CP Study 1
175. A nurse is caring for a client who is receiving oxygen when a fire starts in an adjacent room. Identify the sequence of actions the nurse should take. (Move steps in order)
1. Move the client to a safe location 2. Pull the nearest fire alarm 3. Shut all doors and windows 4. Attempt to extinguish the fire
143. A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer?
1.5 mL
118. A nurse is preparing to administer paroxetine 15 mg PO oral suspension to a client who has a depressive disorder. The amount available is 10 mg/ 5 mL. How many mL should the nurse administer?(Round answer to the nearest tenth.)
7.5 mL
5. A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first?
A client who has schizophrenia and is having command hallucinations
32. A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasma?
Lady with eyes closed with nodule on eyelid
89. A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate?
Lower left
3. A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?
The client has a decreased energy level
128. A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make?
This medication will decrease the risk of hemorrhage in your newborn
74. A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?
a. "Advance directives include a living will"
97. A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching?
a. "I will instruct the client to sit when putting on a pair of pants."
12. A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching?
a. "Monitor for muscle weakness while taking the medication."
57. A nurse is assisting with the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light." Which of the following is an appropriate response by the nurse?
a. "That must have been a difficult experience for you."
22. A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate?
a. "You should avoid crossing your legs for 3 months."
72. A nurse is reinforcing teaching with a client who has a trichomoniasis vaginalis infection and a new prescription for metronidazole. Which of the following instructions should the nurse include in the teaching?
a. "You should expect your urine to turn brown."
52. A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching?
a. "You should have a sputum examination every 4 weeks."
85. A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching?
a. "You should increase fluid intake to relieve dysuria."
107. A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching?
a. "You should not palpate your child's abdomen prior to surgery."
126. A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietician?
a. A client who has a body mass index of 32
172. A nurse should recognize that a client's right to confidentiality has been breached when which of the following occur?
a. A nurse tells the chaplain that her assigned client has a new diagnosis of cancer
135. A nurse is receiving a report on four clients. The nurse should plan to collect data from which of the following clients first?
a. A preschooler who has epiglottis and is drooling
26. A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse include?
a. Airborne
171. A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the clients vagina and vulva are a purplish color. The nurse should document this finding as which of the following?
a. Chadwick's sign
115. A nurse is attending an educational workshop about client confidentiality. Which of the following actions b y the nurse indicates an understanding of the teaching?
a. Changes her personal login password at random intervals
33. A nurse is assisting with the admission of a client who has Vancomycin-resistant enterococcus of the urine. Which of the following types of precautions should the nurse implement for this client?
a. Contact precautions
67. A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation precautions when caring for this client?
a. Contact precautions
60. A nurse is reviewing laboratory findings for four clients. Which of the following laboratory values is an expected finding for a client who has end stage kidney disease?
a. Creatinine 15 mg/dL
68. A nurse is documenting client care in the nurses notes and notices that a space was left blank. Which of the following actions should the nurse take?
a. Draw a horizontal line through the space and sign at the end of the line
75. A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?
a. Encourage the client to take frequent walks during the day
153. A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching?
a. Engage in low-impact aerobic exercises
178. A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?
a. Establish a daily exercise routine
129. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse report to the provider?
a. Fruity breath odor
177. A nurse is caring for a client who has a new mastectomy. Which of the following statements by the client should indicate to the nurse that the client is beginning to cope with the changes in her body image?
a. I am afraid to discuss my concerns with my husband
44. A nurse is assisting with the admission of a school-aged child. Which of the following actions should the nurse plan to take? (Exhibit)
a. Initiate contact precautions for the child
84. A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?
a. Instruct the client to remain as still as possible during the recording
145. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal?
a. Lorazepam
132. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
a. Measure the duration of the seizure
94. A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls?
a. Medication record
58. A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?
a. Neisseria gonorrhoeae
61. A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider?
a. Obtain an aPTT level
20. A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?
a. Oral suction equipment
108. A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
a. Place a pillow under the child's head
65. A nurse is preparing a sterile field to perform a dressing change for a client's leg wound, which of the following actions should the nurse take?
a. Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field
109. A nurse is contributing to the plan of care for a client who is to begin receiving intermittent enteral feedings. Which of the following actions should the nurse recommend?
a. Place the client in high-fowler's position during feedings
50. A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
a. Remind the client of the day and time often
38. A charge nurse in a long-term care facility is developing a performance improvement plan for an assistive personnel (AP). Which of the following actions should the nurse take when developing the plans? (Select all that apply)
a. Set a specific time frame for meeting performance goals b. Ask the nurse supervisor to review the plan e. Include the performance standard that the AP should meet
127. A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
a. Soiled dressings should be placed in a biohazard trash receptacle
166. A nurse is preparing to administer medications to a client who has pneumonia and is on droplet precautions. Which of the following supplies should the nurse use while caring for this client?
a. Surgical mask
136. A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include?
a. The headaches should decrease as you get used to the medication
105. A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed exacerbations, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
a. Veracity
4. A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply)
a. allows the nurse to touch him on the arm c. answers questions asked by the nurse d. makes eye contact with the nurse
25. A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching?
b. "I should take this medication in the morning and at night."
27. A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?
b. "Perform pulmonary hygiene 1 hour before meals."
41. A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?
b. "You will need to urinate before the procedure."
173. A nurse on a medical-surgery unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?
b. A client who had a radical mastectomy 36 hr ago and has a surgical drain
13. A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?
b. A social worker who is assigned to an involuntary committed school-age client
99. A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
b. Administer liquid supplements
76. A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply)
b. Administer terbutaline 0.25 mg subcutaneous d. Massage the client's fundus e. Assist the client to empty her bladder
A nurse is caring for an older adult client who reports pain and has a prescription for ketorolac 15 mg IM every 5 hr PRN. The client's current blood pressure is 114/55 mm Hg. Which of the following actions should the nurse take?
b. Administer the medication to the client
124. A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?
b. Advanced practice nurse
79. A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?
b. Allow the client to choose treatment times
116. A nurse is assisting with discharge planning for a group of clients. Which of the following clients should the nurse recommend a home health referral?
b. An older adult client who has heart failure and lives alone
80. A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?
b. Appears greenish-brown in color
152. An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?
b. Ask the AP to discuss the issue in a private area
69. A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill?
b. Bleach
16. A nurse in a provider's office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately?
b. Blurred vision
66. A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?
b. Countertransference
123. A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medication?
b. Decreased kidney function
24. A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching?
b. Eat a small meal every 2 to 3 hr
30. A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction, which of the following actions should the nurse take?
b. Ensure that the weights are hanging freely
131. A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?
b. I am thankful I am done having children
169. A nurse is reinforcing teaching about safe food handling with a client who is recovering from food poisoning. Which of the following statements by the client indicates an understanding of the teaching?
b. I will be sure to cook chicken to 180 degrees fahrenheit
158. A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements made by the client indicates an understanding of the teaching?
b. I will feel a warming sensation after the injection of the dye
112. A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?
b. I will mix the medication with water
102. A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?
b. Identify data collection methods
161. A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority action on which of the following actions?
b. Identifying the client's perception of the changes in her physical appearance
83. A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?
b. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation
59. A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?
b. Nuchal rigidity
170. A nurse is assisting with the discharge plan for a client who has burns on his arms and hands. Which of the following referrals should the nurse recommend to improve the client's ADL's?
b. Occupational therapist
110. A nurse is collecting data from a client in an outpatient clinic and observes extensive bruising on the client's arms. This nurse suspects the client is experiencing intimate partner abuse. Which of the following is the nurse's priority action?
b. Offer support and create a safe, trusting environment
140. A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following findings should the nurse include in the teaching as an adverse effect of this medication?
b. Orthostatic hypotension
31. A nurse is reviewing the medication record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings?
b. Peripheral vascular disease
154. A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
b. Secure the tubing with adhesive tape to the lower abdomen
96. A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?
b. Skin rash with fever
10. A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?
b. Somnolence
90. A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
b. Suctions for 30 seconds
157. A charge nurse working in a long-term care facility overhears two AP's in the nurses stations discussing a client who was just admitted. Which of the following actions should the charge nurse take?
b. Tell the APs to stop the conversation
19. A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene?
b. Tells a client he will lose his phone privileges if he does not take his medication
70. A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of the following findings should the nurse identify as a safety risk?
b. The client's electrical wires are run under carpeting
14. A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?
b. Urine protein 3 plus
77. A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?
c. "Gently stroke her abdomen during contractions."
82. A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?
c. "I should discuss this document with my family after I sign it."
100. A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
c. "I will document in the medical record the support nurse who assists with planning care for my clients."
56. A nurse is talking with the partner of a client who recently died, which of the following statements should the nurse make?
c. "Tell me what I can do for you at this time."
29. A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?
c. "The psychiatric staff is not FBI. They are here to help you."
71. A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching?
c. "You can sign the informed consent form after the provider explains the pros and cons of the procedure."
98. A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge?
c. A client who has a sodium level of 140 mEq/L after one episode of diarrhea
134. A nurse is caring for four clients. Which of the following situations require a signed consent form?
c. Administering an iron injection Z-track method
49. A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?
c. Apply support stockings
144. A nurse is caring for a child who has terminated cancer. Which of the following responses by the child's school-age brother should the nurse expect ?
c. Believes his bad behavior is causing his brother's death
113. A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?
c. Boggy fundus 3 fingerbreadths above the umbilicus
104. A nurse is assisting in the care of a client who has an arteriovenous (AV) shunt in his right arm. Which of the following actions should the nurse take?
c. Check a bruit over the shunt on a regular basis
9. A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client's foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first?
c. Check for pain with passive movement of the affected extremity
88. A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship?
c. Defining responsibilities
147. A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure?
c. Disorientation
62. A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following indicates fluid volume excess?
c. Distended neck veins
125. A nurse is collecting data from a client who just received his first dose of sulfasalazine to treat ulcerative colitis. Which of the following findings should the nurse identify as an indication of an allergic reaction to this medication?
c. Dyspnea
48. A nurse is assisting with the care of a client who has increased intracranial pressure following a closed head injury. Which of the following actions should the nurse take?
c. Elevate the head of the bed to 30 degrees
21. A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching?
c. Encourage the client to be assertive
142. A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?
c. Encourage the client to use positive self talk
34. A community health nurse is assisting in the development of a brochure about hypertension. Which of the following actions should the nurse take?
c. Explain medical terminology using basic, one-syllable words
43. A nurse is reinforcing teaching about breastfeeding with a client who gave birth 2 days ago. Which of the following information should the nurse include?
c. Feed the newborn 8 to 12 times every 24 hr
18. A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate of blood glucose effective management?
c. Glycosylated hemoglobin
51. A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?
c. Grapes
156. A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect?
c. Hypotension
91. A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client?
c. Hypotension
119. A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a contraction stress test. Which of the following statements by the client indicates an understanding of the teaching?
c. I am having this test because my baby was not reactive during a nonstress test
155. A nurse is assisting with a support group for clients who have experienced intimate partner violence. The nurse should identify which of the following client statements as indicating the greatest risk for violence?
c. I have decided to tell my husband I am leaving him
121. A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching?
c. I should check my heart rate while taking this medication
180. A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of this medication?
c. I will place the patch on a hairless area of skin
64. A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this error?
c. Incident report
45. A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?
c. Measure the client's abdominal girth daily
148. A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first?
c. Observe the client during and after meals
15. A nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy. Which of the following findings is the nurse's priority, requiring immediate intervention?
c. Oxygen saturation 89%
53. A nurse is assisting with the care of a client who is at 37 weeks of gestation and is undergoing a nonstress test. Which of the following actions should the nurse take?
c. Remind the client to press the button when she feels fetal movement
106. A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?
c. Semi-fowler's
54. A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?
c. Tilt the client's head forward during meals
36. A nurse is placing a dressing over a stage 1 pressure ulcer on a client's heel, which of the following types of wound dressing should the nurse use?
c. Transparent film
176. A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicate that the client is experiencing an adverse effect of the medication?
c. Urinary retention
101. A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?
c. Urine output 12 mL/hr
78. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?
c. Use a moisture barrier on the client's skin
130. A nurse is caring for a client who has a vacuum-assisted closure system to treat a pressure ulcer. Which of the following actions should the nurse take?
c. Use an adhesive remover to remove tape before reapplying a dressing
159. A nurse is assisting with the plan of care for a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. Which of the following actions should the nurse take?
c. Verify the status of the client's advance directive
122. A nurse is collecting data from a preschooler who has severe dehydration. Which of the following findings should the nurse expect?
c. Weight loss of 10%
117. A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching?
c. You might experience swollen gums while taking this medication
7. a nurse is using a glucometer to a measure a client's capillary blood glucose level, which of the following actions should the nurse take
c. keep the finger in a dependent position
6. a nurse is caring for a patient that recently gave birth to her first child. the new born is crying and the client states, " I cant seem to do anything right. what should I do? which of the following responses should the nurse make?
c. let me show you how to swaddle the baby and cuddle him, then yo try.
93. A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider?
d. "I try not to look at the scales on my body."
A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client is the nurse's priority?
d. "I would rather be alone than with my friends."
103. A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?
d. "Move clients to a room above ground with few windows."
63. A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching?
d. "The harness can promote hip joint development."
146. A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy?
d. 16 lb
11. A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the st aff can medicate a client against his will, without a court hearing, in which of the following situations?
d. A client who is attempting to hurt himself or others
87. A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?
d. Administer the medication to the toddler each evening
165. A nurse is planning to administer four different medications to a client via gastrostomy tube. Which of the following actions should the nurse take?
d. Allow separate medications to flow through the tube by gravity
39.A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?
d. Avoid exposing the neck to the cold
138. A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take?
d. Check for residual urine after voiding
95. A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
d. Complete post mortem care for a client who has died
86. A nurse is preparing to empty a postoperative client's closed-wound drainage system. Which of the following actions should the nurse plan to take?
d. Compress the container before replacing the drainage plug
40. A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement?
d. Determine the client's ability to use the call light
17. A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first?
d. Elevate the head of the client's bed
111. A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect?
d. Hallucinations
168. A nurse in an inpatient psychiatric unit is caring for a client who was raised in an Asian culture. Which of the following communication techniques by the nurse demonstrates cultural sensitivity?
d. Holding eye contact for brief instances
167. A nurse is reinforcing dietary teaching with a client who is at risk for cardiovascular disease. Which of the following statements by the client indicates an understanding of the teaching?
d. I have unsalted pretzels for a snack
120. A nurse is discussing health practices with the mother of a toddler who is from a different cultural background than the nurse. Which of the following statements by the mother indicates that she practices cupping?
d. I sometimes place a bottle containing steam against my child's skin
160. A nurse is reinforcing teaching with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
d. I will have an identification band that matches the one my baby wears
151. A nurse is reinforcing discharge teaching with a client who has a bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching?
d. I will plan to avoid grapefruit juice while taking this medication
151. A nurse is reinforcing discharge teaching with a client who has a bipolar disorder and a new prescription for carbamazepine. Which of the following statements by the client indicates an understanding of the teaching?
d. I will plan to avoid grapefruit juice while taking this medication 152. An assistive personnel tells the charge nurse that her assignment is too
81. A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take?
d. Inform the adolescent that he might experience a headache
163. A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect?
d. Initiate contact precautions for the client
139. A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care?
d. Lie on your left side with your top leg forward
133. A nurse is collecting data from a client who is at 12 weeks of gestation. The client states, "We've been trying to get pregnant for several months, but now I'm not so sure I'm ready." Which of the following responses should the nurse make?
d. Many women experience feelings of ambivalence during pregnancy
73. A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?
d. Notify the charge nurse about the situation
149. A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?
d. Observe the movements of the client's chest wall
55. A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and has a medical history of mild hypertension. For which of the following findings should the nurse instruct the client to monitor and report to the provider?
d. Persistent headache
28. A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?
d. Reduced fat in the stools
176. A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the teaching?
d. Skim milk
179. A nurse is caring for an adolescent that states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?
d. Sublimation
42. A nurse is caring for a client who has terminal cancer and has declined treatment. The nurse attempts to convince the client to reconsider his decision and discusses this attempt with the charge nurse. Which of the following actions should the charge nurse take?
d. Talk with the nurse about the need to support the client's decision
150. A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report?
d. Time of last pain medication
92. A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client's identity?
d. Verify the client's identity using a photograph
162. A nurse is reinforcing teaching with a client who is at risk for hypertension. Which of the following risk reduction strategies should the nurse include in the teaching?
d. Walk for 30 min 5 days per week
46. A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurence of diarrhea?
d. Yogurt
8. a nurse is reviewing the home medications of a client who recently had transient eschemic attacks and is to begin taking clopedicrel. the nurse should the client that which of the following over the counter medications interacts adversely clopedigrel?
d. naproxen
174. A nurse is reviewing laboratory values for a client who has respiratory acidosis. Which of the following arterial blood gas values should the nurse expect?
d. pH 7.30, PaCO2 50 mm Hg
