurse report to the provider as unexpected?

Expected • urine color • voiding pattern • oxygen saturation • blood pressure Unexpected • temperature • skin • Bowel elimination

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Report of chest pain Epinephrine increases cardiac workload and oxygen demand, which can result in angina.

*. A nurse is caring for a client who is pregnant in the acute care setting. The nurse should first address the clients _____, followed by the clients _____.

Respiratory rate Level of consciousness

A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching?

Sedation is a common adverse of this medication

A nurse is caring for a school age child who has dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicate that the treatment regimen is effective?

Serum sodium one 38 mEq/L Urine specific gravity range, 1.005 - 1.030.

A nurse is preparing a sterile field in order to insert an indwelling urinary catheter for a male client. Which of the following techniques should the nurse use to maintain surgical aseptic technique?

Set the catheter tray on the overbed table at waist height To maintain sterility, the nurse should place the catheter tray on a work surface at or above waist level

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground which of the following action, should the nurse take first?

Survey the scene for potential hazards to staff and children

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Instruct the client to void

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following method should the nurse manager used to evaluate the nurse's time management skills?

Maintain regular notes about the nurse's time management skills

A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?

Occlusive dressing on the insertion site

A nurse is planning teaching about allowable foods for a client who has a history of uric-acid based urinary calculi formation, which of the following foods does the nurse include in the teaching?

Oranges A client who is prone to uric acid calculation, avoid eating food, which contains purine such as chicken, liver, and wine

A nurse is caring for a client who has had nausea and vomiting for the past two days. The nurse should identify which of the following findings as an indication. The client is experiencing fluid volume deficit?

Orthostatic hypotension

A nurse is assessing a client following a vaginal delivery in notes heavy lochia and a boggy fundus. Which of the following medication should the nurse expect to administer?

Oxytocin Oxytocin is a hormone that stimulates uterine contractions to decrease, vaginal bleeding

* a nurse is caring for a client on a medical surgical unit. Click to highlight the findings that require follow up.

Painful and demitasse area on sacrum Client reposition every four hours

A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following action should the nurse take?

Place the BP cuff in a labeled bag to send it for decontamination

A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instruction should the nurse include in the teaching?

Use a three-point gate

A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?

acute confusion along with fatigue, lethargy, and anorexia

A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?

audible stridor

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?

sedentary lifestyle also, small framed body with a thin build, estrogen deficiency

A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first?

inform the nurse manager of the issue. The greatest risk to the clients is injury from not receiving medications on time and developing a medical complication. Therefore, the priority intervention the charge nurse should take is to follow the chain of command and contact the nurse manager who is her supervisor.

A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?

instruct the client to elevate the affected extremity when sitting

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?

irritability

A charge nurse is observing a newly licensed nurse, administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

keeps the head of the bed elevated to 45 degrees for 1 hour after feedings

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?

low back pain other signs include hypotension, tachycardia

A nurse is assessing a school age child who has bacterial meningitis. Which of the following findings should the nurse expect?

nuchal rigidity also weight loss

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster Response stage of the plan?

performing a rapid needs assessment

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

pink frothy sputum

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take?

place the skin barrier over the stoma and hold for 30 seconds

A nurse is assessing a client who has skeletal traction for a femur fracture which of the following findings should the nurse identify as a priority?

upper chest petechiae (fat embolism syndrome)

A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?

urine specific gravity 1.052

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

use the ventrolateral site it has a thick area of muscle and contains no large nerves or blood vessels

A nurse and a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

"Have you had any stomach pain or bloody stools?"

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

"I will make sure my child receives a yearly influenza immunization"

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for a break. Which of the following statements should the charge nurse make to address this conflict?

"I would like to talk to you about the unit policies regarding break time"

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the clients prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?

"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments"

A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience increased thirst"

A nurse is caring for a client who is at 28 weeks of gestation. The client asked the nurse to explain what is causing the constipation. Which of the following responses should the nurse make?

"The enlarged uterus compresses the intestines and causes constipation." •Estrogen and progesterone levels increase during pregnancy, leading to decrease peristalsis and relaxation of the smooth muscles of the intestine leading to constipation •The intestine absorbs more water from the school during pregnancy leading to constipation • The small intestine absorbs iron more readily during pregnancy due to increased maternal, needs leading to constipation

A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instruction should the nurse include in the teaching?

"You will need to fast the night before the test"

A nurse is preparing to administer diazepam, 0.3 mg/kg IV bolus to a toddler who weighs 10 kg and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer?

0.3mg X 10kg = 3mg 3mg X 1mL / 5mg = 0.6mL

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

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

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

A client who has cellulitis and is receiving oral antibiotics every 8 hr

A case manager is reviewing the medical records of several clients. For which of the following client, should the nurse request an intrerprofessional care conference?

A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis

A nurse is caring for multiple clients in an antepartum clinic. Which of the following client should the nurse plan to perform fetal heart monitoring?

A client who has premature rupture of membranes A client who has gestational hypertension A client who reports decreased fetal movement

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag?

A client who has significant head trauma and agonal respirations

And antepartum nurse is caring for four clients. For which of the following client should the nurse initiate seizure precautions?

A client who is at 33 weeks of gestation and has severe gestational hypertension

A nurse has received change-of-shift report on for assigned client. For which of the following client should the nurse intervened to prevent a potential food and medication interaction?

A client who is receiving an MAOI, and is requesting a cheeseburger for dinner

*. A nurse is caring for a client in the emergency department(ED). Which of the following interventions should the nurse implement?

Administer IV fluids Use humidification with oxygen therapy Assess the client's mouth every eight hour Assess peripheral circulation, hourly

* a nurse is planning morning care for a client who has heart disease and type 2 diabetes myelitis. Upon review of the clients medical record which of the following action, should the nurse take?

Administer daily medications

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information and teaching?

Advocacy is a leadership role that helps others to self-actualize

* a nurse is caring for a client following a laparoscopic cholecystectomy. For each potential providers prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Anticipated • apply heat for abdominal pain as needed • encourage deep, breathing exercises every hour • change dressing when soiled Contraindicated • Zofran, 4 mg PO scheduled

* a nurse is caring for a client for each potential providers prescription click to specify if the potential prescription is anticipated, are contraindicated for the client

Anticipated • keep the lights in the clients room dim • Monitor blood glucose Q for hour • administer oxygen therapy to keep oxygen saturation above 95% Contraindicated • keep the client supine • cluster nursing care • Maintain the clients hips in flexion

A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following action should the nurse take when suctioning the clients airway?

Apply section for 10 seconds

A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?

Ask the client to point to items on a picture menu

A nurse working on a medical-surgical unit received a telephone call requesting the status of a client from an individual who identifies themselves as the client's guardian. Which of the following action should the nurse take?

Ask the color for verification of their identity

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurses priority?

Assist with deep breathing and coughing The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia.

*. A nurse is caring for a client who is on the spinal cord injury unit. The client is most likely experiencing manifestations of _____ and ______.

Autonomic dysreflexia Pneumonia

A nurse manager is reviewing clients rights with the nurse on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles.?

Autonomy This refers to the clients ability to make their own decisions about treatment. Informed consent promotes autonomy by providing clients with complete information about treatment.

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following intervention should the nurse include in the plan?

Avoid including raw fruits in the clients diet

*. A nurse is caring for an adolescent in the emergency department. For each assessment, finding click to specify if the assessment finding is consistent with bacterial meningitis encephalitis or rye syndrome.

Bacterial meningitis •fever •photophobia •nuchal rigidity •rash •mental status Encephalitis •fever •nuchal rigity •mental status Reye syndrome •AMS •impaired hepatic function

When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort?

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

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of this medication?

Blurred vision

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on the forearm. The nurse should identify these behaviors as characteristics of which of the following personality disorders?

Boarderline

A nurse on a medical surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

Difficulty performing ADL's

*. A nurse and a providers office is caring for a client. The nurse is assessing the client. Which of the following assessment findings should the nurse report to the provider

Frequency Dysuria Urgency

A nurse is caring for a client who states, "my boss accuse me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize that the client is demonstrating which of the following defense mechanisms?

Sublimation

A nurse in an acute mental health facility is planning care for a client has anorexia nervosa. Which of the following intervention should the nurse include in the clients plan of care?

Supervise the client during and after eating

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?

Jaundice Clients who take valproic acid are at risk for liver damage, which can lead to jaundice.

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?

Confusion When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is confusion because it indicates advanced lithium toxicity. The nurse should monitor the client for additional indications of lithium toxicity, including coarse hand tremors, confusion, ECG changes, and sedation.

* a nurse on the medical surgical unit is caring for a client who was admitted from the emergency department. The client is at risk for developing. _____ due to.____

Confusion Sodium level

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrist. The nurse suspects physical abuse. Which of the following action should the nurse take?

Contact child protective services

*. A nurse is caring for a one month old infant. The infant is at high risk for developing. _____ as evidenced by the infants ._____

Dehydration Vomiting

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following method to the nurse include in the teaching?

Delegate non-nursing tasks to ancillary staff.

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

Determine the client's reading skills The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost.

A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client safety which of the following action, should the nurse take first?

Determine the clients perception of the personal impact of the crisis

A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first?

Develop a safety plan with the client The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is the develop a safety plan with the client.

A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect?

Diaphoresis Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care?

Encourage the parents to bring toys from home

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

Dyspnea Fluid overload can lead to the backup of fluid in the pulmonary system resulting in shortness of breath.

* a nurse is caring for a client who is postoperative following a coronary artery bypass surgery. The client is at greatest risk for developing _____ as evidence by _____.

Dysrhythmias laboratory report

* a Nursing And providers office is caring for a client. Which of the following provide a prescription to the nurse anticipate for this client?

Educate the client on a new prescription for phenazopyridine Collect urine specimen for urine culture Collect a urine specimen for urinanalysis Educate client on new prescription for sulfamethoxazole/trimethoprim

*. A nurse is caring for a client who has a new diagnosis of anorexia nervosa. The nurse should first address the client _____, followed by the client _____

Electrolyte imbalance Fear of weight gain

A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as a priority?

The client's heel is reddened and tender The greatest risk to this client is injury from a pressure injury. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The clients family tells the nurse that they are concerned about the level of care of the client will receive. Which of the following action should the nurse take?

Facilitate an interdisciplinary conference at the new facility for the family

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of their last menstrual period(LMP) was May 8. According to Naegele's Rule which of the following dates are the nurse document as the client estimated date of birth(EDB)?

February 15 The nurse should add seven days to the last day of the clients LMP and then subtract three months (8+7=15)

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?

Floating dark spots

A nurse is administering medication to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following action should the nurse take to prevent clogging of the tube?

Flush the clients gastrostomy tube with 30 mils of water before administering the medication

*. A nurse is caring for a five year old child. Complete the diagram by dragging choices below to specify what condition the child is most likely experiencing two actions. The nurse should take to address that condition and two parameters, the nurse and monitor to assess the child's progress.

• initiate droplet precautions • request a prescription for IV antibiotics Epiglottitis • temperature • Breath sounds

*. A Nursing And providers office is caring for a client. The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instruction should the nurse plan to include?

Gently cleanse the perineum before intercourse

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect?

Grandiose delusions Rationale: Clients who are in the manic phase of bipolar disorder typically exhibit behaviors that appear to be euphoric. Clients can also have abrupt mood changes, expansiveness, unlimited energy, poor impulse control, and grandiose delusions.

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Have the client wear a surgical mask while being transported outside the room

A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider?

Hemoptysis 275 mL/24 hr Rationale: Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report. Fever

* a nurse is caring for a client who has abdominal pain. For each condition click to specify if the characteristics is consistent with acute infection of hepatitis A, hepatitis B, or hepatitis C

Hepatitis A, hepatitis B and hepatitis C include jaundice, yellow sclera RUQ pain upon palpation, dark yellow, urine, and elevated AST and ALT levels Hepatitis A contracted through fecal, oral route during recent travel to an underdeveloped country Hepatitis B and hepatitis C through blood borne transmission Current standard of practice for treating hepatitis B and hepatitis C infections is with antiviral medication

A nurse is assessing a client who has obstructive sleep apnea. For which of the following complications should the nurse monitor?

Hypertension Rationale: The nurse should assess the client for hypertension, a complication of obstructive sleep apnea from hypoxia. Other complications include heart failure and cardiac dysrhythmias.

* a nurse is caring for a client who has one day postoperative following a total thyroidectomy. The client is at highest risk for developing _____ as a evidendenced by the _____.

Hypocalcemia Clients report of muscle spasms

A nurse is teaching a client who has a new prescription for total parenteral nutrition, three central line. Which of the following information should the nurse include in the teaching?

I will need to measure your weight daily IV. Tubing should be changed every 24 hours to prevent bacterial growth. Abdominal distention, nausea and vomiting are all potential complications of overfeeding through a gastrointestinal tube

A nurse is providing teaching to the guardians of a newborn client about measures to prevent sudden, unexpected infant death (SUID). Which of the following guardian statements indicates an understanding of the teaching?

I will not allow anyone to smoke near my baby

A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is a priority for the nurse to assess?

Ideas of self-harm

A nurse is caring for a client who has generalized anxiety disorder and us to begin taking alprazolam. Which of the following action should the nurse take?

Initiate fall precautions for the client

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following intervention should the nurse identify as a priority?

Initiate transmission based precautions

A nurse is preparing to administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following action should the nurse plan to take?

Inject 20 units of air into the NPH insulin vile

A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Install a raised toilet seat at home - The client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation.

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?

Instruct the client to avoid coughing during the procedure. -avoid coughing and to lie still during a thoracentesis to avoid puncturing the pleura.

A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include?

Introduce new foods one at a time over 5 to 7 days. Rationale: The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take?

Involve the client in selection of a physical therapy provider

A nurse is assessing a client who has an antisocial personality disorder. Which of the following manifestations should the nurse expect?

Lack of remorse

A nurse on a medical surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones which of the following action should the nurse take?

Make a referral for social services

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measure the client's daily weight

* a nurse is caring for a client who is postoperative following an appendectomy. Which of the following for client findings should the nurse report to the provider?

Nausea Oxygen saturation Heart rate Pain level

A nurse working on an inpatient mental health unit is caring for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?

Observe the client every 15 minutes

A nurse is planning to delegate client car tasks to an assistive personnel (AP). Which of the following tasks the nurse plan to delegate to the AP?

Perform gastrostomy feedings three clients establish gastrostomy tube

A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect?

Persistent uterine contractions The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding.

* a nurse is caring for a client at a providers office. For each assessment, finding noted above click to specify if the finding against expected of pneumonia, COPD or heart failure.

Pneumonia • tobacco use • elevated WBC • productive, cough with blood tinged sputum • elevated temperature • decreased oxygen saturation • ABG, indicating respiratory acidosis COPD • tobacco use • decreased oxygen saturation Heart failure • tobacco use • BNP level • Decreased oxygen saturation

A nurse is administering one unit of packed RBCs to a client. The client becomes anxious and reports shortness of breath and urticaria 15 min after initiation of the transfusion. Which of the following action should the nurse take?

Prepared to administer epinephrine to the client

A nurse manager is planning to make changes to the current scheduling system on the unit. Facilitate the staff's acceptance of this change, which of the following action should the nurse manager take first?

Provide information about scheduling issues to the staff

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Proceed with provision of medical care When a client is unable to give informed consent in an emergency, healthcare personnel can proceed with necessary life, saving care because the law considers this implied consent

*. A nurse in an emergency department is assessing a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing two actions. The nurse should take to address that condition in to perimeters the nurse should monitor to assess the clients progress.

Provide a cooling blanket Hold all antipsychotic medication's Neuroleptic malignant syndrome Temperature Hydration status

*. A nurse and a providers office is caring for a client. The client is at highest risk for developing._____ as evidence by the clients_____

Pyelonephritis Urinanalysis results

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Radial vein of the inner arm

A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for the development of a pressure injury?

Recent weight loss Weight loss can increase the risk for pressure injury. Inadequate nutrition will cause decreased nutrients for the skin and tissues and increases the chance for shearing against the bony prominences

*. A nurse is caring for a client who is pregnant. The nurse is providing discharge teaching to the client. For each discharge instruction click to specify if each action is recommended or contraindicated for the client.

Recommended • alternate eating, solid foods and liquids • eat every 2 to 3 hours • drink, warm ginger ale when nauseated Contra indicated • increase intake of high fat foods

Identify the sequence of steps, the parent should follow to perform tracheostomy care

Remove the inner cannula Remove the soil dressing Clean the stoma with NS Change the tracheostomy collar

* the client returns to the providers office three days later. Click to highlight. The finding that indicate the clients urinary tract infection is improving.

Specific gravity PH WBC

* a nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow up.

Speech Auditory hallucinations Restlessness

A nurse is providing teaching to a client who has a prescription for levothyroxine 25 mcg PO daily. Which of the following instruction should the nurse include in the teaching?

Take the medication on an empty stomach 30 minutes before breakfast Medication should be taken four hours apart from calcium supplements to optimize absorption of the medication If I dose Isthmus, the client should take it as soon as possible. The client should avoid doubling dosing the medication. It is recommended to take a full glass of water when taking this medication

* a nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Select the for client findings that leave the nurse to suspect that the client is experiencing thyroid storm.

Temperature Blood pressure Heart rate Mental status

* a nurse is caring for an adolescent in the emergency department(ED). The nurse is reviewing the adolescent's electronic medical record (EMR). Which of the following findings requires immediate follow up by the nurse?

The nurse should identify that the adolescent has a potential skin infection. Such as cellulitis. The adolescence temperature and WBC count, or above the expected reference range The adolescent casual blood glucose and potassium are above the expected reference range

A nurse is caring for four clients at the beginning of a shift. After receiving change-of-shift report, which of the following clients should the nurse attend to first?

a client who is confused and has been attempting to get out of bed (risk for injury)

*. A nurse is assessing a newborn who is three days old. Click to highlight the findings that require follow up.

• temperature • breast-feeding every 3 to 5 hours for 5 to 10 minutes • 12% weight loss • Presence of mild tremors

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following action should the nurse take?

Turn off the CPM machine during meal time The nurse should turn off the CPM machine during meals to promote client, comfort and dietary intake

A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35-7.45) PaO2 56 mm ahh (80-100) PaCO2, 54 (35-45) HCO3 -26 mEq/L (21-28) SaO2 87% Which of the following is the correct interpretation of these values?

Uncompensated respiratory acidosis

* a nurse is caring for a client who is postoperative following administration of general anesthesia.

Upon recognizing and analyzing the client cues of tachycardia, tachypnea, hypotension, and irregular heart rhythm, the nurse's priority hypothesis should be that this client is most likely experiencing malignant hyperthermia and that it is important to generate solutions and take actions that will correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. Therefore, the nurse should prepare to administer dantrolene and administer oxygen. The nurse should monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles.

A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?

Use a protective cover on the scale when weighing the infant Heat loss by conduction is a loss of heat between the newborns skin and the cooler surfaces beneath it. Using a protective cover prevents contact with the scale, which prevents the loss of heat through conduction.

* a nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation.

•Avoid cervical examination • insert a large bore IV catheter Abruptio placenta • blood pressure • platelet count

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedure should the nurse follow to ensure proper client identification?

Verify the client and blood product information with another licensed nurse

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3 (2,500-8,000/mm3). Which of the following intervention should the nurse include in the plan?

Withhold administering the varicella vaccine to the child A child who has severe immunodeficiency, should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are amino compromised

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

cough due to build up of bradykinin in the lungs

A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent?

the client is able to accurately describe the upcoming procedure

A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene?

the newly licensed nurse writes detailed notes while performing the head to toe assessment