PN Comprehensive Online Practice 2023 A 12.11.23

Select the 4 results of the client's urinalysis that require follow-up for a ur cary tract infection.

Leukocyte esterase RBC WBC Nitrates When analyzing cues, the nurse should identify that positive RBC, positive WBC. positive leukocyte esterase, and positive nitrites in the urine are indicative of a urinary tract infection. The nurse should report the results of the urinalysis to the provider.

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

List of potential complications to report Discharge instructions are defined as any form of documentation provided to the client, upon discharge to home, which facilitates safe and appropriate continuity of care. The nurse should plan to include a list of potential complications that should be reported to the provider in the client's discharge instructions.

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 system below the level of the client's chest. The nurse should maintain the drainage system below the level of the client's chest to prevent the backflow of secretions and water from the system into the chest cavity.

A nurse is caring for a client who is immunocompromised. Which of the following immunizations is contraindicated?

Measles, mumps, rubella (MMR) The MM vaccine consists of a live virus and is contraindicated for a client who is immunocompromised.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Client reports nocturia, urinary frequency and urgency, and fatigue for 3 days.

Most likely experiencing: Pyelonephritis Actions to take: Prepare to administer antibiotics Encourage increased fluid intake Parameter to monitor: Fever BUN

A nurse is reinforcing teaching with a client who has hypercholesterolemia and a new prescription for atorvastatin. The nurse should instruct the client that which of the following findings is an adverse effect of this medication and should be reported to the provider?

Muscle pain atorvastatin is a HMG-CoA reductase inhibitor used to reduce liver cholesterol. Serious adverse effects of these include myopathy, rhabdomyolysis, liver dysfunction and myoglobinuria

A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion?

My doctors glasses have lasers that will burn holes in my brain if i look at them. rationale: The client's statement demonstrates a belief that is contrary to reality that someone intends to cause them harm using unrealistic means. Therefore, the nurse should identify this statement as a delusion of persecution.

A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using eating utensils. The nurse should identify the need for a referral to which of the following interprofessional team members?

Occupational therapist. rationale: to teach client how to use special eating utensils.

A nurse is monitoring a client who is receiving telemetry. Which of the following ECG findings should the nurse report to the provider?

PR interval 0.24 seconds An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval can indicate a heart block. Therefore, the nurse should report this finding to the provider.

A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse include?

Place the client in a private room. The nurse should place a client who has viral meningitis in a private room to prevent the transmission of the virus. Direct contact with a contaminated surface or the saliva, mucus, or feces of the person who has the infection transmits viral meningitis.

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 client's left side. *The nurse should place the wheelchair on the client's stronger side to reduce the risk of falling.

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 babies crib away from heat vents

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Potential condition: somatic symptom disorder Actions to take: • Monitor the clients physical manifestations • Monitor the client for a secondary gain from illness. Parameters to Monitor: • Vital signs • Pain level

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 for injection. *Insulin is administered using an insulin syringe with a preattached needle. Therefore, to ensure the sterility of the needle, the nurse should prepare a new dose of insulin for injection using a new syringe and new dose of insulin.

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

Provide a picture board. *A client who has expressive aphasia has difficulty expressing needs or wants through verbalization or writing. The use of a picture board provides an alternative means of communication that might be less frustrating for the client.

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. *The nurse is demonstrating sterile technique when they put a glove on their dominant hand first. Using the dominant hand to apply the second glove helps prevent contamination because the nurse's dominant hand is more likely to have better dexterity than their non dominant hand.

For each discharge instructipn, click to specify if each action is recommended or contraindicated for the client. The client reports repeated episodes of vomiting and two episodes of diarrhea in the past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.

Recommended: Eat every two to three hours Alternate eating solid foods and liquids. Increase intake of high-protein foods. Contradicted: Drink warm ginger ale when nauseated.

A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex?

Stroke the sole of the newborn's foot upward and toward the great toe. The nurse should stroke upward along the lateral aspect of the sole of the foot, beginning at the heel, to elicit the Babinski reflex.

A nurse is assisting with planning care for a client who has a history of seizures. Which of the following pieces of equipment should the nurse place in the clients room?

Suction catheter The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a patent airway.

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. This is the correct action by the client. The cylinder should be elevated by the client inhaling deeply.

Complete the following sentence by using the lists of options.

The client is at greatest risk for developing dysthymia evidenced by electrolyte imbalance The nurse should assist to analyze cues to determine if the client is at greatest risk for developing dysrhythmias related to hypokalemia, as evidenced by the laboratory report and the client's report of muscle cramping. Potassium and magnesium depletion are common manifestations in clients who are postoperative following CABG. Due to medication or hemodilution, it is important for the nurse to closely monitor electrolytes.

Complete the following sentence by using the lists of options.

The client is at greatest risk for developing hypocalcemia evidenced by the clients report of muscle spasms, numbness around the lips, and decreased calcium level.

Complete the following sentence by using the lists of options. Urinalysis results were reported to the primary care provider's office.

The client is at greatest risk for developing urosepsis as evidenced by the client's prior catheterization.

Complete the following sentence by using the lists of options.

The client is at risk for developing delayed wound healing ~ due to glucose level

Complete the following sentence by using the lists of options.

The client is at risk for developing seizures severe as evidenced by severe features of preeclampsia When analyzing cues, the nurse should recognize that the client is at risk for developing seizures as evidenced by the presence of severe features of preeclampsia. The client is reporting a new onset of headache, blurred vision, and nausea. The client has significantly elevated blood pressure, hyperreflexia, and clonus. These findings indicate central nervous system irritability, which increases the risk for seizures, also known as eclampsia.

Complete the following sentence by using the lists of options.

The client is exhibiting manifestations of heart failure evidenced by the clients BNP level. Rationale: When analyzing cues, the nurse should determine that the client is exhibiting manifestations of heart failure as evidenced by the client's NP level, The client is experiencing dyspnea and fatigue, which might be manifestations of decreased cardiac output. Auscultation of S3 is an early indication of heart failure. A BNP level greater than 400 pg/ml. is associated with heart failure. Chronte hypertension leads to myocardial hypertrophy and decreased ability of the heart to fill during diastole and is a common cause of heart failure

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 had 12% fewer UTI over the past 6 months Quality improvement relates to improving outcomes for clients, staff, or the facility. The nurse should document a reduction in urinary tract infections as an improvement in care quality.

A nurse is preparing to administer amoxicillin 875 mg PO every 12 hr. The amount available is amoxicillin oral suspension 400 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse should administer amoxicillin 11 mL PO every 12 hr.

Complete the following sentence by using the list of options.

The nurse should first address the client's respiratory rate followed by an action to increase the level of consciousness.

Drag words from the choices below to fill in each blank in the following sentence.

The nurse should identify that the child may be developing an infection and skin breakdown

Click to highlight the data collection findings that the nurse should report to the provider prior to the procedure. To deselect a finding, click on the finding again. Client reports restlessness and inability to sleep more than 3 to 4 hr per night for the last week. Client reports pain of 2 on a scale of 0 to 10, constant for 2 weeks and increases after meals.

hemoglobin level allergy family history

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 of the teaching?

i should wait 1 minute before taking a second puff of the medication The client should wait 1 min between puffs of medication to increase absorption.

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 Rationale: The nurse should assist the client into the lateral recumbent position for a lumbar puncture to ensure the proper placement of the needle.

A nurse is using the FLACC scale to determine the pain level of an 11-month-old infant who is postoperative. Which of the following factors should the nurse consider when using this pain scale?

level of activity The nurse should consider the infant's activity level when using the FLACC pain scale. The FLACC score is determined by five categories of behavior: facial expression (F), leg movement (L), activity (A), cry (C), and consolability (C).

A nurse is assisting a client who is scheduled for a nonstress test (NST). Which of the following actions should the nurse take?

provide the client with a handheld event marker to record fetal activity.

A nurse is reinforcing teaching with an older adult client who has severe left-sided heart failure. Which of the following statements should the nurse make?

rest for 15 minutes between activities. The nurse should instruct the client to increase activity gradually and to rest for a period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with rest to reduce cardiac workload.

A nurse in an urgent care clinic is completing a client examination. Upon listening to the client's lungs, the nurse hears a high-pitched, crowing sound. Which of the following adventitious sounds should the nurse document?

stridor The nurse should document this sound as stridor. Stridor is a high-pitched, crowing sound heard during inspiration.

A client in a mental health facility accuses a nurse of stealing money from their room. Which of the following therapeutic responses should the nurse make?

tell me how you decided who took your money

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 The nurse should reinforce with the client that a barium enema uses fluoroscopy, which is a type of diagnostic imaging, to locate and identify tumors or other causes of a bowel obstruction.

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

we cant decide whether to try homeschool our child or move them to a private school The nurse should identify that this statement indicates an ethical dilemma because there are multiple valid solutions that could result in different outcomes.

A nurse is reinforcing teaching about puberty with a group of prepubescent female clients. Which of the following information should the nurse include in the teaching?

you will likely gain weight before you start to get taller

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 A client who is pregnant and has diabetes mellitus should gain the same amount of weight as a client without diabetes mellitus.

A nurse is assisting with the care of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect to administer?

• Chlordiazepoxide The nurse should expect to administer chlordiazepoxide to decrease anxiety and the risk for seizures associated with alcohol withdrawal.

I nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to the provider?

• Generalized petechiae Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, and also anywhere on the head of newborns who had a nuchal cord, which is an umbilical cord around the neck. However, petechiae all over the newborn's body dan indicate infection or a decreased platelet count and should be reported to the provider.

A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?

"I should check my blood sugar if my appetite is decreased." Rationale: The nurse should instruct the client to monitor blood glucose levels closely. Change in appetite can be an early sign of hyperglycemia and inadequate intake may cause blood glucose to drop.

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." Rationale: Iron preparations can stain the teeth. The nurse should instruct the client to use a straw to drink the medication and rinse the mouth immediately after taking the medication.

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 bowl cleansing prior to the procedure." *The client will receive a bowel preparation prior to the procedure and an enema immediately before the procedure to ensure the bowl is free to stool to allow for visualization of the intestinal mucosa. Therefore, this statement indicates that the client understand the teaching.

A nurse is caring for a client who is crying and states their provider informed them that they have a tumor and will need a biopsy. Which of the following responses should the nurse make?

"What have you done to help yourself get through stressful situations before?"

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." This response uses reflection as a therapeutic technique. This communication technique lets the client know that their concerns and feelings are heard and understood.

A client is requesting information from a nurse about creating a health care proxy. Which of the following statements should the nurse make?

"the person you appoint will make healthcare decisions for you if you cannot do so yourself"

A licensed practical nurse (LP) is reviewing client assignments for the upcoming shift. Which of the following clients should the LP ask the charge nurse to reassign to a registered nurse (RN)?

A client who has a new colostomy and requires the development of a teaching plan

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 client who has pneumonia and displays a new onset of confusion is manifesting a decrease in oxygenation and is unstable. Therefore, the nurse should see this client first.

A nurse is working in an acute care facility when a natural disaster occurs. The facility must discharge clients to provide room for new admissions. Which of the following clients should the nurse recommend the charge nurse discharge?

A client who has pneumonia and is currently receiving oral antibiotics. The nurse should recognize that this client can continue oral antibiotics at home. Therefore, this client is a candidate for discharge in a disaster situation.

A nurse is reviewing the electronic health records of four clients. Which of the following client conditions should the nurse recognize as reportable to a regulatory agency?

A client who is newly diagnosed with tuberculosis The nurse should identify that certain communicable diseases, such as tuberculosis, require notification of the local and state health departments.

For each data collection finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process.

ADHD: Interrupting others Social functioning deficit Losing necessary things Hyperreactivity to sensory input ID: Social functioning deficit impaired language skills

A nurse is assisting with the care of a client who has a terminal illness. The client practices Orthodox Judaism. Which of the following actions should the nurse take?

Assure the client that a family member will stay with his body after death. The nurse should assure the client that a family member will remain with the body until burial.

The nurse is preparing to reinforce teaching to the client on how to prevent further urinary tract infections from occurring. Which of the following information should the nurse include? Select all that apply.

Avoid coffee, teas, colas, and alcoholic drinks because they are considered urinary tract irritants. Shower rather than bathe in a bathtub because bacteria in bath water can enter the urethra, causing an infection. Cleaning the perineum from front to back prevents Escherichia coli from entering the urinary tract. Voiding every 2 to 3 hr during the day prevents overdistention of the bladder which decreases - blood supply to the bladder wall.

For each finding, click to specify if the finding is consistent with bacterial meningitis or encephalitis. Each finding may support more than 1 disease process.

Bacterial meningitis: fever, photophobia, pain, mental status, and rash. Encephalitis: Fever, pain, and mental status.

A nurse is assisting with the admission of an older adult client. Which of the following actions should the nurse take first?

Complete a fall risk assessment on the client The first action the nurse should take when using the nursing process is to collect data from the client. By completing a fall risk assessment, the nurse can identify the client's risk for falls and can then assist in planning interventions to prevent client injury.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition Most Likely Experiencing: automatic dysreflexia Actions to Take: Prepare to administer nifedipine. Assess for urinary retention. Parameters to Monitor: Blood pressure Changes in vision

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 *Confusion is a sign of a decreased level of consciousness and is an indication of increased intracranial pressure.

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 caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take?

Encourage the client to reminisce about the past The client who has Alzheimer's disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remote memory remains in place for a longer period of time and can elicit feelings of happiness.

A nurse is working with an interpreter to assist the provider with explaining a diagnostic procedure 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. The nurse should ensure that the interpreter and client speak the same dialect and share similar cultural norms and practices.

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?

Feed the newborn at least every 3 to 4 hr. *Although it is unnecessary to be rigid about feeding times, six to eight feedings every 24 hr should support a full-term newborn's nutrition needs adequately. Fewer feedings in the initial weeks could delay the establishment of an adequate weight-gain pattern.

For each finding, click to specify if the finding requires follow-up or does not require follow-up.

Follow up: heart rate, BP, HbA1c, BMI Doesn't require follow-up: sodium & BUN

A nurse is collecting data from a client who has a suspected urinary tract infection. The nurse should identify that which of the following findings indicates a urinary tract infection? Select all that apply.

Frequency, dysuria, and urgency can indicate the client has a UTI.

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. Children who have lactose intolerance should be offered dairy products that have a probiotic, such as lactobacillus. The probiotic promotes tolerance of lactose in the colon.

A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril. Which of the following over-the-counter medications should the nurse instruct the client to avoid?

Ibuprofen Ibuprofen, or any other nonsteroidal anti-inflammatory medications, can reduce the antihypertensive effects of this medication. Therefore, the nurse should instruct the client who is taking captopril to avoid taking ibuprofen.

A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hr ago and has 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. *The nurse should instruct the client to use a sitz bath for at least 20 min twice per day. For the first 24 hr following delivery, the sitz bath should contain cool water to reduce edema and pain. After 24 hr following delivery, the sitz bath should contain warm water to promote circulation and reduce pain.

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

"The people I live with should be tested for TB."

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

"Advance directives are written instructions regarding end-of-life care." The nurse should inform the client that advance directives allow the client to make decisions and provide written instructions regarding end-of-life care. These directives take effect if the client is unable to make their own health care decisions.

A nurse is assisting with the care of a client who has terminal cancer. Which of the following statements by the client's family should indicate to the nurse that they are coping effectively with their situation?

"Dad, I remember the time we all went fishing at the lake." Reminiscence is a normal task of the grieving process that allows the family to cope as the client's life nears its end.

A nurse is assisting with teaching a group of local residents at a community health fair about the Dietary Approaches to Stop Hypertension (DASH) diet. Which of the following statements by a resident indicates an understanding of the teaching?

"I will keep my intake of sodium less than 2,300 milligrams per day." Rationale: DASH principles include limiting daily sodium intake to less than 2,300 mg/day. Individuals who have an increased risk for hypertension, such as clients who have kidney disease and diabetes, should reduce intake of sodium to 1,500 mg/day.

A nurse is reinforcing teaching with a 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." The nurse should instruct the client to limit fat intake to no more than 30% of their daily caloric intake. Reducing fat consumption can help decrease caloric intake because fats typically have twice as many calories as proteins or carbohydrates.

A nurse is collecting data from an older adult client. Which of the following client statements should the nurse Identify as an indication of possible maltreatment?

"My child took my wallet so they can keep track of what I'm spending."

A nurse is assisting with planning care for a 5-year-old child who is 8 hr postoperative following a tonsillectomy. Which of the following interventions should the nurse include in the plan of care?

Administer PRN analgesics regularly for the first 24 hr. The nurse should administer analgesics for the first 24 hr, even if they are ordered on an as-needed basis. It is necessary to control pain postoperatively. Giving the analgesics regularly provides a steady state of analgesia. With pain being managed, children are more likely to consume fluids, remain hydrated, and avoid delayed discharge or readmissions for fluid volume deficit.

A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa. Which of the following instructions should the nurse include?

Administer the medication subcutaneously The nurse should instruct the client to self-administer epoetin alfa via the subcutaneous route.

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

Administering an initial NG tube feeding to a client who had a stroke It is within the LP's scope of practice to administer an initial NG tube feeding to a client who had a stroke. Because this task requires use of the nursing process, it is outside the range of function for an AP. Therefore, the LP should expect to be assigned this task.

A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the electronic health record to locate information about the client's personal health insurance?

Admission Sheet The nurse will find client data, such as date of birth, occupation, and the client's source of health insurance, on the client's admission sheet.

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

Difficulty concentrating *In clients who have iron deficiency anemia, body cells do not receive the required oxygen because there is less hemoglobin for binding. The nurse should recognize that impaired oxygenation of brain tissue can lead to dizziness and difficulty concentrating.

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

Gently close the patient's eyelids. *The nurse should hold the client's eyelids closed for a few seconds to ensure that they remain closed.

Which of the following 4 client findings should the nurse report to the charge nurse?

Pain, nausea, heart rate, and oxygen saturation

Select the 3 prescriptions the nurse should anticpate from the provider.

Phenazopyridine 200 mg PO three times daily • Sulfamethoxazole 160 mg PO every 12 hr Obtain a culture and sensitive test

Complete the following sentence by using the lists of options.

The nurse should suspect the client is experiencing serotonin syndrome as evidenced by the client's altered mental status

For each body system below, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than 1 potential nursing intervention.

The nurse should take action by administering naloxone, an opioid antagonist for opioid toxicity. The nurse should monitor the client for hypotension and observe the client for pinpoint pupils, which are findings that suggest opioid toxicity.

A nurse is assisting with an educational session for newly licensed nurses about partner violence. Which of the following should the nurse include as increasing a person's risk of being a recipient of partner violence?

Threats to leave the relationship The nurse should include threats to leave the relationship as a factor that increases a person's risk of experiencing partner violence. Perpetrators want to maintain control of the relationship and this would undermine the perpetrator's position of power.

A nurse is collecting a urine specimen from a female client who has diabetes insipidus. Which of the following findings should the nurse expect?

Urine specific gravity of 1.002 rationale: Clients who have diabetes insipidus typically have colorless urine with a specific gravity of 1.005 or less.

A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group of assistive personnel (AP). Which of the following instructions should the nurse include?

Use lower-body strength. The nurse should instruct the AP to use lower-body strength when lifting a client to reduce stress on the back.

A nurse is reinforcing teaching about managing manifestations of anxiety with a client who has generalized anxiety disorder. Which of the following information should the nurse include?

Use the word "stop" when upsetting thought occur. rationale: encourage thought stopping as a form of behavior therapy to decrease and manage anxiety.

Click to highlight the findings that indicate that the treatment has been effective. To deselect a finding, click on the finding again. Urinalysis results were reported to the primary care provider's office.

When evaluating outcomes, the nurse should recognize that the treatment has been effective by the client's reports of urinating without discomfort, voiding clear yellow urine, and drinking 1.5 L of water daily.

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

cardiac workload decreases. Digoxin reduces effects of HF & improves CO by improving the conduction of the heart. This action allows the heart to work less to provide adequate perfusion, reducing the overall O2 demand on the heart.

A nurse is caring for a client who reports an intense headache, nuchal rigidity, nausea and vomiting, along with fever and chills. Which of the following diagnostic tests should the nurse expect the provider to prescribe?

cerebrospinal fluid analysis The client's findings are consistent with bacterial meningitis. A lumbar puncture should be performed to obtain cerebrospinal fluid to confirm the diagnosis.

A nurse in an urgent care clinic is caring for a child who has a minor burn on their palm after touching the burner on a hot stove. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

[1] clean the Burn with mild soap and tepid water [2] Remove any embedded debris. [3] Apply an antimicrobial ointment. [4] Wrap the hand with a gauze dressing. [5] Inform the parent of dressing change schedule.

A nurse in a provider's office is reviewing pediculosis capitis management and prevention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? Select all that apply.

[1] store the child clothing in a separate cubicle when at school. [2] Boil brushes and combs in water for 10 mins [3] Dry bed linens and clothing in a hot dryer for at least 20 mins

A nurse is caring for a group of clients. The nurse should fill out an incident report for which of the following situations?

a visitor who develops a bruise on their head following a syncope episode. The nurse should complete an incident report for an injury involving a client or visitor.

A nurse is assisting with planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care?

administer atropine to reduce the clients resp secretions

A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease peripheral edema. Which of the following instructions should the nurse include?

apply the stocking in the morning rationale: The nurse should instruct the client to apply the elastic stockings in the morning and remove them at the end of the day before bedtime.

A nurse on a medical unit is reviewing a client's health record. The nurse should identify that which of the following procedures requires the client to sign a separate informed consent form?

blood transfusion The nurse should identify that a client needs to provide consent for general treatment as well as a separate written informed consent for any treatment that has an element of higher risk.

Select the 6 actions the nurse should take

• administer methylergonovine • weigh the perineal pads •provide emotional support • insert an indwelling urinary catheter • administer oxygen at 12 L/min via nonrebreather face mask. • firmly massage the uterine fundus