NCLEX 5

A client diagnosed with a severe sprain of the right ankle must avoid all weight-bearing on the right foot. Which demonstration by the client indicates proper use of the crutches? (Select all that apply.)

5) INCORRECT- Crutches should be kept 8 to 10 inches out to side. NOT 14 to 16 inches out to the side. Also elbows should be flexed 20-30 degrees. Ensure rubber tips are on both crutches.

A client comes to the clinic and reports general sadness, exhaustion, and a loss of interest in activities. The client is interested in taking St. John's wort. Which medications, currently prescribed to the client, cause the nurse to be concerned? (Select all that apply.)

Digoxin.3.Nifedipine.4.Simvastatin.5.Escitalopram.

The nurse provides care for a client following a permanent pacemaker insertion 4 hours ago. Which assessment finding indicates the procedure was successful? (Select all that apply.)

Paced spikes noted on the cardiac monitor. Pulse is 78 beats per minute.2.Blood pressure is 118/78 mm Hg.

A client who has been confined to bed for several weeks begins to show early signs of a pressure injury on the heel. Which action does the nurse take? (Select all that apply.)

Place a rolled towel under the calf.4.Have the client wear socks when moving in bed. do NOT massage the area or apply lotion

A client diagnosed with a head injury is being prepared for a lumbar puncture. Which action will the nurse take first?

Measure pre-procedure vital signs. Before education or implementation.

The nurse reviews the medical record under the prescription tab. Which prescription documented in the medical record should the nurse address with the health care provider regarding appropriate abbreviations and standard terminology when documenting care? (Select all that apply.)

"Aspirin 81 mg q.d." "MS 4 mg PRN" ASA is ok to use

The nurse prepares a client diagnosed with cervical cancer for the insertion of an internal radiation implant. Which client statement requires immediate follow-up by the nurse?

"I will get up only when I have to urinate, and then I will go right back to bed." 3) CORRECT — This is the priority concern. The client will be on strict bed rest, supine with the head of the bed elevated no more than 20 degrees. Movement is restricted and an indwelling catheter is inserted into the bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts. Severe radiation burns can result from a distended bladder or from the client attempting to go to the bathroom and void.

The nurse has educated a client diagnosed with esophageal cancer who will be having an implanted port for chemotherapy and possible total parenteral nutrition (TPN). Which statement made by the client indicates that teaching is successful? (Select all that apply.)

"I will have less risk of infection this way." "My port will only be accessed when needed."5."I will remind health care providers that I have a port." WILL not have to flush it daily, and can still do the morning swimming

The nurse performs teaching for a client being discharged on dexamethasone 0.75 mg PO daily. Which statement by a client helps the nurse to determine teaching is successful?

"I will take my medication with breakfast. "

The nurse provides care for the client receiving radiation therapy for breast cancer. Which client statements indicate to the nurse that further intervention is needed due to the effects of radiation? (Select all that apply.)

"I'm having trouble swallowing these days."2."I need to work from home most days." 2) CORRECT - This statement may indicate fatigue, a common side effect of radiation therapy. If the fatigue is severe enough to interfere with daily activities, further assessment and possible intervention is warranted. "I seem to have a rash under my arm."

A hospice client is actively dying. The client's spouse asks why the client is agitated, restless, and "mumbling things that don't make sense." Which response by the nurse is best?

"Your spouse is experiencing terminal delirium." 4) CORRECT- The client is experiencing terminal delirium. This occurs at the end of life and may be reduced through the administration of haloperidol.

The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN? (Select all that apply.)

A client diagnosed with herpes zoster ophthalmicus and dementia. A client following L-4 to L-5 laminectomy with a history of breast cancer.3.A client diagnosed with multiple sclerosis with increased bilateral leg weakness. 2) CORRECT— A client who had a laminectomy is a stable client with predictable outcomes. This client can be safely assigned to the LPN/LVN.

While making hourly rounds, the nurse notices a fire in a trash can in a client's room. Upon inspection, the client is not in the room. Which intervention does the nurse initiate first to manage the fire? (Select all that apply.)

Activate the fire alarm. Close door to the room

The emergency department (ED) charge nurse is notified that a city bus has overturned on the road. Several casualties are expected to be transported to the ED. Which nursing action is appropriate? (Select all that apply.)

Activate the hospital emergency response plan.2.Instruct assistive personnel to stock treatment areas.Assign increased numbers of staff to the triage area. DO NOT call off-duty nurses to come in. 3) INCORRECT- The command center team will assign the most appropriate person to begin calling in extra staff.

A client with a recent diagnosis of human immunodeficiency virus infection suddenly reports confusion and dizziness. The client's vital signs are: BP 100/70 mm Hg, P 130 beats/min, R 28 breaths/min, and T 102.2°F (39°C). Which nursing intervention is appropriate? (Select all that apply.)

Administer broad-spectrum antibiotics, as prescribed.3.Infuse normal saline solution, as prescribed.4.Coordinate with the laboratory department for a blood culture test.5.Assess BP and P every 15 minutes. NO NEED FOR AIRBORNE PRECAUTIONS

A toddler is brought to the emergency department by the parents. They report that the child has had a barklike cough and difficulty breathing for the past 24 hours. Physical assessment of the client reveals bluish discoloration of the hands and feet. Which action does the nurse take first?

Administer racemic epinephrine, as prescribed. 4) CORRECT- The priority intervention for this client is to maintain airway clearance through administration of racemic epinephrine, which widens the lumen of the airway.

The nurse provides care for a client who has just given birth. The client begins to cough and the client's color becomes ashen. The client then goes limp on the birthing chair. Which action does the nurse take first?

Assess the client for responsiveness. BEFORE activate the emergency reponse system

The public health nurse assesses a client reporting a persistent cough with blood-tinged sputum and night sweats. Which action does the nurse take first?

Assist the client in putting on a mask. 3) CORRECT — A cough with bloody sputum and night sweats are classic symptoms of tuberculosis. The nurse's priority is preventing the potential spread of disease.

The nurse provides care for a client who is one day postpartum. The client voids large amounts of urine frequently. Which action does the nurse implement?

Assure the client that this is expected after delivery. 1) CORRECT - Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Postpartum diuresis is caused by several factors, including a decrease in serum estrogen levels, the elimination of increased venous pressure in the lower extremities, and by the loss of any remaining pregnancy-induced increases in blood volume. All of these factors work together to aid the body in ridding itself of excess fluid. A urine output of 3000 mL or more each day during the first 2 to 3 days is expected.

The nurse prepares to discharge a client who had a laryngectomy. Which information will the nurse include in the discharge instructions regarding stoma and laryngectomy care? (Select all that apply.)

Avoid swimming. Avoid direct exposure to cold air. Get a medical identification bracelet. NO NEED to restrict fluid intake

The nurse prepares a teaching plan for a client who is prescribed captopril for hypertension. Which information does the nurse include in the teaching plan? (Select all that apply.)

Avoid using salt substitutes.2.Do not stop the medication abruptly. Avoid using salt substitutes.2.Do not stop the medication abruptly.

An adult client diagnosed with cerebral palsy that makes walking difficult is about to be discharged from the hospital after a cholecystectomy. Which ability should be assessed to evaluate the client's ability to live independently? (Select all that apply.)

Bathing. Toileting. Performing current job functions. 6) CORRECT- If a client is returning to work, it is important that the client can still perform the expected functions of the job. Holding a job is important to live independently.

The nurse provides care to a client receiving an epinephrine infusion following a cardiac arrest. Which assessment findings demonstrate that treatment is effective? (Select all that apply.)

Blood pressure 130/67 mm Hg . 1) CORRECT - Epinephrine is a vasopressor and is used off-label to help maintain an adequate blood pressure. A BP within normal limits indicates the treatment is effective. 2.Apical heart rate 99 beats/min. Capillary refill less than 2 seconds.

The client diagnosed with dehydration is treated with IV normal saline (NS). Which client responses noted by the nurse demonstrate a therapeutic effect of the NS? (Select all that apply.)

Blood pressure increases.3.The pulse rate decreases.4.Urine output increases. 5) INCORRECT - The HCT increases with dehydration, since it is relative to volume. An indication of effective IV NS therapy would be a decreased, or normal, HCT.

The nurse reviews the care needs for a group of postpartum clients. Which client does the nurse identify as being the most at risk for developing a hemorrhage?

Client with a distended bladder. 1) CORRECT - A distended bladder is likely to displace the uterus to the left or the right. This will interfere with uterine contraction, which could cause a postpartum hemorrhage.

A client is prescribed intravenous fluid therapy with 0.9% sodium chloride 100 mL per hour into the left-hand IV catheter. Which step will the nurse take while administering and changing the IV fluid solution? (Select all that apply.)

Don clean gloves prior to assessing the IV catheter site.2.Use aseptic technique to change out IV solution bags.3.Perform hand hygiene before changing the IV solution.4.Inspect the tissue around the IV entry site.5.Use an alcohol swab to clean the cap on the short extension tubing.6.Monitor the IV infusion at periodic intervals. RECOGNIZE THAT ASEPTIC AND SEPTIC ARE DIFFERENT

The nurse provides care for a client 18 hours after a left below-the-knee amputation. Which nursing action is most important?

Elevate the residual limb on a pillow or other soft surface. 2) CORRECT— The nurse's priority is to reduce the risk of complications at the operative site. In the initial post-operative period, limb elevation minimizes edema. Do not elevate the residual limb for more than 24 hours because it will cause hip flexion complications.

The nurse supervises the staff providing care to four clients receiving blood transfusions. Which client will the nurse see first?

Experiencing emesis. 2) CORRECT- Emesis is a symptom of a hemolytic reaction, which is the most dangerous type of transfusion reaction. Symptoms include nausea, vomiting, pain in lower back, and hematuria. Treatment is to the stop blood transfusion, obtain a urine specimen, and maintain blood volume and renal perfusion.

The nurse assesses several newborns after delivery. Which findings are anticipated by the nurse during the physical examination? (Select all that apply.)

Head circumference 13 in (33 cm). Irregular respiration. NOT respiratory grunting

The nurse provides care for a term neonate born to a client diagnosed with diabetes mellitus (DM). Which manifestation does the nurse monitor the newborn for when conducting the physical examination?

Hypoglycemia. 2) CORRECT- Neonatal hyperinsulinemia occurs after birth. The maternal glucose is no longer available, but insulin production remains high. This results in hypoglycemia.

The nurse assesses a client diagnosed with gastroesophageal reflux disease (GERD) who is taking famotidine. Which finding indicates the medication is effective? (Select all that apply.)

Increased appetite. Weight gain.

The nurse plans a presentation to discuss the concept of malpractice. The nurse covers which elements required to be present in a malpractice case? (Select all that apply.)

Injury.3.Causation.4.Duty.5.Breach of duty.

The nurse provides care for a client who had an above the knee amputation. Which intervention reduces phantom limb sensation?

Mirror therapy. 2) CORRECT— The mirror is thought to provide visual information to the brain, replacing sensory feedback expected from the missing limb.

The nurse is assigned to care for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) of a draining wound. Which personal protective equipment (PPE) does the nurse wear when measuring vital signs? (Select all that apply.)

Plastic gown Gloves NOT face mask - not needed

The nurse at a health fair screens clients for vitamin B12 deficiency. Which client will the nurse determine as needing vitamin B12 supplementation? (Select all that apply.)

Recently diagnosed with pernicious anemia. Stomach does not secrete intrinsic factor. Follows a strict vegan diet. Takes metformin for type 2 diabetes. Metformin is risk factor for B12 definciency. 6.Had a gastrectomy 2 years ago. No stomach to secrete intrinsic factor

The nurse provides care for a client diagnosed with systemic lupus erythematosus (SLE). Which clinical manifestation does the nurse anticipate when completing a physical assessment?

Red rash. 1) CORRECT — The nurse can anticipate seeing a red rash, especially on the face, for this is a clinical manifestation associated with systemic lupus erythematosus. Will also see ulcerrs in the mouth but not dry mouth.

A client has refused all pain medications. The nurse plans care to provide non-pharmacological pain relief and comfort to the client. Which action is appropriate to delegate to the LPN/LVN?

Reinforcing teaching about the use of heat and cold applications.

The nurse provides care to a client who reports pain at an IV site. The nurse notes tenderness and redness at the insertion site and redness proximally along the vein. Which intervention does the nurse implement?

Remove the IV and apply a warm, moist compress. 4) CORRECT - Signs and symptoms of phlebitis include pain and tenderness at the IV insertion site and redness along the affected vein. Management of phlebitis includes removal of the IV catheter and application of a warm, moist compress to the affected area.

The nurse provides care to a client admitted with mild hyponatremia secondary to excessive water consumption. Which intervention does the nurse anticipate including in the client's plan of care?

Restricting fluid intake.

The nurse observes the unlicensed assistive personnel (UAP) perform mouth care on an older adult client admitted to the hospital with fever of unknown origin. Which action performed by the UAP requires an intervention by the nurse?

Rinsing the client's mouth with a glycerin-based mouthwash. 3) CORRECT - A mouthwash with glycerin causes dehydration and irritation of the oral tissues. The nurse should intervene and provide the UAP and client with a non-glycerin mouthwash.

The nursing team consists of a nurse, an LPN/LVN, and two unlicensed assistive personnel (UAP). Which client care activity does the nurse recognize as appropriately utilizing the LPN/LVN's skill set? (Select all that apply.)

Suction a client's tracheostomy. Care for a 2-year-old client who has a systolic blood pressure of 84 mm Hg. Others here are better for hte UAP - have to pay attn to who else you have to use. They cannot administer IV meds for pain.

The LPN/LVN delegates tasks to the unlicensed assistive personnel (UAP). The nurse intervenes if which action is observed? (Select all that apply.)

The UAP administers prescribed eye ointment. This is a prescription. The UAP delegates client ambulation to another UAP.3) CORRECT - It is not within the UAP's scope of practice to re-delegate tasks.4.The UAP takes a phone prescription from a health care provider. The UAP listens to breath sounds.

The nurse asks the unlicensed assistive personnel (UAP) to perform soapsuds enemas for a client scheduled for a diagnostic test. Which action does the nurse expect from the UAP?

The UAP observes the returns from the enemas in the bedside commode. Should not describe the returns but needs to observe.

The nurse is made aware of a client's situation during hand-off of care via the Situation-Background-Assessment-Recommendation (SBAR) report. Which detail about the client should the nurse address with the off-going nurse? (Select all that apply.)

The client has a troponin level of 1.5 ng/mL (1.5 mcg/L).2.The client has a newly placed nasogastric tube in the right nare.3.The client is on a 1.5-liter fluid restriction.4.The nurse noticed blood in the client's stool.5.The client's temperature reached a peak of 101.2°F (38.4°C) during the past 12 hours. ALL OF THESE .

The nurse provides care for an adult client on a mechanical ventilator. Which finding most concerns the nurse?

The client is moving about restlessly in bed. 4) CORRECT — Confusion, agitation and restlessness suggest hypoxemia. The nurse should assess for hypoxemia and manually ventilate the client with 100% oxygen. This is a breathing concern that represents an immediate risk of harm to the client. This is the priority concern.

The nurse assesses an older adult client diagnosed with altered mental status. The client is cyanotic and has profound diaphoresis. Vital signs are: R 26 breaths/minute, P 96 beats/minute, SpO2 90% on room air. Which finding from the client's history does the nurse report to the health care provider immediately?

The client's last recorded ejection fraction (EF) was 20%. 1) CORRECT- Acute decompensated heart failure is among the most common causes of acute respiratory failure among older adult clients. Normal EF is 55% to 65%. This represents a real issue.

The nurse provides care for four newborn clients. Which client does the nurse assess first?

The newborn who has not voided since having a circumcision 7 hours ago. 3) CORRECT - Noting the first urination after circumcision is important because edema could cause an obstruction. If the infant goes home before voiding, the mother is instructed to call the health care provider if there is no urinary output within 6 to 8 hours.

A client is a devout Jehovah's Witness and is scheduled for surgery. Which action should the nurse implement?

The nurse requests that other non-blood volume expanders be discussed as alternatives. THEY DO NOT accept autologous blood donation.

The nurse prepares assignments related to nutrition for the evening shift. Which client can be assigned to the unlicensed assistive personnel (UAP)? (Select all that apply.)

The weak client diagnosed with human immunodeficiency virus (HIV) and pneumonia. The client diagnosed with rheumatoid arthritis (RA) and who is allergic to fish. The client diagnosed with epilepsy and who is alert and oriented. NOT post brain aneurism.

The nurse provides care for a client with a history of heart failure. The health care provider writes prescriptions for the client. Which prescription does the nurse question?

Verapamil 120 mg orally three times daily. 3) CORRECT - Verapamil is contraindicated in clients diagnosed with heart failure and in clients taking digoxin, because it can cause severe bradycardia.

An infant diagnosed with failure to thrive has been prescribed enteral feedings via a nasogastric (NG) tube. Which intervention does the nurse include in the plan of care? (Select all that apply.)

Weigh the infant daily.3.Flush the tube once per shift. Allow the infant to suck a pacifier. DO NOT irrigate with 100mL this is too much

The nurse has been assigned to evaluate the occurrence of nursing errors on a telemetry unit. Which action will be reported to the supervisor? (Select all that apply.)

When administering medications, the nurse asks clients their names and then administers the medications.2.The health care provider prescribes "5.0 mg metoprolol IV push now" for a client with new onset atrial fibrillation.3.The unit is short-staffed and nurses are regularly requested to work 16-hour shifts.4.The nurse is unable to read a prescription due to poor handwriting and requests another nurse to verify what is written.5.The nurse completes a client's initial fall risk assessment 36 hours after admission.

The nurse conducts an education program for a client who is diagnosed with acute pancreatitis. The nurse includes which statement when teaching about the common causes of this type of pancreatitis?

"Gallstone migration and alcohol abuse cause acute pancreatitis."

The nurse provides care for a client at 28 weeks' gestation. The nurse teaches the client how to perform fetal kick counts. Which client statement indicates to the nurse that the client understands the teaching?

"I should feel my baby move more than five times in one hour." Should try to count at the same time each day- not various times.

The nurse teaches a client about the correct use of the transdermal nicotine patch. The client states, "Using the patch will help me cut down on smoking." Which response does the nurse provide to this client?

"If you smoke while you are using the nicotine patch, then you are at risk of having a heart attack."

A client's spouse of 45 years died 6 months ago. Which client statement indicates the client is adequately coping with the loss? (Select all that apply.)

"My friends have been trying to keep me busy." 5) CORRECT- It is a good sign that the client still engages with friends and recognizes that continued activity is an important part of the grieving process.

The nurse plans care for a client diagnosed with dementia. Which nursing intervention is the priority?

Assume a face-to-face position when speaking to the client. 4) CORRECT - By speaking face-to-face, the nurse maximizes verbal and nonverbal cues. The nurse should use short, simple words and phrases, and speak slowly to give the client time to process information.

The nurse provides care for a client who had abdominal surgery 2 days ago. The nurse notes a moderate amount of green-tinged drainage with the dressing change. Which action does the nurse take?

Check the client's morning white blood cell count. 3) CORRECT- Green-tinged wound drainage is an indication of infection. The nurse should check the white blood cell count, as well as the client's temperature.

The nurse provides care for a client who underwent a lumbar puncture. Which action by the nurse is priority?

Encourage increased fluid intake following the procedure. 1) CORRECT- Extra fluid helps the body replace any lost cerebrospinal fluid and may decrease the risk for headache.

The nurse palpates a pregnant client's uterus. The nurse notes that the fetal position is left sacrum anterior (LSA). Which location does the nurse place the Doppler to hear the point of maximum intensity of the fetal heart tone?

Mother's left side near the level of mother's umbilicus.

The nurse provides care to several hospitalized clients. Which clients does the nurse monitor closely for the development of pneumonia? (Select all that apply.)

NOT someone with addison's - not a risk factor A client diagnosed with cystic fibrosis. A client with a fractured rib due to an auto accident.6.A client in Buck traction due to a fractured hip.

The nurse orients a novice nurse to the unit. The nurse recognizes that the novice nurse understands principles of safe IV therapy when which action is observed?

The novice nurse scrubs the hub of the access port for 45 seconds. 1) CORRECT- Access ports should be cleansed with alcohol, tincture of iodine, or chlorhexidine gluconate/alcohol prior to each use. The access port should be scrubbed for 30 to 60 seconds, or per facility protocol.

The nurse preceptor works with a novice nurse on a medical-surgical unit. Which action by the novice nurse breaches client confidentiality and requires an intervention by the nurse preceptor? (Select all that apply).

The novice nurse shares laboratory results with the client's cousin over the phone. 1) CORRECT- Nurses and health care providers must avoid sharing client information with third parties, including spouses or parents, unless the client provides express consent. The issue of confidentiality breaches represents a heightened concern when it comes to telephone or electronic communication of sensitive information. Breaches of confidential information may result in legal action being taken against both the health care establishment and the nurse(s) or health care provider(s) involved. The novice nurse takes a picture of a client and posts it to social media. The novice nurse shares client information with another nurse while entering the elevator.

The nurse receives a report on clients who reside on the psychiatric unit. Which actions, if performed by the off-going nurse, require follow-up by the nurse? (Select all that apply.)

The nurse assessed a suicidal client every 15 minutes. 1) CORRECT - The suicidal client must have one-on-one supervision at all times. The client could attempt suicide in a 15-minute interval. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal. 4.The nurse allowed a suicidal client to remain in street clothes. 5.The nurse initiated a signed PRN prescription for physical restraints.

The nurse in the emergency department assists forensic investigators with evidence preservation and collection after a client's sudden death. Which actions by the nurse are considered professionally negligent? (Select all that apply.)

The nurse cuts holes through fabric to remove client's shirt. The nurse gives the client's clothing to the family.5.The nurse places any evidence in a plastic bag. They retain moisture wich could promote mold and mildew formation, destroying evidence. 6.The nurse removes intravenous lines before the medical examiner arrives.

The nurse observes a teach-back session with a client newly diagnosed with type 1 diabetes. Which client action indicates that additional teaching is needed?

The nurse observes a teach-back session with a client newly diagnosed with type 1 diabetes. Which client action indicates that additional teaching is needed? 1) CORRECT- Clear insulin (lispro) should be drawn up prior to cloudy (isophane) insulin when mixing the two in one syringe. This action indicates additional teaching is needed.

The nurse teaches a group of women about breast self-examination. In which order are the steps performed to ensure proper self-examination of breasts? (Place the answers in priority order. All options must be used.)

To perform a proper breast self-examination, women need to first look in the mirror and note any changes in appearance of breasts and nipples. Second, women examine their breasts with their arms raised above their heads. This action allows them to see if the breasts move freely over the chest wall. Third, women must lie down, placing a pillow under their shoulders along with their hands behind their heads. This position distributes breast tissue. Finally, they should use the pads of their middle three fingers to palpate the breasts in a circular motion.

The nurse provides care to a client with chronic pain due to knee osteoarthritis. The client asks about ways to manage pain in addition to taking medication. Which non-pharmacologic pain relief measure is appropriate for this client? (Select all that apply.)

Yoga.2.Water aerobics.3.Cushioning footwear.4.Massage.5.Adequate sleep.6.Application of heat 2-3 times/day.

The nurse prepares teaching material for a client prescribed levothyroxine. Which information does the nurse include when instructing the client? (Select all that apply.)

"Call your health care provider if you feel your heart is racing."3."You should have more energy once the medication has reached a therapeutic level."4."Ensure you have an adequate supply of medication when going on vacation." "Ask your health care provider before taking over-the-counter cold remedies." 6) CORRECT — Some over-the-counter medications may interfere with levothyroxine. All over-the-counter medications should be approved by the health care provider before the client takes them.

The nurse speaks to the spouse of a client who has concerns about the client's sleeping pattern. The spouse states, "I am having a hard time getting a good night's rest because of my spouse's noisy breathing." Which response by the nurse will help to further evaluate the problem? (Select all that apply.)

"Does your spouse report feeling drowsy during the day?" "How many times does your spouse awaken at night?"5."What is your spouse's current weight?"6."Describe the types of sounds your spouse makes at night."

The nurse provides cares for an older adult client diagnosed with type 2 diabetes, heart failure, and mild cognitive impairment. The client is preparing for discharge to home. Which recommendation to the caregiver will the nurse include in the discharge instructions? (Select all that apply.)

"Effective management of blood glucose can improve oral health." "Encourage the client to moisturize the lips in the morning and at night to soothe and prevent cracking."5."If the client reports fatigue during oral care, the caregiver should allow the client to rest before completing the task." 2) CORRECT- Because of the diabetes mellitus, the client is more prone to develop cavities and periodontal disease. Improved blood glucose management can help prevent these complications. The nurse should recommend oral care be completed at least twice a day to prevent dental caries.

The nurse instructs the client who is diagnosed with mastitis of the left breast about breastfeeding the client's infant. Which statement by the client best indicates understanding of the instructions?

"Everyone in my family should use good handwashing techniques at all times." 3) CORRECT— Anyone who is in contact with the infant should use good handwashing techniques to prevent the spread of infection. 1) INCORRECT - It is not necessary to discontinue breastfeeding on the affected breast and is not desired, as discontinuing breastfeeding will increase breast engorgement and exacerbate pain. 4) INCORRECT - A tight bra will reduce milk production. This will not improve the mastitis. The nurse should advise the client to wear a bra that is as supportive as possible and still comfortable. Constrictive clothing should be avoided.

The health care provider has prescribed a transcutaneous electrical nerve stimulation (TENS) for a client experiencing back pain. The nurse has just completed education about the TENS unit. Which client statement indicates additional education is needed?

"I recognize that the transmitter cannot be adjusted." 1) CORRECT- A TENS provides an electrical stimulation over an area of pain. The transmitter can be adjusted by the client. The adjustment can alter the quality of skin stimulation and intensity. This statement indicates additional education is needed.

The nurse instructs a client about trimethoprim/sulfamethoxazole. The nurse needs to intervene if the client makes which statements? (Select all that apply.)

"I should take the medication with food."3. "This medication is safe during pregnancy."

The nurse provides care to a client 4 weeks after a kidney transplant. Which client statements require immediate follow-up by the nurse? (Select all that apply.)

"I take an antacid after meals, which helps with my indigestion." 1) CORRECT — Indigestion is a symptom of a peptic ulcer, which is common when corticosteroids are used for immunosuppression after organ transplantation. This statement requires immediate follow-up. "I found that a little wine in the evening helps me sleep better." 3) CORRECT — Cyclosporine is commonly prescribed for immunosuppression after organ transplantation. It can be hepatotoxic, so alcohol is contraindicated. The nurse should determine if the client needs a different intervention to aid in sleep. "My feet were so itchy until my adult child told me to start using lotion twice a day." 4) CORRECT — Symptoms of graft-versus-host disease start with a pruritic or painful rash on the palms and soles of the feet. The client's report of itching requires follow-up. "I saw that my blood pressure was up a little. I think I get nervous when I come to the office." 6) CORRECT— Cardiovascular disease, including hypertension, is a common problem after transplantation and needs immediate follow-up.

The hospice nurse visits a client at home. The spouse meets the nurse at the door and says, "I just hate to see my spouse this way. I don't know that I can handle this much longer." Which response by the nurse is appropriate? (Select all that apply.)

"In times of stress, what gives you strength and hope?"2."What questions do you have about the care your spouse is receiving?"3."What cultural needs may I assist you with?"4."Do you have any spiritual or religious support?"5."Tell me what you understand about the pain relief and comfort your spouse is receiving." ALL OF THEM

The community health nurse provides care to a newborn client who is prescribed enteral feedings through a gastrostomy tube. Which statement by the client's mother indicates a need for immediate follow up by the nurse?

"It is easy to give liquid medicine through the feeding tube." 4) CORRECT— Liquid medication may contain sorbitol, which can cause diarrhea. Follow up is required, as additional information is needed to determine whether or not the client's medication contains sorbitol.

The nurse cares for a client diagnosed with end-stage bone cancer who is newly electing hospice care. The client's spouse asks, "What can we do instead of using medications for pain?" Which response by the nurse is best? (Select all that apply.)

"Massage and heat or cold therapy are interventions that we can try."4."I'll share your concerns with the health care provider as a transcutaneous electrical stimulator may help with pain management."5."Our interdisciplinary team may have some additional treatments that would alleviate pain without medications." 6) INCORRECT- Asking a "why" question may be viewed as confrontational and is therefore non-therapeutic. Alternatively, the nurse could make an open-ended statement such as, "Tell me about your concerns with using medications."

The nurse provides discharge teaching to a client diagnosed with diabetes mellitus, obesity, and chronic kidney disease (CKD). Which statement should be included in the teaching? (Select all that apply.)

"Take your enalapril as prescribed." Smoking CESSATION not reduction needs to happen. NSAIDS should be completely avoided

The nurse prepares to administer the polio vaccine by intramuscular injection to a child. The parent says "I am afraid my child will get polio from the vaccine." Which response by the nurse is best?

"The vaccine cannot cause polio because it contains killed virus particles."

The nurse admits a client with severe, persistent headaches. Which question is appropriate to ask when assessing the client's orientation? (Select all that apply.)

"What is your health care provider's name?"2."What is the name of this health care facility?" "What year and month is it currently?"

The nurse receives a hand-off report and four clients require venipuncture for labs to be drawn at the same time. Which client will the nurse draw labs on first? The client diagnosed with sepsis. The current blood pressure is 100/70 mm Hg, with a lactic acid lab due now.2.The client diagnosed with anemia. The previous hemoglobin was measured at 8 g/dL (80 g/L), with a complete blood count lab due now.3.The client diagnosed with respiratory failure on continuous bilevel positive airway pressure (BiPAP) therapy. The arterial blood gas lab due now.4.The client diagnosed with angina. The electrocardiogram (ECG) showed no ST elevation, and a troponin lab is due now.

1) INCORRECT- The client is hemodynamically stable at this time with a mean arterial pressure (MAP) of 80 mm Hg. To calculate MAP, the formulate is: 2(diastolic pressure) + systolic pressure ÷ 3. For example, 2 × 70 mm Hg + 100 mm Hg ÷ 3 = 80 mm Hg. 2) INCORRECT- The client has a stable hemoglobin at this time and does not need to be drawn first. 3) INCORRECT- Although respiratory failure is serious, the client is getting oxygen support therapy. An arterial blood gas (ABG) will determine if the intervention on BiPAP is working. 4) CORRECT- An elevated troponin, despite lack of ST elevation on the ECG, could signify a non-ST-elevation myocardial infarction (NSTEMI). If NSTEMI is diagnosed, the client will require an urgent cardiac catheterization to determine the degree of blockage.

The emergency department triage nurse has a limited number of open beds. Which client does the nurse place in an emergency bed? (Select all that apply.)

17-year-old client who intentionally ingested 15 acetaminophen tablets prior to arrival. 63-year-old client who reports a severe, localized headache with no history of headaches.4.77-year-old client who has had generalized weakness for the past day. 4) CORRECT - This client requires assessment and diagnostic work-up to exclude myocardial infarction, electrolyte imbalance, and stroke. Therefore, the nurse places this client in an emergency bed.

The charge nurse must rearrange client room assignments to accommodate a new admission. Each client is currently in a private room. Which client can be safely cohorted with another client from this list? (Select all that apply.)

A 58-year-old female client with alcohol-induced pancreatitis. A 47-year-old female client who is receiving IV opioids to treat renal calculi.

The nurse provides care for clients in the emergency department. Which client situation most benefits from having a case manager assigned to the care plan team? (Select all that apply.)

A middle-age adult diagnosed with chronic obstructive pulmonary disease. An adolescent diagnosed with type 1 diabetic ketoacidosis. 1) CORRECT- Nurses and designated case managers understand that chronic and advanced stages of chronic illnesses require close monitoring, medication management, and exacerbation prevention. This is often done for known disease processes such as chronic obstructive pulmonary disease (COPD) to prevent emergency department visits and hospitalizations. 2) INCORRECT- A toddler with otitis media is a fairly routine visit. Case management resources traditionally are used to help link clients with resources to help manage complex, chronic, or long-term care symptoms and conditions. 3) INCORRECT- A client with acute symptoms that are life-threatening is a traditional and appropriate case for the emergency department. Case management resources traditionally are used to help link clients with resources to help manage chronic or long-term care symptoms and conditions. 4) CORRECT- In this case, the growing emotional, developmental, and hormonal changes in an adolescent can make them at risk for frequent blood glucose fluctuations. A nurse case manager can assist in educating for prevention of exacerbation of diseases such as diabetes and asthma. They also can help clients understand how to cope with their disease and provide symptom management to help clients manage the disease and reduce or prevent the occurrence of emergency department visits. 5) INCORRECT- Case management resources traditionally are used to help link clients with resources to help manage chronic or long-term care symptoms and conditions. This client will require assessment of knowledge related to STIs and routine education on prevention. 6) INCORRECT- A client with routine infant symptoms and illnesses with no other extenuating circumstances or diseases would not create a high need situation to require case management. Clients who have complex or chronic conditions or who require extensive assistance to prevent exacerbation and hospitalizations and to reduce resources expended have the greatest need for case management resource allocation.

The nurse prepares to remove a central venous access device in a hemodynamically stable client. Which action by the nurse will help prevent the development of embolism during the procedure?

Ask the client to hold breath during removal. 2) CORRECT- Valsalva maneuver increases intrathoracic pressure, which prevents air from entering through the opening of the skin.

A client experiencing regular contractions reports "water breaking. " Which action does the nurse take first?

Auscultate the fetal heart rate. 1) CORRECT— The priority is assessment of fetal well-being. This is completed by auscultating the fetal heart rate. This heart rate should range from 120 to 160 beats per minute. A heart rate above 160 beats per minute is an early sign of fetal hypoxia. A heart rate below 110 beats per minute is a later sign of fetal hypoxia, which could be caused by prolapse of the umbilical cord.

The nurse provides care for an older adult client who had a stroke. Assessment findings include right-sided weakness, facial drooping, difficulty swallowing, and limited mobility. The nurse recognizes which sites are appropriate for use when assessing the client's temperature? (Select all that apply.)

Axillary. Tympanic membrane. Temporal artery. NOT oral or rectal. 4) INCORRECT - Rectal temperature measurement is not ideal for the client who demonstrates limited mobility (including the client whose mobility is impaired due to a stroke), as maintaining a side-lying position may be challenging. Rectal temperature assessment provides no significant advantages over other routes of temperature assessment.

A newborn exhibits signs of pain following a heel stick for a blood sample. Which non-pharmacologic pain management approach, if provided prior to painful procedures, should the nurse initiate to help reduce pain? (Select all that apply.)

Breastfeeding.4.Kangaroo care.5.Swaddling.6.Oral sucrose. NO mobile or dimming the lights - research does not support this

While ambulating a client, the client suddenly reports dizziness and weakness. Which action does the nurse prioritize? (Select all that apply.)

Call for help.2.Stand with feet apart to create a broad stance.3.Grasp the gait belt.4.Slide client down leg, lowering client to the floor. CALL FOR HELP DURING IT

An infant with an unrepaired congenital heart defect has been prescribed digoxin for heart failure. Which assessment finding indicates the medication is having the desired effect? (Select all that apply.)

Clear breath sounds.4.Normal sinus rhythm.5.Easy work of breathing.

The charge nurse is reviewing medical records. The charge nurse follows up as a result of which documentation entry? (Select all that apply.)

Ferrous sulfate 60 mg given orally. Client reported GI discomfort because of medication; calcium carbonate chewable tablets given.v1) CORRECT - This documentation entry requires follow up by the charge nurse. Calcium decreases iron absorption and should not be administered with iron replacement. Iron is administered separately from foods and other medications to ensure absorption. Carvedilol 12.5 mg orally administered as prescribed. Temperature 99.1oF (37.3oC), pulse 54 bpm, respirations 18 breaths/min, BP 146/86 mm Hg. 4) CORRECT - This documentation entry requires follow up by the charge nurse. The beta-blocker should be held if the client's heart rate is less than 55 to 60 bpm, as this medication will further decrease the heart rate. Oxycodone 10 mg prescribed orally every 6 hours as needed for pain. Medication was administered at 0400, 0800, 1200, 1600, and 2000. 5) CORRECT - This documentation entry requires follow-up by the charge nurse. The medication is prescribed every 6 hours as needed; however, the client has received the medication at 4-hour intervals. Oxycodone is an opioid analgesic that can lead to respiratory depression if taken in large doses or too frequently.

A client, diagnosed with atrial fibrillation, receives digoxin 0.25 mg per day. The client reports blurred vision and says everything looks yellow. The cardiac strip reveals a prolonged PR interval. After assessment and stabilization of the airway, breathing, and circulation (ABCs), which intervention should the nurse implement first?

Hold the digitalis and furosemide. 4) CORRECT- If signs and symptoms associated with digoxin toxicity are present, the first nursing action after assessing ABCs is to hold the digoxin and furosemide, which is a potassium-depleting diuretic.

The nurse provides care to a client who is newly prescribed lithium carbonate 600 mg by mouth three times a day. Which finding causes the nurse to hold the next scheduled dose?

Loose stools. 4) CORRECT- Diarrhea is a sign of lithium toxicity, along with oversedation, ataxia, tinnitus, slurred speech, and muscle weakness/twitching. The nurse should withhold the next prescribed dose and obtain serum levels when diarrhea occurs.

A school-age client diagnosed with exocrine pancreatic insufficiency due to cystic fibrosis reports fatty stools. Which intervention does the nurse implement to prevent nutritional deficiency in this client?

Maintain a high-fat diet. 3) CORRECT- A high-fat diet prevents worsening of the client's nutritional status that can result in stunted growth and weight loss.

4) CORRECT - By speaking face-to-face, the nurse maximizes verbal and nonverbal cues. The nurse should use short, simple words and phrases, and speak slowly to give the client time to process information.

NOT going right up to the armpit. 5) INCORRECT- Properly fitting crutches should not go all the way up to the axilla, as weight bearing on the axillae can cause nerve damage.

A novice nurse is completing an incident report after a client fell while getting out of bed. The nurse's preceptor reviews the nurse's proposed documentation for the electronic health record (EHR) and the incident report. Which information should the preceptor guide the nurse to exclude from the documentation?

Notation in EHR that an incident report was completed. 3) CORRECT- The nurse should not record in the EHR that an incident report was filed. The EHR is a record of the client's health. An incident report is a form used by the facility for tracking variances and improving quality and safety.

The nurse provides care for a client receiving a blood transfusion. Ten minutes after the transfusion is started, the client reports a headache, chest pain, low back pain, chills, and nausea. Which action by the nurse is appropriate? (Select all that apply.)

Notify the blood bank.4.Assess the client's vital signs.5.Obtain a sample of the client's blood.6.Obtain a sample of the client's urine. DO NOT DC the peripheral IV or administer aspirin. THe infusion should be stopped but the IV should not be DC'd. Aspirin is unsafe because it is antiplatelet.

The nurse monitors a client receiving 1 unit of packed red blood cells intravenously. Which action is appropriate when the client states "I can't catch my breath!"? (Select all that apply.)

Notify the health care provider. Follow facility protocol. Applying oxygen is 3) INCORRECT- While oxygen may be needed, the client's pulse oximeter reading should be obtained first.

The nurse notices a client becomes confused every day in the afternoon. Which intervention by the nurse is appropriate to reduce the risk for falls when the client becomes confused? (Select all that apply.)

Offer the client pain medication to promote rest. 2.Move the client closer to the nurses' station.3.Leave one side rail down on the side of the bed where the client normally gets up. 4.Monitor the client closely during the afternoon.5.Place a rocking chair in the client's room. 3) CORRECT- It is appropriate to leave the side rail down on the side of the bed where the client normally gets up to stand. Clients who are confused often get out of bed to wander. Leaving the side rail down will allow the client to freely exit the bed without climbing over a side rail, which would increase the risk of a fall. 5) CORRECT- A rocking chair assists clients who are confused in expending energy, as the chair makes them less likely to wander and decreases the likelihood of falling.

Nurses on a newborn nursery unit are developing security measures to prevent infant abductions. Which method is likely to be effective in preventing abductions? (Select all that apply.)

Parents and staff will use a daily password whenever an infant is removed from the room.2.Staff will be trained to identify a "typical" abductor.4.Staff will compare identification bands on both infant and parents.5.Parents will be taught not to use the bathroom when the infant is in the room alone. 1) CORRECT- Daily passwords help eliminate fraudulent use of an identification (ID) badge or unauthorized personnel from removing the infant. 2) CORRECT- Infant abductions are often taken by females between 12 and 55 years old. Staff should be alert to visitors fitting this profile and without a specific client they are visiting. 3) INCORRECT- Parents can choose whom they want to visit. Limiting who can visit would not prevent abductions. 4) CORRECT- Matching ID bands help prevent abductions and accidental mix-ups of infants by staff. 5) CORRECT- Parents should never leave an infant unattended in the room. Leaving an infant unsupervised is a risk for abduction.

The nurse provides care for four clients receiving chemotherapy for non-Hodgkin lymphoma. Which client finding should the nurse address first?

Periorbital and facial edema. 2) CORRECT- Facial and periorbital edema are early signs that may indicate superior vena cava syndrome, which is an oncologic emergency. This condition occurs when tumors near the superior vena cava cause increased pressure, which can lead to significant breathing and circulation deficits.

The nurse conducts a class for clients in their first trimester of pregnancy. Which information is appropriate for the nurse to include? (Select all that apply.)

Quickening should occur around 16 to 20 weeks' gestation.2.The fundal height is the measurement from the top of the symphysis pubis to the top of the fundus. Nausea usually ends by 14 to 16 weeks.

An adolescent client sustains a spinal cord injury at the level of L1 in a motor vehicle accident (MVA). The adolescent returns to school after rehabilitation and tells the school nurse, "I am determined to lead a normal life. " To assist the adolescent to achieve this goal, which action by the school nurse is most appropriate?

Reinforce teaching about the Cred é maneuver. 1) CORRECT— Applying manual pressure to the bladder aids in emptying the bladder completely and helps reduce risk for infection. Performing the Cred é maneuver at the same times every day can result in bladder control.

The nurse provides care for clients on the psychiatric unit. A client yells that nobody cares and throws a lunch tray at a group of other clients. Which action does the nurse take first?

Remove the client from the lunchroom. 2) CORRECT— When the client becomes violent, the nurse should intercede immediately. The nurse should remove the client from the group environment as quickly as possible, and then address the client's behavior with the client.

The health care provider prescribed 40 mg of furosemide IV for a client. The electronic medication dispensary has 40 mg vials of furosemide available and the screen reads, "Take 2 vials." The nurse realizes that the 40 mg vials are in the designated 20 mg vial cubicle. Which action does the nurse take? (Select all that apply.)

Report the error to the pharmacy and wait to remove medication from the cubicle. DO NOT put up a sign in the med room and do not administer a 40 mg vial. The sign will not help, couldf fall down, etc.,

The nurse provides care for a school-age client who sustained a dog bite on the forearm a few hours earlier. The wound has been cleansed and irrigated with normal saline solution, and a dressing has been applied. The health care provider has prescribed oral antibiotics to be taken over 3 days. Which additional action is required in this situation?

Reporting the dog bite to the Department of Health. 3) CORRECT- Health care providers are mandated to report all dog bites, whether from strays or family pets, to the Department of Health. The incident should be reported to the local animal control agency or police department, as well.

When providing care for a client diagnosed with primary adrenocortical insufficiency, which laboratory findings does the nurse expect?

Sodium 130 mEq/L (130 mmol/L), fasting glucose 50 mg/dL (2.8 mmol/L), potassium 5.3 mEq/L (5.3 mmol/L). 2) CORRECT - Hyponatremia, hypoglycemia, and hyperkalemia are expected findings in this client.

A client is admitted to the emergency department for persistent vomiting following a chemotherapy treatment 1 week ago. Which precaution does the nurse take when handling the client's bodily fluids?

Standard. 3) CORRECT- Special precautions should be taken when handling the client's bodily fluids 48 hours after receiving chemotherapy. Since this client received chemotherapy a week ago, the nurse needs to use standard precautions when handling this client's bodily fluids.

The nurse begins administering packed red blood cells (PRBCs) to a client with hemophilia who has received blood twice this admission. Shortly after the nurse begins the blood transfusion, the client reports mild lower back pain and asks to stand and stretch. After standing, the client reports that the back pain is worse and now accompanied by shortness of breath. Which action does the nurse take first?

Stop the blood transfusion and remove the blood tubing. 4) CORRECT- Stopping the blood transfusion and removing the blood tubing is the priority nursing intervention when the nurse suspects the client is having a blood transfusion reaction. Dyspnea and lower back pain are signs of an acute hemolytic reaction related to ABO-incompatibility. Additional clinical manifestations include fever, hypotension, abdominal or chest pain, and hematuria.

The nurse provides care for a client who experienced a pulmonary embolism. The client is receiving a continuous heparin infusion. Which instruction will the nurse provide to the unlicensed assistive personnel (UAP) assisting with the care? (Select all that apply.)

Use an electric razor to shave the client's face. Tell the nurse if the client reports cold, painful, or blue feet.6.When assisting the client to reposition, use a lift sheet.

The nurse prepares to administer newly prescribed clonazepam and meloxicam to the client. Upon assessment, the client reports hives and difficulty breathing after taking midazolam and oxycodone years ago. Which actions will the nurse implement? (Select all that apply.)

1) CORRECT— The nurse should hold the clonazepam because of the client's previous allergic reaction. A client could develop an allergic reaction to midazolam if clonazepam is administered, as both medications are benzodiazepine medications. A client could also develop an allergic reaction if clonazepam is administered. Can still give the melloxicam which is an NSAID. HCP should also be notified.

The health care provider prescribes doxorubicin for a client diagnosed with bladder cancer. Which vein is most appropriate to administer doxorubicin therapy?

A central venous access device (CVAD) subclavian catheter with a double lumen. 3) CORRECT- Infusion administration of vesicant antineoplastic agents frequently is done through a CVAD to minimize the likelihood of venous injury and the consequences of any subcutaneous extravasation.

The nurse assesses a client who is admitted to the postpartum unit. The client appears anxious and frightened. The client's lochia has saturated two perineal pads in the last hour. For which additional finding does the nurse assess?

Continuous trickling of vaginal blood.

The nurse assesses a client in labor. Which data indicate that the client is in the active phase of the first stage of labor? (Select all that apply.)

Contractions are occurring 3 to 5 minutes apart. The client becomes doubtful of ability to control pain.

The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.)

DO not need to keep the voice even tone or decrease background noise - this is for hearing impairment.

The nurse assigns a client prescribed a continuous bladder irrigation to an unlicensed assistive personnel (UAP). Which tasks can be delegated to the UAP? (Select all that apply.)

Do perineal care and clean around the catheter.4.Report pain and bladder spasms to the nurse.5.Record the intake and output as prescribed. CANNOT manually irrigate the catheter if outflow is decreased.

The nurse monitors a client for the early signs and symptoms of dumping syndrome. Which assessment findings indicate to the nurse that this complication has occurred? (Select all that apply.)

2) CORRECT - Vertigo is an early manifestation that occurs 5 to 30 minutes after eating. 3) CORRECT -Tachycardia is an early manifestation that occurs 5 to 30 minutes after eating. 4) CORRECT - Profuse sweating is an early manifestation that occurs within 5 to 30 minutes after eating. 5) CORRECT - Pallor is an early manifestation that occurs 5 to 30 minutes after eating. 1) INCORRECT - Abdominal cramping may be a late manifestation of dumping syndrome. Rapid gastric emptying occurs when sugar or food moves too rapidly from the stomach into the small bowel. Refined sugar quickly absorbs water, resulting in the characteristic symptoms of dumping syndrome. Osmotic fluid shifts and hypoglycemia triggers vasomotor and gastrointestinal symptoms. Hypoglycemia results from taking in too much carbohydrate and a quick, overactive insulin response by the pancreas, resulting in that carbohydrate being used incorrectly. Minimizing consumption of simple carbohydrates is helpful when aiming to control symptoms of dumping syndrome. Some clients might find that fluids and foods should not be consumed together. The nurse will be both a teacher and resource person to the client with dumping syndrome.

The nurse provides care for a client diagnosed with cholelithiasis. Which assessment findings will the nurse identify as risk factors to the development of the cholelithiasis? (Select all that apply.)

A body mass index of 46.3.Having five children. Age. not aspirin or being vegan

The nurse provides care to clients on a telemetry unit. The nurse will intervene if which action is observed? (Select all that apply.)

A nurse obtains informed consent prior to a client being taken to the operating room. The health care provider obtains informed consent in English from a client whose primary language is Spanish.4.The surgeon arrives to obtain informed consent from a client just after the anesthesiologist has administered the preoperative benzodiazepine.5.When obtaining informed consent for a left heart catheterization, the cardiologist states, "Risks of the procedure included myocardial infarction, arrhythmias, cerebral vascular accident, and acute tubular necrosis."

The nurse prepares to administer an angiotensin II receptor blocker (ARB) to a client. Which laboratory value requires the nurse to contact the health care provider prior to the administration of the prescribed medication? (Select all that apply.)

A serum potassium level of 5.2 mEq/L (5.2 mmol/L).

The nurse provides care to a client being transferred from an acute care setting to an extended care facility (ECF). Once the nurse verifies that the client has signed a release of medical records form, which action facilitates client continuity of care? (Select all that apply.)

An updated Situation-Background-Assessment-Recommendation (SBAR) report is prepared and relayed to the ECF admissions nurse.2.The lab and diagnostic test results are printed and sent with the client to the ECF.3.The current electronic medication record (EMR) is printed and sent with the client to the ECF. An updated plan of care is prepared and relayed to the ECF admissions nurse. 4) INCORRECT- Communication with the admitting department, as with other bed/client tracking systems, is important. However, it does not directly affect individual client continuity of care.

The home health nurse provides care for a partially deaf older adult client and notices several home safety concerns. Which environmental adaptation is most important for the nurse to recommend to this client?

Add a flashing light to the phone. 1) CORRECT- Since this client is partially deaf, a hearing adaptation such as adding a light to the phone is best to increase safety at home.

A client with a vertebral compression injury at the level of C4 to C5 is evaluated in the emergency department and receiving oxygen at 8 L/minute via nasal cannula. The client's respirations are shallow, rate is 32 breaths per minute, and oxygen saturation is 88%. Which action does the nurse take first?

Administer 100% oxygen via non-rebreather mask. 3) CORRECT- Respiratory arrest is impending, so provision of high-flow oxygen is prioritized. BEFORE contacting HCP.

The nurse provides care for a client 2 days post coronary artery bypass grafting. As the nurse prepares to deliver the client's nighttime medications, the client reports not sleeping well the night before because "I could never get comfortable, and my incision hurts." The nurse notes a PRN pain medication was not administered. In addition to pharmacological interventions, which action can promote client comfort? (Select all that apply.)

Ask the client if there is an intervention that would help them be more comfortable.3.Provide the client with a foot rub before bed.4.Ensure the client is not lying on IV tubing and drainage tubes.5.Encourage the client to splint the chest with a pillow when coughing. DO NOT distract with a card game before bed. 3) CORRECT- A massage can enhance the effectiveness of pain medication and reduce anxiety related to the pain. A massage before bed can improve comfort and rest for the client.

The nurse provides care for a client who is experiencing cancer-related chronic pain. Which non-pharmacological comfort intervention should be included in the plan of care? (Select all that apply.)

Guided imagery. Meditation. Diaphragmatic breathing. NOT Application of heat or cold, this is for acute. NOT therpautic touch because research does not say it is effective.

Which finding during a newborn client examination requires immediate action by the nurse?

The red reflex is absent in the newborn's right eye. 4) CORRECT — The absence of a red reflex indicates an ophthalmic emergency. This is because light is not being transmitted to the retina, and the early suppression of optic nerve function, which results in the obstruction of the light, can cause blindness. Notify the health care provider immediately.