exit 2021

1. A nurse is reinforcing teaching about adl's with a client who has multiple sclerosis. which of the following client statements should indicate to the nurse and understanding of the teaching? ● "I will take rest periods throughout the day" ● "I will eliminate Vitamin D from my diet" ● "I will take that baths rather than showers" ● "I will decrease my fiber intake"

"I will take rest periods throughout the day"

1. A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in one week. Which of the following client statements indicates an understanding of the teaching? I will follow a full liquid diet the day before the procedure ● I will have my friend drive me home after the procedure ● This procedure will take place while I'm under general anesthesia I can expect rectal bleeding for a week after the procedure.

I will follow a full liquid diet the day before the procedure

1. 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? ● Restrict the client's sodium intake to 3 g/day Measure the client's abdominal girth day ● Keep the clients daily protein intake below 0.8 g/kg ● Position the client supine with legs elevated

Measure the client's abdominal girth day

1. A nurse overhears two assistive Personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first? Tell the staff members to stop there discussion ● Speak to the staff members in private about client confidentiality ● Participate in an in-service about their confidentiality ● Report the incident to the charge nurse

Tell the staff members to stop there discussion

1. A nurse is assisting with the care of a client who is 6 hrs postoperative following a right total arthroplasty. Which of the following actions should the nurse take? ● Remove the clients dressing when it becomes saturated ● Check the clients pedal pulse every hr ● Place an abductor wedge under the clients right knee ● Maintain a head of the clients bed in a high-fowler position.

check the clients pedal pulse every hr

1. A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching? ● "I can have two glasses of wine with dinner" ● "I should decrease my salt intake to 3g/day" ● "I should exercise for 15 minutes 2 times per week" ● "I will set my blood pressure goal at 130/84"

● "I should decrease my salt intake to 3g/day"

1. A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching? ● "I should have waited using spermicide with the cervical cap" ● "I need to keep the cap in place for at least 6 hours after intercourse" ● " I should use the cap during my menstrual cycle to prevent pregnancy" ● "I need to have my provider checks the size of the cap every 6 months"

● "I need to keep the cap in place for at least 6 hours after intercourse"

1. A nurse is reinforcing teaching with a client about collecting a stool specimen to check for occult blood. which of the following statements by the client indicates an understanding of the teaching? ● "having urine mixed in with the stool will not affect the result" ● "I should collect a specimen once each week for 4 weeks" ● "I should avoid eating red meat for 3 days before my test" ● "Eating pasteurized Dairy products will affect my test result"

● "I should avoid eating red meat for 3 days before my test"

1. A nurse is reviewing Laboratory data from a client who has diabetes mellitus. Which of the following Laboratory tests is the most accurate indicator of long-term disease management? ● Fasting blood glucose ● Urine Ketones ● Glucose tolerance test ● Glycosylated hemoglobin.

● Glycosylated hemoglobin.

1. A nurse is reinforcing teaching with a client who has cystocele. Which of the following statements by the client indicates an understanding of the teaching? ● "I will decrease my food intake to reduce incontinence" ● "I should use a perineal spray to reduce odor from urinary leakage" ● " I will experience less urinary incontinence if I use artificial sweeteners" ● " I will practice perennial exercises to decrease urinary leakage"

● " I will practice perennial exercises to decrease urinary leakage"

1. A nurse is reinforcing teaching with a support person of a client who is in the first stage of Labor. Which of the following instructions should the nurse include regarding effleurage? ● "Assist her to breathe in deeply at the beginning of each contraction" ● "Apply steady pressure with this tennis ball to her sacral area" ● "Gently stroked her abdomen during contraction" ● "Help her focus on an object in the room"

● "Gently stroked her abdomen during contraction"

1. A nurse is collecting a health history from the guardian of a four-year-old child. Which of the following statements by the guardian is the priority of the nurse to address? ● "My child still wets the bed at least two times per week" ● "My child continually ask me the same question" ● "I have noticed that my child is withdrawn since we switched daycare provider close ● "I have difficult time getting my child to eat green vegetable"

● "I have noticed that my child is withdrawn since we switched daycare provider close

1. A male nurse is assigned to care for an older adult female client. The client tells the nurse that she wants a female nurse to care for her. Which of the following statements should the nurse make? ● "I will get a female assistive Personnel to provide your bath" ● "I will ask to have you assigned to a female nurse" ● "I care for other female clients and they do not mind having a male nurse" ● "You will need to speak with a nurse manager about this"

● "I will ask to have you assigned to a female nurse"

53. A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching? ● "I can use synthetic blanket on my bed" ● "I will increase the flow rate if I feel short of breath " ● "I will check my oxygen equipment at least once daily ● "I can use isopropyl alcohol to clean the nasal cannula when necessary.

● "I will check my oxygen equipment at least once daily

1. A nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicates an understanding of the teaching? ● "I will know my BP is too high if i get a reading of 140/90 or higher" ● "I will loosely wrap the BP cuff around my upper arm" ● "I will check my BP at a different time each day" ● "I will make sure my hands is about 6inches below my heart when i use the device"

● "I will know my BP is too high if i get a reading of 140/90 or higher"

1. 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? ● "I will mix the medication with a full glass of water" ● "I can prevent constipation if I drink more milk while taking this medication" ● "I can prevent nausea if I take medication on an empty stomach" ● "I will report black stool to my doctor"

● "I will mix the medication with a full glass of water"

1. A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements indicates an understanding of the teaching? ● "I will remove the patch if I develop a headache" ● "I will replace the patch every 12 hour" ● "I will apply the patch in the same place every day" ● "I will place the patch on a hairless area a skin"

● "I will place the patch on a hairless area a skin"

1. A nurse is reinforcing teaching with the parent of a four-month-old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching? ● "I will leave the plastic covering on the crib mattress" ● "I will use a cool mist vaporizer in my baby's room" ● I will leave my baby's bib on while he is sleeping" ● "I will lay my baby's head on a pillow while he is on the crib.

● "I will use a cool mist vaporizer in my baby's room"

1. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states "I can't seem to do anything right. What should I do? Which of the following responses should the nurse make? ● "Let me show you how to swaddle and cuddle him, then you try" ● "I'll take him back to the nursery so you can get some rest" ● "If I turn him on his side maybe he'll go back to sleep" ● "Babies need to cry soon after they are born to develop their lungs"

● "Let me show you how to swaddle and cuddle him, then you try"

1. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective? ● "Our child has lost some weight since his last appointment" ● "Our child has increased his caloric intake" ● "Our child is able to complete his homework on time" ● "Our child has a better grasp of reality"

● "Our child has lost some weight since his last appointment"

1. A 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? ● "For client who has Clostridium difficile I will cleanse my hands with an alcohol-based rub" ● "Soiled dressings should be placed in a biohazard trash receptacle" ● "Droplet precaution require that I wear a gown and gloves when providing client care" ● "following a blood spill I should use a bleach solution with the ratio of 1 to 20"

● "Soiled dressings should be placed in a biohazard trash receptacle"

1. A nurse is assisting with the admission of a client who states "the last time I was in this Hospital the nurses took forever to answer my call light" which of the following is an appropriate response by the nurse? ● "Let's discuss what brought you to the hospital this time" ● "That must have been a difficult experience for you" ● "It will not happen this time because we have more staff" ● "I am sure no one meant to ignore you"

● "That must have been a difficult experience for you"

1. A nurse is providing a change of shift report for a client. Which of the following information should the nurse include in the teaching? ● "The client's mother died four years ago from breast cancer" ● "the client reports pain is reduced when he is position on his side" ● "The clients partner visited earlier today for 2 hours" ● "The client received the prescribed antibiotic every 8 hours"

● "The client received the prescribed antibiotic every 8 hours"

1. A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin. Which of the following information should the nurse include in the teaching? ● "Taking antacid if the medication causes gastrointestinal upset" ● "This medication can increase your risk for sunburn" ● "Restricted daily fluid intake while taking this medication" ● "Expect to experience diarrhea while taking this medication"

● "This medication can increase your risk for sunburn"

1. A nurse is preparing a vitamin K injection to give to a newborn. The newborn mother questions the purpose of the medication. Which of the following responses should the nurse make? ● "This medication will decrease the risk of hemorrhage in your newborn" ● "This medication will increase the absorption of nutrients in the intestines" "This medication will decrease the possibility of your newborn developing jaundice" ● "This medication will increase the immunity of your newborn"

● "This medication will decrease the risk of hemorrhage in your newborn"

1. A community health nurse is assisting with the development of pamphlet recording choking hazards for toddlers which of the following foods should the nurse include ● Potatoes ● Grapes ● Corn ● Oranges

● Grapes

1. A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? ● "This must be very frightening for you. Let's talk more about it" ● "Why do you feel the staff is the FBI" ● "The psychiatric staff is not FBI. They are here to help you" a ● "What makes you think the staff is following you?"

● "This must be very frightening for you. Let's talk more about it"

1. A nurse is preparing to administer 0.9% sodium chloride 1000ml IV to infuse over 8 hour. The nurse should set the IV pump to deliver how many ml per hour?

● 2 mL/hr

1. a nurse is reviewing the medical record of a client. For which of the following events should the nurse write an incident report? (Select all that apply) ● A client received an 0900 daily medication at 1000 ● A client fell when ambulating to the bathroom alone ● A client who has infection refuse the evening meal ● A client received the first dose of an antibiotic 1 hour before the collection of blood for culture and sensitivity testing ● An approximate amount of urine was recorded after the urine leaked from the client's catheter bag

● A client received an 0900 daily medication at 1000, ● A client fell when ambulating to the bathroom alone, ● A client received the first dose of an antibiotic 1 hour before the collection of blood for culture and sensitivity testing

1. A nurse on a medical-surgical 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? ● A client who has cervical cancer and an internal radioactive implant ● A client who had low back to me and has a chest tube drainage system ● A client who had a radical mastectomy 36 hours ago and has a surgical drain ● A client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy.

● A client who had a radical mastectomy 36 hours ago and has a surgical drain

1. A nurse is reviewing clients confidently with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality? ● A nurse tells the chaplain that a client has a new diagnosis of cancer. ● A social worker reads the client's chart as follow up to a requested consultation. ● A nurse discusses a client's postoperative complications during a shift report. ● A facility risk manager includes information from a client's medical record in a written report

● A nurse tells the chaplain that a client has a new diagnosis of cancer.

1. 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? ● Provide privacy during client care procedures ● Allow the client to choose treatment times ● Administer pain medication on a routine schedule ● Be honest with a client about the prognosis

● Allow the client to choose treatment times

1. A nurse is assisting with the plan of care for a client who has Burns to his lower extremities. Which of the following actions should the nurse include in the plan? ● Use hydrogen peroxide for wound cleaning. ● Applied dressing with sterile gloves. ● Cleanse the most contaminated wounds first. ● Perform dressing changes every other day.

● Applied dressing with sterile gloves.

1. A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first? ● Open the flap on the stereo kid nearest to the nurse and place the flap on the work surface ● Open the side flap of the steroid kid allow it to lie flat on the work surface ● Apply sterile gloves ● Open the outermost flap of the steroid get away from the nurse's body

● Apply sterile gloves

1. A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take? ● Call the provider about admitting the client to the facility overnight ● Give the client a list of home care assistance to contact ● Assist with the referral to a home healthcare agency ● Contact the next of kin to assist the client at home.

● Assist with the referral to a home healthcare agency

1. 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. ● Eat 3 large meal each day ● Avoid exposing the neck to the cold ● Clean the neck by rubbing with a washcloth ● Limit fluid intake to 750 ml per day

● Avoid exposing the neck to the cold

1. A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group? ● Believe that death is a punishment for bad behaviour. ● Express curiosity about the funeral service. ● Recognizes the parent will never wake up. ● Understand that everyone dies eventually.

● Believe that death is a punishment for bad behaviour.

1. A nurse at a provider's office is caring for a client who is in the third trimester of pregnancy. Which of the following findings should the nurse report to the provider? ● Periodic numbness of the fingers ● Blurred vision ● Leukorrhea ● Shortness of breath when climbing stairs

● Blurred vision

1. A nurse is completing post-mortem documentation for a client. Which of the following information should the nurse include in the documentation? ● Copy the clients advance directive ● Location of the identification tag on the client's body ● Cause of the client's death ● Last set of the client's vital signs

● Cause of the client's death

1. A nurse is assisting with the care of a client who is hearing loss and has questions regarding their medication. Which of the following actions should the nurse take? ● Sit on the client right side ● Ask a few questions at a ● Exaggerate lip movement while speaking ● Choose the room that is well-lit

● Choose the room that is well-lit

1. A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client? ● Room number of the client ● Name of the client-provider ● Clients telephone ● Clients full medical diagnosis.

● Clients telephone

1. A nurse is collecting data from a client who has alcohol use disorder and experiencing withdrawal. Which of the following manifestations should the nurse expect? ● Bradycardia ● Polyuria ● Constipation ● Hypertension

● Hypertension

1. A nurse is reinforcing teaching with a client who is about to start using an albuterol metered dose inhaler. Which of the following instructions should the nurse include in the teaching? ● Take 3 quick breaths while depressing the canister ● Close your mouth around the mouth piece ● Exhale immediately after inhaler ● Tilt your head forward while inhaling

● Close your mouth around the mouth piece

1. A nurse is collecting data from a client who is 20 wks of gestation and has been taking ferrous sulfate. For which of the following findings should the nurse monitor as a common adverse effect of iron supplement and report to the provider? ● Hematuria ● Tinnitus ● Constipation ● Dry mouth

● Constipation

1. A client is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching? ● Consume soft Bland Foods. ● Rinse the mouth with an alcohol-based mouthwash ● Eat foods high in vitamin B12 ● Use lemon glycerin swabs.

● Consume soft Bland Foods.

1. A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take? ● Raise the HOB to a 45 deg angle ● Place the client's knee in an extended position. ● Hold gentle. direct pressure on the protruding organ. ● Cover the wound with sterile soaked gauze.

● Cover the wound with sterile soaked gauze.

1. A nurse is collecting data from a client who is 1-day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? ● Dark red urine ● Occasional small clots in the urine ● Urine output of 300 ml / 8 hour ● Frequent urge to urinate

● Dark red urine

1. A nurse is collecting data from a 9-year-old child during a Well child visit. Which of the following findings should the nurse expect? ● Grasps concept of cause and effect ● Displays emotional Detachment from parents ● Expresses conflict over Independence and control ● Demonstrate self-centered thinking

● Demonstrate self-centered thinking

1. A nurse Is caring for an older adult client who has acute delirium. which of the following actions should the nurse take first? ● Administer an anxiolytic medication ● Determine the client's level of consciousness ● Encourage message from family man ● Keep lights on in the client's room

● Determine the client's level of consciousness

1. A nurse is assisting with the development of an education program for a group of older adults which of the following actions should the nurse take first? ● Schedule a time to implement the program ● Establish learning outcomes ● Determined literacy level of participants ● Create handouts for participant

● Determined literacy level of participants

1. A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. the nurse should monitor for which of the following adverse effects? ● Diarrhea ● Uterine relaxation ● Hematuria ● Elevated blood pressure

● Diarrhea

1. A nurse in a medical surgical unit is assisting with admission of a client who has advanced lung cancer. Which of the following actions regarding advance directives should the nurse take? ● Ensure that an attorney has reviewed the clients advanced directives ● Document the client's decision about end of life care in the medical record ● Tell the client that a family member should serve as a healthcare surrogate. ● Contact the facility's risk manager to verify if the client has a living will.

● Document the client's decision about end of life care in the medical record

1. 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 procedures when caring for this client? ● Droplet precaution ● Contact precaution ● Airborne precautions ● Protective Environment

● Droplet precaution

1. A nurse is caring for a client who suddenly developed chest pain and dyspnea. Which of the following actions should the nurse take first? ● Prepare the client for ventilation perfusion scan ● Obtain the clients ABG levels ● Elevate the head of the client's beds ● Place the client on bed rest.

● Elevate the head of the client's beds

1. A nurse is reinforcing discharge teaching with a caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching? ● Limit the clients social interactions ● Assume responsibility for making the client's decision ● Maintain a verbal no harm contract with a client ● Encourage the client to be assertive

● Encourage the client to be assertive

1. A nurse is caring for a client who is 2 days postoperative following an above-the knee amputation. Which of the actions should the nurse take to promote progression toward independence and mobility for the client? ● Caution the client to avoid a prone position while in bed ● Encourage the client to use the over bed trapeze ● Keep a loose absorbent dressing over the client's surgical site ● Maintain abduction of the client's residual limb with a pillow

● Encourage the client to use the over bed trapeze

1. A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure? ● Administer an oral contrast solution ● Ensure that the client gave informed consent ● Ensure that the clients bladder is full ● inform the client the procedure will take 60 minutes

● Ensure that the client gave informed consent

1. A community health nurse is developing a brochure about hypertension. Which of the actions should the nurse take? ● Use a 12-point font size ● Write the information at an 8th-grade reading level ● Present information from complex to simple ● Explain medical terminology using basic one-syllable words.

● Explain medical terminology using basic one-syllable words.

1. A nurse is collecting data from a client who has diabetic ketoacidosis. which of the following findings should the nurse expect? ● Clammy skin ● Bounding pulse ● Elevated blood pressure ● Fruity breath odor

● Fruity breath odor

1. A nurse is caring for a client who has a prescription for acetaminophen of 300 mg with codeine 30mg. 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 client care incident? ● Provide a progress notes ● Controlled substance inventory record ● Nursing care plan ● Incident report

● Incident report

1. A nurse is reinforcing teaching with a client who is postoperative following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? ● Ambulate for 15 minutes after each meal ● Consume high fiber food at each meal. ● Drink at least 240 mL (8 oz) of liquid with each meal ● Include 1 serving of protein with each meal.

● Include 1 serving of protein with each meal.

1. A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? ● Administer aspirin if the client develops a fever ● Have visitors remain at least 0.91 meter (3 ft) away from the client ● Assigned a client to negative pressure airflow room ● Initiate contact precaution for the client.

● Initiate contact precaution for the client.

1. A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. after injecting 10 units of air into the NPH insulin vial which of the following actions should the nurse take next? ● Withdraw 10 units of NPH insulin ● Verified the dosage with another nurse ● Inject 15 units of air into the regular insulin ● Place the cap over the needle.

● Inject 15 units of air into the regular insulin

1. A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use? ● Insert the catheter 10 cm (4 in) ● Wait 1 min between suctioning attempts ● Apply suction while inserting the catheter. ● Apply intermittent suction for 30 second

● Insert the catheter 10 cm (4 in)

1. A nurse is using a glucometer to measure a client capillary blood glucose level. Which of the following actions the nurse takes? ● Test the first drop of blood that form after puncture ● Wear sterile gloves ● Keep the finger in a dependent position ● Select the central tip of a finger

● Keep the finger in a dependent position

1. A nurse is positioning a client in preparation for a lumbar puncture. In which of the following positions should the nurse place the client? ● Lateral recumbent ● Semi-fowler ● Lithotomy

● Lateral recumbent

1. A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include? ● Use confrontation to manage the client's Behavior ● Provide a stimulating environment for the client ● Limit the number of choices for the ● Use written signed to assist a client with locating the bathroom

● Limit the number of choices for the

1. A nurse is reinforcing teaching with a newly licensed nurse about transcribing medications prescription. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription? ● Heparin 5000 units subcutaneously every 8 hour ● Doxazosin .5 mg PO at bedtime ● Lorazepam 0.5 mg PO PRN at bedtime ● MgSO4 10 g PO daily

● Lorazepam 0.5 mg PO PRN at bedtime

1. A nurse is preparing to apply a tight length sequential compression device for a client who is postoperative. Which of the following actions should the nurse take? ● Turn the mechanical unit prior to applying the sleeve ● Wrap the sleeves loosely around the client lower leg ● Measure the circumference of the client upper leg ● Position the client prone to apply the device

● Measure the circumference of the client upper leg

1. A nurse in a Mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first? ● Minimize environmental stimuli in the clients surroundings. ● Administer an anti-anxiety medication. ● Explain to the client that anxiety causes physical manifestation. ● Explore behaviour that has helped to reduce the clients anxiety in the past.

● Minimize environmental stimuli in the clients surroundings.

1. 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 the client to a safe location 1 ● Pulled the nearest fire alarm 2 ● Shut all doors and windows 3 ● Attempt to extinguish the fire. 4

1. A nurse is reviewing the whole medication of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. nurse instructs the clients which of the following over the counter medications interacts adversely with clopidogrel? ● Ranitidine ● Vitamin D3 ● Docusate sodium ● Naproxen

● Naproxen

1. A nurse is collecting data from a client who is 12-hour postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to the client ambulation? ● Oxygen saturation 90% ● Respiratory rate 20 per minute ● Oral temperature 37.6 degree C (99.7 degree F) ● Apical pulse rate 88 per minute

● Oxygen saturation 90%

1. A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take? ● Add moisturizing oil to the client's bath water ● Encourage the client to bathe frequently ● Apply powder to the client's skin ● Place a humidifier in the clients room

● Place a humidifier in the clients room

1. A nurse enters the room of a school age child and finds them on the floor experiencing a clonic tonic-clonic seizure. Which of the following actions should the nurse take? ● Place a padded tongue blade in the child's mouth Turn the tiles on to their back ● Restrained. Charles upper extreme ● Place a pillow under the child's head

● Place a pillow under the child's head

1. A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphasia. Which of the following instructions should the nurse include in the teaching? ● Place oral suction equipment next to the client's bedside ● Use a needleless syringe to instill feeding ● Provide thin liquids to help the clients swallow ● Give the clients a straw to use for drinking.

● Place oral suction equipment next to the client's bedside

1. A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include? ● Place the shoulder harness at the level of the infants shoulders ● Position. Carseat in a 90 degree angle ● Keep the air back on if the car seat is in the front seat ● Put a small cushion under the newborn's head for support.

● Place the shoulder harness at the level of the infants shoulders

1. A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures? ● Irrigation of a wound with antibiotic solution ● Placement of a central venous catheter ● Administration of an iron injection using Z-track technique ● Insertion of a nasogastric tube

● Placement of a central venous catheter

1. A nurse in an acute mental facility is caring for an adolescent who is exhibiting destructive behaviour. Which of the following actions should the nurse take after applying physical restraints to the client? ● Monitor the clients ROM every 60 min ● Plan to remove the restraint as soon as the client is calm. ● Offer the client nutritious snacks every 4 hr. ● Ensure a provider has signed a prescription for restraints within 48 hr.

● Plan to remove the restraint as soon as the client is calm.

1. A nurse is collecting data from a client during a routine prenatal visit. the client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nursetake? ● Position the client on their left side ● Provide the client with a glass of orange juice ● Check the clients temperature ● Instruct the client to take a brisk walk

● Position the client on their left side

1. A nurse is caring for a client who has anorexia nervosa and a Behavioral Management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective ● Sodium 130 mEq/L ● Hgb 10g/ dL ● Potassium 3.5 mEq/L ● BMI 14.5

● Potassium 3.5 mEq/L

1. A nurse is contacting an occupational therapist for a client who had a stroke with right-sided weakness and has difficulty eating. Which of the following roles should the nurse expect the occupational therapist to perform? ● Provides in adjust devices to assist a client with daily living activities ● Assist in finding an economic living arrangement for the client ● Uses heat, massage and water to treat the client strength and movement ● Promotes Health by ensuring the clients nutritional needs are met.

● Provides in adjust devices to assist a client with daily living activities

1. A nurse is administering pancreatic lipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? ● Decrease sodium excretion ● improve absorption of vitamins B and C ● Reduce fat in the stools ● improved respiratory function

● Reduce fat in the stools

1. A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the clients from self-harm the nurse places the wrist restraints on the client. Which of the following actions should the nurse take? ● Remove the restraints from the clients wrist every 2 hours Fast and the restraints ties to the bed side rails ● Contact the provider within 48 hours to obtain a prescription for that restrained ● Check that one finger will fit between the clients wrist and the restraints.

● Remove the restraints from the clients wrist every 2 hours

1. A charge nurse is monitoring a group of assistive Personnel regarding the use of gloves in contact isolation. For which of the following actions by an AP should the charge nurse intervene? ● Wash his hands after removing gloves ● Removes gloves last after other personal protective equipment ● Pulls gloves off inside out when task are completed ● Changes gloves between tasks for the same client.

● Removes gloves last after other personal protective equipment

1. A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, " I guess i will be locked in my room again for wetting the bed," Which of the following actions should the nurse take? ● Report the suspected abuse to the nurse manager. ● Review the medical record to see if the client has reported abuse in the past ● Contact family members from visiting with the client. ● Restrict family members from visiting with the client.

● Report the suspected abuse to the nurse manager.

1. A nurse is caring for a client who follows a Kosher diet. Which of the following menu items should the nurse include on the tray? ● Pulled pork sandwich ● Clam chowder ● Shrimp salad ● Roasted salmon

● Roasted salmon

1. A nurse is collecting data from a client who received oxytocin 10 unit IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? ● Client reports of burning with urination. ● Client report of uterine cramping. Boggy fundus three-fingerbreadths above the umbilicus. ● Saturation of perineal pad in 15 minutes

● Saturation of perineal pad in 15 minutes

1. A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray which of the following methods should the nurse use to verify the placement? ● Measure the gastric residual ● Add food coloring to the formula ● Inject air and listen for bubbling. ● Test the pH of the gastric aspirate.

● Test the pH of the gastric aspirate.

1. A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, Which of the following findings indicates the information likely contains credible medical information? ● The website URL is listed as .com ● The website was last updated 3 years ago ● The author's name is listed without credentials. ● The author cites references to statements made.

● The author cites references to statements made.

1. A nurse is collecting data from a client whose partner died 1 year ago. Which of the following findings indicates that the client is experiencing complicated grief? ● The client attends a grief support group twice each month. ● The clients keep a framed picture of his partner on the wall. ● The client reports he has no interest in dating. ● The client develops chest pain each time he talks about his partner.

● The client develops chest pain each time he talks about his partner.

1. A nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings as the priority to report to the provider? ● The client neglects personal hygiene ● The client reports a change in sleeping patterns ● The clients have a sudden increase in energy. ● The client is withdrawn and uncommunicative

● The clients have a sudden increase in energy.

1. A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching? ● The staff will weigh me every night before I go to bed ● The staff will watch me closely for 1 hour after each meal ● I should gain half a pound per week to meet my treatment goal. ● The treatment goal is to be within 60% of my ideal body weight.

● The staff will watch me closely for 1 hour after each meal

1. A nurse is preparing to give a change of shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? ● Preferred bath time ● Steps required for dressing change ● Admission vital signs ● Time of last pain medication

● Time of last pain medication

1. A nurse is assisting in providing post-mortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family? ● To stay with the client body for 8-hour following their death ● To cremate the client's body ● To prohibit medical personnel from touching the client's body ● To bury the client's body with in 24 hours of their death

● To stay with the client body for 8-hour following their death

1. A nurse is administering Hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication? ● Tachypnea ● Dilated pupils ● Urinary retention ● Hypertension

● Urinary retention

1. 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? ● Hgb 13.2 g /dL ● Fasting blood glucose 72 mg/dL ● Urine protein 3 plus ● BUN 15mg/dL

● Urine protein 3 plus

1. A nurse is caring for a client who has been admitted to the mental health unit. well reinforcing teaching about the client's prescribed medications the nurse communicates truthfully about the adverse effects of the medication. Which of the following ethical Concepts is the nurse exhibiting? ● Beneficence ● Autonomy ● Veracity ● Justice

● Veracity

1. A nurse is supervising an assistive personnel who is providing client care. The nurse should identify which of the following actions by the AP demonstrate effective use of supplies? ● Empties the sharps container when it is full ● Wear clean gloves when performing oral hygiene ● Where's an n95 mask when bathing a client who is clostridium difficile ● Dispose of contaminated sheets in a linen bag

● Wear clean gloves when performing oral hygiene

1. A nurse is collecting data from a 6mnth old infant during a well-child visit. Which of the following findings should the nurse report to the provider? ● Temperature ● Gross motor skills ● Feeding habits ● Weight

● Weight