let’s hope this is it
A nurse is reinforcing with a client who is about to start using albuterol metered dose inhaler. Which of the following instructions should the nurse include in the teaching?
"Close your mouth around the mouthpiece."
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 will check my oxygen equipment at least once daily."
A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?
"I will notify my doctor if the stoma starts to look purple."
A nurse is reinforcing teaching with a client who has new prescription for ciprofloxacin. Which of the following information should the nurse include in the teaching?
"This medication can increase your risk for sunburn."
A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?
''I will give this medication to my child once daily in the evening.''
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?
''Lie on your left side with your top leg forward.''
Additional info
**1. Epi pens can be injected through clothing 2. Epi pens have expiration dates3. Epi pens have a predosed amount4. Epinephrine is a vasodilator. 5. Can cause headache, dizziness, fatigue, nausea and vomiting**
**It is important to ask the client about allergy to penicillin or other antibiotics before administering nafcillin.
**It is important to ask the client about allergy to penicillin or other antibiotics before administering nafcillin.
A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
- " I lost my balance and fell when I got out of bed to go to the bathroom."
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 medication is effective?
- " Our child is able to complete his homework on time."
A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
- "Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom."
A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?
- "Discontinue the medication. I will ask your provider for another antibiotic."
A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states,
- "I guess I have to take some of the blame because of the way my friends
A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching?
- "I will use a cool mist vaporizer in my baby's room."
A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?
- "My partner will use condoms with spermicides."
A nurse is assisting in the care of an older adult who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?
- "Prednisone can cause blood glucose levels to increase."
nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to undergo an amniocentesis. Which of the following information should the nurse include in the instructions?
- "You will need to have an empty bladder for the test."
A nurse is reinforcing teaching to the parents of an infant who has Pavlik harness. Which of the following statements should the nurse include in the teaching?
- "the harness promotes hip joint development."
A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?
- ''Have your child wear a medical identification wristband.''
A nurse is reinforcing teaching about home safety with the parents of a 6-week-old infant. Which of the following instructions should the nurse include?
- - "Keep one hand on your baby's abdomen if you must turn away while he is on the changing table."
A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching
- -Information regarding client health can be emailed if encrypted
Active Shooter
- -run, hide, fight, call 911 when safe to do so
A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following clients should the nurse identify as the priority?
- A client has full thickness burns to face and trunk
A nurse in a mental health facility receives a change of shit report on 4 clients. Which of the following clients should the nurse plan to assess first?
- A client placed in restraints for aggressive behavior
A nurse is reviewing the medical records of five clients. 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 nurse is assisting with discharge planning for a group of clients during a mass casualty incident which of the following client should the nurse recommend for discharge
- A client who had diabetic ketoacidosis and has a blood glucose level of 120 mg/dL
A nurse is receiving a change of shit report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A client who has a hip fracture and a new onset of tachypnea
A nurse is recommending a client for discharge to allow for admission of a client following a tornado disaster. Which of the following clients should the nurse recommend for discharge?
- A client who has a sodium level of 140meq/L ater one episode of diarrhea
A nurse is receiving change of shift reports from four clients. Which of the following clients should the nurse see first?
- A client who has cirrhosis and hematemesis
A nurse is receiving change of shift report on four clients. Which of the following clients should the nurse plan to see first?
- A client who has femur fracture and reports numbness of the toes
A charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A client who is one day post-operative following a vertebroplasty
A nurse has just received a change of shit report for four clients. Which of the following clients should the nurse assess first?
- A client who was just given a glass of orange juice for a low blood glucose level
A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?
- A nurse discovers that a clients family member has administered a PCA dose
A nurse is reviewing confidentiality with a group of newly nurses. Which of the following situations should the nurse as an example of breach in confidentiality?
- A nurse tells the chaplain that a client has a new diagnosis of cancer
A nurse is assisting with the planning of an in service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?
- A peer reviewed journal article
A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?
- A social worker who is assigned to an involuntarily committed school age client
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?
- Administer the medication to the toddler each evening
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?
- Advance directives include a living well
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?
- Anaphylactic
A nurse is delegating client care assignments. Which of the following tasks should the nurse assign to an assistive personnel?
- Apply anti embolic stockings for a client who is 2 days postoperative.
A nurse is caring for a client who has depressive disorder the client states everyone will be better off if I were not around which of the following responses should the nurse make
- Are you thinking of hurting yourself?
A nurse is preparing to admit a 6-year-old with varicella to the Pediatric clinic. Which of the following actions should the nurse take?
- Assign a child to a negative air pressure room
A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?
- Assist in discharging stable clients to home.
A nurse at long term care facility is reviewing the plan of care who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to assistive personnel?
- Assist the client with range of motion exercises of the hands
A client is collecting nutritional data from a group of adult clients. Which of the following clients should the nurse recommend an inter-professional conference with dietician?
- BMI of 32
a nurse is caring for a school-age child who is post-operative and received morphine via IV blouse for pain 10 minutes ago. which of the following findings is the nurse's priority
- Bradypnea
A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?
- Check the client's status every hour.
A nurse is caring for a client who adheres to kosher dietary practices. Which of the following foods should the nurse plan to offer the client?
- Chicken sandwich
NGN #10 A nurse in an emergency department for a client (click to the finding that requires follow up.
- Clean presents for evaluations of severe pain in upper abdomen that radiates into his back. - States pain began approximately 12 hr ago and it works when he is supine or after he eats - Sclera is noted to be yellow.- Abdomen firm, bowel sounds hypoactive. - Client guards abdomen and grimaces during palpation
Thenurseiscaringforanolderadultwhowearshearingaidswith detachable ear molds. Which of the following actions should the nurse take when caring for the hearing aids?
- Clean the hearing aids with a soft cloth.
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?
- Client report of uterine cramping
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?
- Client's telephone number
A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- Complete post mortem care for a client who has died.
A charge nurse is observing a newly licensed nurse who is having difficulty finishing all client care activities by the end of his shift. Which of the following statements should the nurse make to help the newly licensed nurse improve his time management skills?
- Complete the task for one client before moving onto the next client
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?
- Cover the wound with a sterile saline soaked gauze
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
- Determine if the client's Health Care surrogate is aware of the risks and benefits of the procedure
A nurse is assisting with the development of an education program for a group of adult clients. Which of the following actions should the nurse take first?
- Determine the literacy level of participants
A nurse on a medical surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- Determine the medical needs of incoming clients through the emergency department
nurse is providing a client with IV fluids and finds that the IV pump screen us malfunctioning. Which of the following actions should the nurse take?
- Discontinue use and tag the IV pump
A nurse delegates a task to an assistive personnel (AP) and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?
- Discuss the AP's concerns about performing the task.
A nurse is caring for a client who has bipolar disorder.The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?
- Displacement
A nurse is assisting with the care of a client who is receiving continuous IV infusion. Which of the following indicates fluid volume excess?
- Distended neck veins
A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?
- Dry hands thoroughly from fingers to wrist
A nurse is contributing to the plan of care of a client who has urinary incontinence which of the following interventions should the nurse suggest to help prevent skin breakdown
- Dry the skin thoroughly after cleansing the perineal area
A nurse is caring for a client who has peptic ulcer disease and is schedule to undergo esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?
- Ensure that the clients gave informed consent
A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?
- Ensure the device is kept below the level of the client's chest.
A home health and nurse is caring for a child who has Lyme disease. which of the following is an appropriate action for the nurse to take.
- Ensure the state department has been notified
A nurse is caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously. Which of the following adverse effects of the medication should the nurse report to the provider?
- Epistaxis
A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?
- Fidelity
A nurse and an assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions?
- Flex his hips while pulling the client.
A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client?
- Head flexed to the chest and her knees pulled up to the abdomen
A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?
- Headaches with aura
A nurse is performing post mortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
- Hold the clients I shut for a few seconds
A nurse in a long-term care facility is observing an assistive personnel (AP) who is performing hand hygiene. Which of the following actions by the AP requires intervention?
- Holding his hands up and elbows down while washing his hands
Contraindication for oral contraceptives?
- Hypertension
A nurse is reinforcing teaching with a client about advance directives and a healthcare proxy which of the following client statements and the kids and understanding of the teaching
- I do not need to name a relative as my designee in my health care proxy
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 need to keep the cap in place for at least 6 hours after intercourse
A nurse is reinforcing discharge teaching with a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?
- I should throw away my used tissues in a closed plastic bag
A nurse is reinforcing teaching with a female client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?
- I should use supplemental birth control while I am taking this medication
A nurse in a provider office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?
- I will dry my skin by patting it with towel
The nurse on a mental health unit is caring for a client who has anorexia nervosa. Which of the following statements by the nurse promotes the ethical principle of client autonomy
- I will only discuss your medical information with the healthcare team
A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?
- I will wash my baby's face with a warm, wet washcloth without soap
A charge nurse is concerned about a recent increase in facility acquired catheter infections. Which of the following actions should the nurse take first?
- Identify possible precipitating factors related to the infections
A nurse is caring for a client who has a prescription for acetaminophen 300mg with codeine 30mg, 1 tablet every 3 to 4 hr. PRN for pain. Th nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?
- Incident report
A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching?
- Information regarding client health be e-mailed if encrypted
Anurseiscaringforaclientwhohasschizophrenia.Whichofthefollowing behaviors of the client should the nurse identify as a negative symptom?
- Initiates speech rarely
A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?
- Instruct the client to change positions frequently
A nurse is reinforcing teaching about hand hygiene with a newly licensed news which of the following information should the nurse include in the teaching
- Interlace the fingers while rubbing hands together
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.
A home health nurse is collecting data from a client who has advanced dementia and whose caretaker recently passed away. The client is not violent or suicidal. For which of the following treatment settings should the nurse recommend a referral for this client?
- Long term nursing care center
A nurse is preparing to apply a thigh-length sequential compression for a client who is postoperative. Which of the following actions should the nurse take?
- Measure the circumference of the client's upper leg
A nurse in a long-term care facility is delegating care for a group of clients for the upcoming shift which of the following tasks the nurse delegate to assistive personnel (select all that apply)
- Measure vital signs for a client who requires contact precaution - record urine output for a client who has a super pubic catheter - trees for a client who is receiving radiation therapy to radiology
A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?
- Move the client's bed to the main floor of the house
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?
- Onset of hearing loss
A nurse is supervising 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?
- Oral suction equipment
A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practitioner nurse?
- Perform a sterile dressing change for a client who has an abdominal wound
A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?
- Perform pelvic rocking exercises several times per day.
A nurse is caring for an older adult client who reports dry itchy skin. Which action should the nurse take?
- Place a humidifier in the client's room
A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention
- Place the client in a room that is ventilated to the outside.
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- Place the shoulder harnesses at the level of the infants' shoulders
A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?
- Plan to remove the restraints as soon as the clients is calm
A nurse is reviewing the medical record of a client who is at 37 weeks of gestation and has HELLP syndrome. Which of the following laboratory findings should the nurse expect?
- Platelet count 77,000/mm3
A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy ECT for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?
- Provide frequent reorientation after ECT
Anurseisreinforcingteachingaboutcarseatsafetytotheparentsofanewborn. The nurse should instruct the parents to place the car seat in a....
- Rear-facing position in the back seat.
A nurse's developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?
- Remind the client to use an incentive spirometer
A nurse is reinforcing teaching about home safety precautions with the parents of a 3- month-old. Which of the following instructions should the nurse include in the teaching?
- Remove bibs when the infant is going to sleep.
While performing a routine assessment, a nurse notices praying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?
- Remove the device from the room
A nurse is caring of a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?
- Remove the restraints from the client's wrists every 2 hr.
A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the following actions should the nurse take?
- Request the services of an interpreter to determine the client's wishes.
A nurse is caring for a client who speaks a different language than the nurse. The clients partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the ff actions should the nurse take?
- Request the services of an interpreter to determine the clients wishes
A nurse is discussing risk factors for child abuse with members of the parenting group the nurse should identify which of the following findings as that characteristic of perpetrators of a child abuse
- Rigid expectations of behavior
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?
- Roasted salmon
A nurse's assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client's food tray?
- Scrambled eggs and toast with milk
A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply)
- Sensation of tingling - Pale-colored toes - Diminished capillary refill
A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?
- Skin rash with fever
A nurse is planning a health- promotion program for high school students. Which of the following facts about smoking is likely to be most effective in changing the adolescent's attitudes toward smoking
- Smoking causes unattractive stains on the teeth and hand.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. e nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- Speak directly to the client
A nurse manager in a long-term care facility is discussing evidence-based practice with a group of staff nurses which of the following activities should the nurse manager identify as an example of evidence-based practice
- Staffing the unit based on client acuity and needs
A nurse is caring for a client who is receiving continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take?
- Stop the infusion
A nurse is caring for an adolescent who 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?
- Sublimation
A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
- Supplement spoken language with pictures
A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
- Supplement spoken language with pictures. Or review the facility policy about the use of an interpreter
A nurse is assisting with care of a client who is receiving chemotherapy and radiation for advances breast cancer. The client states "I am thinking about stopping the treatment. Which of the following responses should the nurse make?
- Tell me more about what are you thinking
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure?
- Temporary memory loss
A nurse is observing assistive personnel take a client tympanic temperature which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure
- The AP pulls the pinna up and back
A nurse is preparing to delegate client care to an assistive personnel AP. Which of the following information should the nurse verify prior to delegation?
- The AP's job description
A nurse is participating in an inter-professional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?
- The client is unable to grasp eating utensils
A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching?
- The infant is lying in the crib with a stuffed animal.
A nurse in a provider's office is collecting data from a client who has candidiasis. Which of the following findings should the nurse expect?
- Thick, white vaginal discharge
A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take?
- Verify the medication three times with the medication administration record.
A nurse is reviewing the laboratory values of a client who has COPD. Which of the following findings should the nurse report to the provider?
- WBC 13,000/mm3
A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?
- Wash hands with soap and water for 20 seconds.
A nurse is reinforcing teaching with the client family about home oxygen use via nasal cannula which of the following statements by a family member indicates an understanding of the teaching
- We will frequently check the top of his ears for sores
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- Wear clean cotton socks everyday
A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of the following interventions should the nurse include in the plan?
- Wear loose fitting underwear
A nurse is admitting a client who is hesitant to create Advanced directives due to concerns about legal representation. which of the following statements should the nurse make
- advanced directives can be a verbal agreement between you and your provider until legal review can be obtained.
A nurse is caring for a post-op client. Which of the following interventions will reduce the risk of DVT?
- apply venous plexus boots
A nurse is planning to teach a client and their family about home oxygen therapy. which of the following information should the nurse plan to include in the teaching
- avoid using nail polish remover around the client
A nurse is instructing a school-age child who has asthma about the use of a expiratory low meter. which of the following instruction should the nurse include in the teaching
- blow into the meter as hard and quickly as possible
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. for which of the following therapeutic efects should dinners monitor the client
- deep tendon relexes 2 +
a nurse is reviewing the medical records of four clients the nurse should identify that which of the following client findings require follow-up care
- inclined who is taking Warfarin and has an INR of 1.8
A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?
- limit oral feedings to 30 minutes in length
a nurse is providing palliative care to a client whose partner asks why music therapy has been recommended. appropriate responses:
- music therapy can help her verbally express emotions - music therapy works as a distraction and can help alleviate her pain - music therapy can help facilitate mvmt in some clients who have mobility limitations
Breach of confidentiality question
- nurse tells Chaplin pt has cancer
A nurse is assisting a client who has an abdominal incision. which of the following findings should dinners report to the provider
- partial separation of the upper part of the incisional line
A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. which of the following instruction should the nurse include
- perform chest percussion and postural drainage at least twice daily
A nurse is caring for a client who has a placenta previa. which of the following findings should the nurse expect
- spotting
A nurse is teaching a new parent about breastfeeding her 2 week old infant. Which of the following statements by the parent indicates an understanding of teaching?
- the more my baby is at the breast sucking, the more milk I will produce
A nurse is reinforcing teaching with the mother of a 2-month-old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements by the mother indicates an understanding of the teaching?
-"I will check my baby's skin three times each day."
A nurse working in a provider's office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is correct?
-"When all the blisters are scabbed over"
A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching?
-"You should increase fluid intake to relieve dysuria"
A nurse is collecting data from an adolescent who has experienced sexual abuse. Which of the following statements by the client should the nurse recognize as the use of the defense mechanism of suppression?
-'Sometimes I get angry about it, but I know that just creates other problems."
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?
--Protein
Order: carbamazepine 19 mg/kg/day to be divided into 2 doses Weight: 25 kg Dose on hand: carbamazepine 50 mg
-237.5 mg
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV). Which of the following rooms should the nurse assign the infant?
-A private room with contact/droplet precaution
A nurse in an outpatient facility is preparing to administer nafcillin (Unipen) IM to an adult client who has an infection. Which of the following actions should the nurse plan to take? (Select all that apply.)
-Administer the medication deeply into the ventrogluteal muscle. -Ask the client about allergy to penicillin before administering the medication. -Monitor the client for 30 min following the injection.
A nurse is preparing a client on the medical-surgical unit for hemodialysis. Which of the following actions should the nurse take?
-Auscultate the arteriovenous (AV) access
A nurse is caring for a client who has AIDS. which of the following solutions should the nurse use to disinfect the clients overbed table following a blood spill
-Bleach
A nurse is auscultating a client's abdomen for the presence of bowel sounds.Which of the following findings should the nurse expect for hypoactive bowel sounds?
-Bowel sounds heard after 2mins.
A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the inter-professional team?
-Case manager
A nurse is caring for a client in an acute care setting who was admitted with a cerebral spinal fluid (CSF)infection caused by a highly gram-negative bacteria. Which of the following cephalosporinIV antibiotics should the nurse expect to be effective in treating this infection?
-Cefepime (Maxipime)
A nurse is assisting with a prenatal examination of a client who is at 8 week 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
-Chadwick's sign
A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?
-Chadwick's sign
A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks," Why is colostrum so important for my baby?" Which fox of the following responses should the nurse make?
-Colostrum provides many important antibodies that the newborn lacks
A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take to intervene for manipulative behaviors during group therapy?
-Discuss consequences of inappropriate behaviors
A nurse is reviewing the medical record of a client who attempted suicide. Which of,the following findings should the nurse identify as risk factors for suicide? (Select all that apply)...
-Dx of major depressive disorder -Unemployment -Access to firearms
A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regimen. Which of the following instructions should the nurse include
-Eat a piece of fruit before exercising
A nurse is caring for a client who is 1 day post op following a total hip arthroplasty and is receiving heparin sub Q. which of the following adverse effects of the medication should the nurse report to the provider
-Epistaxis
A nurse is collecting data who is taking tranylcypromine and reports ingestion of tyramine rich foods. The nurse should monitor the client for which of the following findings as an adverse effect of this medication
-Hypertension
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car seat. Which of the following statements by the parent indicates an understanding of the teaching?
-I can place a rolled towel on each side of my newborn's head until he can hold his head up.
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? (Idk if this correlates)
-Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride
A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse's role in obtaining informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching
-It is my responsibility to obtain informed consent from the client prior to the procedure
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
-Limit the number of choices for the client
A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client's medications prior to contacting the provider. Which of the following medication is the likely cause of the increased sedation? (Idk if it correlates)
-Lorazepam (Ativan)
A nurse is assessing a client in labor who has had epidural an esthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
-Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication. (*RESTLESSNESS CAN BE INDICATED FOR UNRELIEVED PAIN FOR SPINAL EPIDURAL**)
A nurse in an acute facility is assisting with the development of an in service about reducing environment stressors to improve clients sleep. Which of the following instructions should the nurse include
-Turn on overhead lights briefly when checking IV lines
A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching?
-Wash the bed linens in hot water. Clean the child's toys with 1:10 bleach solution.
A nurse is assessing a school-age child immediately postoperative following a perforated appendix repair. Which of the following findings should the nurse expect?
-absence of peristalsis
A nurse is teaching a client who has multiple allergies about using an epinephrine auto-injector. Which of the following instructions should the nurse include?
-administer the medication through clothing if necessary
What intervention must be implemented for a client who has kidney failure with peripheral edema
-decrease water intake
A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?
-grilled salmon
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
-hacking cough
A nurse is reinforcing with a client who has hypothyroidism and a new prescription for levothyroxine. The nurse should instruct the client to notify the provider of which of the following manifestations?
-pruritus
The nurse helps minimize an older adult patient's risk of developing pernicious anemia by which of the following actions?
-suggesting supplementing vitamin A
A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?
-whooping cough
A nurse is reinforcing teaching with a client about measures to reduce the manifestations of irritable bowel syndrome. Which of the following statements should the nurse make?
-you should chew sugarless gum to decrease bloating
**-IM injection: 90 degree >**Sites: Ventrogluteal, deltoid, vastus lateralis (peds)35**Needle size: 18-25 gauge, 5⁄8 - 1⁄2 inches **Solution amount: 1-3 mL. DIVIDE LARGER VOLUMES INTO 2 SYRINGES AND USE 2 DIFFERENT INJECTION SITE
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A nurse is collecting data from an adolescent who has experienced sexual abuse. Which of the following statements by the client should the nurse recognize as the use of the defense mechanism of suppression?
. "I drink beer as often as I can so that I don't have to think about all of the times it happened."
A nurse is caring for a group of clients. Which of the following clients should the nurse recognize is experiencing fluid volume excess?
A client who has heart failure and has had orthopnea for 2days
NGN 9 a nurse is caring for a client in the emergency department. complete the diagram by dragging from the choices below to specify what conditions the client is most likely experiencing, 2 actions the nurse should take to address the condition 2 parameters the nurse should monitor to assess the client (potential question)
Action 1 - Reduce external stimuli Action 2 - Engage with the client several times each day to establish trust Condition- brief psychiatric disorder Parameter to monitor 1- ability to care for self Parameter to monitor 2- suicide risk
NGN 28 A nurse is caring for a 75-year-old client who was admitted to the medical Surgical unit.
Action 1- Assess for Homan's sign Action 2- Request a prescription for a lower extremity(something)Condition experiencing- Deep vein thrombosis Parameter 1- PT/INR and platelet count Parameter 2- Signs of bleeding ater anticoagulation indication
A nurse is providing site care for a child who has ask in-level gastrostomy enteral tube. Which of the following actions should the nurse take?
Apply a skin barrier protectant to the skin.
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
Hallucinations
A nurse is reinforcing with a client who has pernicious anemia. Which of the following statements by the client indicated an understanding of the teaching
I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize
A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.Which of the following statements by the parent indicates an understanding of the teaching?
I will make sure that I can fit one finger between the mattress and the side of my newborn's crib
A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is anticoagulant therapy. Which of the following actions should the nurse take?
Initiate bed rest.
A nurse is positioning a client in preparation for a lumbar puncture. Which of following positions should the nurse place the client?
Lateral recumbent
Anurseiscaringforaclientwhohascirrhosisoftheliver:
Monitorforabdominal ascites
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 nurse take?
Position the client on their left side
nurse delegates a task to an AP and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?
Report the AP to the risk management OR discuss what's wrong
A nurse is caring for client who has major depressive disorder and is taking antidepressant. The nurse should identify which of the following findings as the priority to report to provider?
The client has a sudden increase of energy
A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? (Select all that apply.)
The client states their muscle spasms are absent. The client denies being confused.
A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply)
Vitamin A: is important for tissue synthesis, wound healing, and immune function. -Vitamin B12: assists in the development of red blood cells, maintenance of nerve function, and is needed for cell maintenance and tissue synthesis. -Vitamin C: is important for capillary formation, tissue synthesis, and wound healing. -Vitamin K: functions as an enzyme in the synthesis of prothrombin and other proteins required for normal blood clotting
HELLP syndrome
disorder that's usually associated with preeclampsia
Caring for Client Who Is Experiencing Fatigue
i. You want to encourage the patient to conserve their energy by resting, eating an adequate meal, and encourage fluid intake. ii. Research has shown that physical activity during or after cancer treatment can decrease fatigue. Referring to an exercise specialist to help safe exercise. Yoga is an example that will improve sleep. iii. An intervention for fatigue is making sure that the patient is getting adequate sleep.
A patient newly diagnosed with hypothyroidism is prescribed Levothyroxine (Synthroid) 0.25 mg PO daily. After 6 weeks of treatment the nurse determines that the medication was effective if the:
thyroid-stimulating hormone (TSH) level is 2 microunits/mL
A nurse in a provider's office is reinforcing teaching about skin care with a client who has a diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? (Idk if it correlates)
● I will dry my skin by pat it with a towel
