Nursing is Awesome

A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

"You should depress the button on the handheld marker when you feel your baby move."

A nurse is reinforcing teaching with a group of clients about the Heimlich maneuver during a first aid class. The nurse should include in the teaching that which of the following manifestations indicates the need for the Heimlich maneuver to be performed? (Select all that apply)

1 Difficulty Breathing 2. Coughing 3. Presence of stridor

A nurse is caring for a client who has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20

A nurse is preparing to administer metoclopramide 10 mg IM. Available is metoclopramide 5mg/mL How many mL should the nurse administer? round to nearest whole number

2ml

A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?

A client who has pneumonia and a new onset of confusion

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client whose urinary output was 100 ml for the past 12 hr

A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client?

Acetylcysteine

A charge nurse on a long term care unit is preparing to delegate teaks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the charge nurse delegate to the LPN?

Administer an initial NG tube feeding to a client who has a stroke

A nurse is reinforcing teaching with a client regarding prescribed asthma medications. The should nurse instruct the client to use which of the following medications for treatment of an acute asthma attack?

Albuterol

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

Allow the weight to hang freely

A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take?

Answer Report the observation about the AP to the Unit nurse manager

A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture Of membranes following a vaginal examination. The provider reports the client's cervix is dilated to1 cm with an unengaged presenting part. Which Of the following actions should the nurse take?

Apply the external fetal heart rate monitor

The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be most important to include in this patient's preparation? a. Place the patient in a clean surgical gown. b. Ask the patient to remove all hairpins and cosmetics. c. Ascertain that the surgical site has been correctly marked. d. Determine where the family will be located during the procedure

Ascertain that the surgical site has been correctly marked

A nurse is collecting data from a client who has multiple sclerosis. Which of the following findings should the nurse expect?

Ataxia

A nurse is reinforcing teaching with a client who has dumping syndrome about measures tor educe manifestations. Which of the following instructions should the nurse include in the teaching?

Avoid foods high in sugar content

A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which Of the following actions should the nurse take?

Avoid massaging the site after injecting vaccine

A nurse is checking a newborn's vital signs. Which Of the following methods Of temperature measurement should the nurse use?

Axillary

A nurse is collecting data from a client who is in the diagnostic center and is scheduled to undergo a colonoscopy. Based on the information provided in the client's chart, which of the following pieces of data places this client at risk for colorectal cancer? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

BMI

A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the following foods should the nurse include in the plan as having the highest amount of iron?

Boiled Spinach

A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

Cap refill of 5 seconds to the clients toes

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the findings should indicate to the nurse that the medication has been effective?

Cardiac workload decreases

A nurse in a long term care facility is contributing to the plan of care for a client who has a new ostomy. Which Of the following interventions should the nurse include?

Change the appliance two times each week

A nurse is reviewing a client's electronic medical record and finds that an assistive personnel recorded the client's temperature as 35.30 C (95.50 F) 2 hr earlier. Which of the following actions should the nurse take first?

Check the clients temperature

A nurse is reinforcing teaching with a client who has fluid volume deficit about selecting foods have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving?

Cherry Tomatoes

A nurse is assisting with the admission of a client who is experiencing alcohol withdrawl. Which of the following medications should the nurse expect the provider to prescribe for the client?

Chlordiazepoxide

A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which Ofthe following findings is the nurse's priority to report to the provider?

Client reports burning with urination

A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?

Consumption of contaminated food

A nurse is reviewing laboratory reports for a client who has an Escherichia coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose?

Creatinine 2.5 mg/dl

A nurse is collecting data from a male client who is scheduled for a left inguinal herniorrhaphy. Which of the following findings is the priority for the nurse to report to the provider?

Decreased Bowel Sounds

A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

Demonstrate Assertiveness

A nurse is collecting data from a client who is experiencing a situational crisis following the loss of a job. The client states, "l don't think I can go through this again." Which of the following actions is the nurse's priority?

Determine if the client is experiencing psychotic thinking

A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

Determine the client's mobility status

A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

Difficult Concentrating

A charge nurse in a long term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

Discuss this behavior with the AP while reinforcing expectations

A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?

Dosage

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which Of the following information should the nurse include?

Eat a bedtime snack

A nurse is preparing to administer purified protein derivative (PPD) to a client who has tuberculosis. Which of the following actions should the nurse plan to take?

Ensure the injection produces wheal on the skin

A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include?

Establish a regular exercise routine 2 hr or more before bedtime

A nurse is reinforcing teaching with a client who is bottle feeding their full-term newborn with formula. Which of the following instructions should the nurse include in the teaching?

Feeding newborn at least every 3-4 hrs

A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. The nurse should report which Of the following to the provider after hearing this sound? (Click on the audio button to listen to the clip.)

Fine Crackles

A nurse is caring for a client who takes prednisone daily for the treatment of chronic asthma. The nurse should plan to monitor the client for which of the following adverse effects?

Gastric Ulcer Formation

A nurse is performing postmortem care for a client prior to the arrival Of the client's family forviewing Of the body. Which Of the following actions should the nurse take?

Gently close the client's eyelids

A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The client states, "l really thought I'd be back to my usual routines by now, but I can't think of anything else except that my son is gone." Which Of the following responses should the nurse make?

Grieving for your son is hard work. it will take as much time as you need to come to terms with your loss

The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented? a. Suturing the surgical incision in the OR suite b. Managing patient care activities in the OR suite c. Assisting with applying sterile drapes in the OR suite d. Handing sterile instruments and supplies to the surgeon in the OR suite

Handing sterile instruments and supplies to the surgeon in the OR suite

A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?

Heart Rate 146/min

A nurse is assisting with the admission of an adolescent who has bulimia nervosa. Which of the following manifestations should the nurse expect?

Hematemesis

A nurse in a long term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?

Hydrogen Peroxide

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Hypervigilance

A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

I am so frustrated I cannot even open my milk carton for breakfast

A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, "l am very upset and I want to be alone for a little while." Which Of the following responses should the nurse make?

I see that you are feeling overwhelmed. i will come back when you are ready

A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I should apply sterile saline to lubricate the suction catheter

A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent indicates an understanding of the teaching?

I should offer my child yogurt that has a probiotic as a snack

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching? a. I can visit my nephew who has chickenpox 5 days after the sores have crusted b. I can clean my cat's litter box during my pregnancy c. I should take antibiotics when I have a virus d. I should wash my hands for 10 seconds with hot water after working in the garden

I should take antibiotics when I have a virus

A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?

I will apply diaper cream to my baby skin during each diaper change

A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which Of the following statements by a parent indicates an understanding Of the instructions?

I will give our baby sponge baths until the cord falls off.

A nurse is reinforcing teaching about stress management techniques with a client who has moderate anxiety disorder. Which of the following responses by the client indicates an understanding of the teaching?

I will imagine myself in a calm place when I can't concentrate

A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

I will rinse my mouth after taking this medication

A nurse is reinforcing discharge teaching about car seat safety with the guardian of a child. Which of the following statements by the guardian indicates an understanding Of the teaching?

I will secure the car seat in the car by using the seatbelt

A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following client statements indicates an understanding of the teaching?

I will undergo bowel cleansing prior to the procedure

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrilation. Which of the following statements by the client indicates an understanding of the teaching?

If I forget to take a dose I can take it later on the same day

A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?

Informing a client the nurse is going to administer an injection even though the client refuses

A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

Instruct the client not to get out of bed

A nurse is contributing to the plan of care for a client who is post operative following a Which of the following interventions should the nurse recommend?

Instruct the client to avoid the Valsalva maneuver

A nurse is assisting in the plan Of care for a female client who is to undergo a 12-lead ECG. Which of the following actions should the nurse include in the plan of care?

Instruct the client to remain still while the test is performed

The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next? a. Notify the operating suite that the medication has been given. b. Instruct the patient to call for help to go to the restroom. c. Waste any unused medication according to policy. d. Ask the patient to sign the consent for surgery

Instruct the patient to call for help to go to the restroom

A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

Irrigate the bladder using sterile technique

A nurse is collecting data from a newly admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

Irritability

A nurse is reinforcing teaching with a female client who requests information about how to lose weight. Which of the following statements should the nurse make?

Keep fat intake to no more than 30 percent of your daily caloric intake

A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Lack of Sleep

A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer?

Lamb

A nurse is positioning a client who is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

Lateral Recumbet

A nurse is caring for a client who is being discharged home following a cerebrovascular. Which of the following documents should the nurse plan to include with the discharge report?

List of potential complications to report

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

Maintain a sequential compression device

A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?

Maintain the drainage below the level of the clients chest

A nurse is providing teaching to a client about the adverse effects of Sertraline. Which of the following adverse effects should the nurse include? a. Metallic taste in mouth b. Dry cough c. Increased Urinary Frequency d. Excessive Sweating

Metallic taste in mouth

A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider?

Metoprolol ER 50 mg per NG tube BID

A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?

Moist mucus membranes

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse expect?

Muscle Weakness

A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?

My son took my wallet so he can keep track of what I'm spending

The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? a. Notify the operating suite that the patient has a latex allergy. b. Document that the patient had a bath at home this morning. c. Administer the ordered preoperative intravenous antibiotic d. Ask the nursing assistive personnel to obtain vital signs

Notify the operating suite that the patient has a latex allergy

A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?

Offering general leads

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

Open the outer package flap of the catheterization kit away from the body

A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?

Perform Kegel exercise daily

A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

Perform a fundal massage to the client

A nurse is contributing to the plan of care for a client who is at risk of developing pressure. Which of the following interventions should the nurse include?

Place the client in a 30 degree lateral position

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

Place the client in a lateral position

A nurse is transferring a client from a bed to a wheelchair. The client has right-sided weakness following a recent stroke. Which of the following actions should the nurse take?

Place the wheelchair on the clients left side

A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?

Place your baby's crib away form heat vents

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider?

Platelet count of 95,000

A nurse is preparing to discharge a client who is immunocompromised. Which of the following vaccines should the nurse plan to administer?

Pneumococcal polysaccharide (PPSV)

A community health nurse is helping to reinforce teaching about Hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

Poor lighting in the Learning Setting

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation Which of the following interventions should the nurse recommend?

Position the head of bed at 30 degree angle

A nurse at a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescriptions is accurately transcribed by the nurse?

Potassium chloride 20mEq PO every morning

A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After drawing up the medication, the nurse accidentally brushes the needle on the counter's surface. Which of the following actions should the nurse take?

Prepare a new dose of insulin injection

A nurse is receiving change-of-shift report for a group Of clients. The nurse should plan to implement which of the following time-management strategies?

Prepare a priority list of client needs for the shift

A nurse in a long-term care facility is reviewing information about health care-associated infections with a newly licensed nurse. Which Of the following information should the nurse include?

Prolonged use of corticosteroids is a risk factor for infection

A nurse is caring for a client who has expressive aphasia following a stroke. Which of the methods should the nurse use when communicating with the client?

Provide a picture board

A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?

Purchase beef that is a loin cut

A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?

Putting a glove on their dominant hand first

A nurse on an acute care unit is collecting data from a school-age child who has cystic fibrosis (CF). Which of the following findings is the priority for the nurse to report to the provider?

Report lack of appetite

A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

Report the situation to the provider who obtained informed consent

A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which Of the following actions should the nurse take?

Report the suspected abuse to the appropriate agency

A nurse is preparing to administer a client's mornings medications. Which of the following actions should the nurse take to verify the client's identity?

Scan the client facility identification band

A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention?

School age child who has allergic rhinitis and is taking diphenhydramine

A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school age child. Which of the following information should the nurse include?

Seperate the Childs used washcloth from those of others

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

Take up to three tablets during a single angina episode

A nurse is contributing to an in-service for newly-licensed nurses about child maltreatment. The nurse should include that which of the following characteristics increases a child's risk of physical maltreatment?

The child was born at 34 weeks of gestation

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has anew prescription for a regular diet. For which Of the following findings should the nurse notify the provider?

The client has absent bowel sounds

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorders?

The client is exceptionally clingy to others

A nurse is reinforcing teaching with a client who has left sided weakness and is learning how to ambulate with a cane. The nurse should identify that the client understands the teaching when the client places the cane in which of the following positions when advancing forward? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

The foot on your Right Side

A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

The nurse administered insulin lispro to a client who has diabetes mellitus and is NPO

A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?

The one with one drooping eye or male with unibrow

A nurse is reinforcing teaching with a client who has Tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching?

The people I live with should be tested for TB

A nurse is reinforcing teaching with a client who is scheduled for a barium enema. Which of the following statements should the nurse make?

This procedure uses diagnostic imaging to locate and obstruction

A nurse is reinforcing teaching about food selection with a client who has a moderate burninjury. Which of the following foods should the nurse recommend as being high in vitamin C?

Tomatoes

A nurse is preparing to administer a rectal suppository to a school-age child. Which of the actions should the nurse plan to take?

Use one finger to insert the suppository past the anal sphincters

A school nurse is having a conversation with the parents of an adolescent. The nurse should identify which of the following situations as an ethical dilemma for the parents?

We can't decide whether to try homeschool our child or move them to a private school

A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?

Where is your pain located

A nurse is caring for a female client who has an indwelling urinary catheter. Which of the actions should the nurse take?

Wipe the drainage port with an antiseptic wipe after emptying urine from the bag

A nurse in a long-term care facility is caring for a client who requires oral suctioning. Which of the following supplies should the nurse plan to use for this task?

Yankeur

A nurse is reinforcing teaching with the adult children of a client who is dying. Which of the following statements should the nurse make?

You can continue talking to your prater until they are gone

A nurse is reinforcing teaching with a client who is at 20 weeks Of gestation and will undergo routine abdominal ultrasonography the following day. Which Of the following statements should the nurse include in the teaching?

You will need to have a full bladder for the procedure

A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. Which of the following instructions should the nurse include in the teaching?

You will need to schedule a bone density test

A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription forlevothyroxine. Which of the following instructions should the nurse include in the teaching?

You will need to take the medication for the rest of your life

A nurse is preparing a client for surgery. The client states, " I'm sure this surgery will not help me get better." Which of the following responses should the nurse make?

You're saying that you are doubtful that this procedure will benefit you

A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?

Zolipedem

A nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes mellitus and inquires about information concerning oral antidiabetic agents. In addition to the provider, where should the nurse refer the client for information? (Select all that apply.

[1] a pharmacist. [2] package inserts. [3] American diabetes association

A nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

[1] expose the glans of the penis [2] cleanse the penis using and antiseptic swab. [3]Begin urination [4] pass the cup into the urine stream [5] move the cup out of the urine stream. [6] replace the foreskin

A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.) a. Do not rinse. b. Clean under breasts c. Inform that the skin will feel sticky d. Dry thoroughly between skin folds. e. Use two wipes for each area of the body

a. Do not rinse. b. Clean under breasts c. Inform that the skin will feel sticky

A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?

advanced directives are written instruction regarding end of life care

A nurse is speaking with the partner of a client who has Alzheimer's disease. The partner states, "l love him, but caring for him is wearing me out." Which of the following responses should the nurse make?

answer lets discuss how caring for your partner is affecting your health

A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include?

apply the prosthesis immediately upon waking each day

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

applying the stocking before the client gets out of bed

A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

as soon as the client awakens in the morning

A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?

avoid lying on the affected side

A nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first?

check for gag reflex

A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation Of increased intracranial pressure?

confusion about knowing their own name

A nurse manager is preparing to complete a performance analysis for a group of assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the following actions should the staff nurse take?

discuss how each AP action measure against the job description

A nurse is working with an interpreter to assist the provider with explaining a diagnostic to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

ensure the interpreter is culturally compatible with the client

A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?

have a supply of prescribed medications

A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

i should use counter pressure for back pain during labor

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions?

i will receive thenutrients i need through my IV fluid.

A nurse is reinforcing teaching with a client who has asthma and a new prescription for an ipratropium inhaler. Which of the following statements by the client indicates an understanding the teaching?

iIshould wait 1 minute before taking a second puff of the medication

A nurse is preparing to administer a medication to a client. The client states, "I'm sick Of all these medications, and I'm not taking any more today!" Which Of the following actions should the nurse take?

inform the client of the possible consequence of the medication refusal

A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago and a fourth-degree perineal laceration. Which of the following interventions should the nurse recommend?

instruct the client to use a sitz bath at least twice a day

A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

lack of change in the pupil size when the client looks form a far to near object

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

obtaining clients vital signs prior to discharge

A nurse manager is providing an in-service on hand hygiene to assistive personnel. Which of the following information should the nurse manager include in the in-service?

remove rings when washing hands with soap and water

A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

the AP reports client information to the oncoming AP in the hallway

A nurse is reinforcing teaching with a client about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

the client attempts to elevate the cylinder by inhaling deeply

A nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?

the facility has 12% fewer urinary tract infection over the past 6 months

A nurse is reinforcing discharge teaching with a client who has undergone vein ligation andstripping to treat varicose veins. Which of the following instructions should the nurse include inthe teaching?

walk for 1-2 hrs each day.

A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

wear a surgical mask within 3 feet of the client

A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?

your oncologist might prescribe acold cap to war during treatment to reduce hair loss

A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

your weight gain should be the same as for someone without diabetes