Poke
Client with indwelling urinary catheter. Which of the following actions should the nurse take to provide catheter care? a. Provide perineal hygiene after defecation b. Empty the collected urine once every 24 hr. c. Hang the drainage bag on a bed rail d. Change the indwelling catheter every 8 hr.
a. Provide perineal hygiene after defecation
Arial fibrillation places the client at risk for which of the following conditions? a. Pulmonary emboli b. Cardiac tamponade c. Widened pulse pressure d. Hemothorax
a. Pulmonary emboli
A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk. After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test? a. PT and INR b. 12 lead ECG c. Chest X-ray d. Serum potassium
b. 12 lead ECG
Which of the following clients should the nurse place near the nurses' station? a. A client who is in Buck's traction b. A client who has orthostatic hypotension c. A client who has an open wound d. A client who is on fluid restriction
b. A client who has orthostatic hypotension
Client experiencing acute mania. Which of the foods should the nurse provide for this client? a. Peanut butter sandwich b. Chicken noodle soup c. Celery sticks d. Oatmeal with butter
a. Peanut butter sandwich
. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Perform the procedure twice a day b. Hold hand to perform percussions on the child c. Administer a bronchodilator after the procedure d. Perform the procedure prior to meals
a. Perform the procedure twice a day
Teaching the parents of a client with new onset of seizures and is to undergo an EEG. Which of the following instructions should the nurse include in the teaching? a. "Ensure the child's hair is clean and without conditioner before the procedure." procedure and eliminate all oils, gels, and sprays) b. "Keep the child out of the sun for 4 hr. following the procedure." c. "Make the child NPO before the procedure." d. "Give the child acetaminophen for pain following the procedure."
a. "Ensure the child's hair is clean and without conditioner before the procedure."
A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statements should the nurse include in the teaching? a. "This test should be performed after your baby is 24 hours old." b. "A nurse will draw blood from your baby's inner elbow." c. "This test will be repeated when your baby is 2 months old." d. "Your baby will be given 2 ounces of water to drink prior to the test."
a. "This test should be performed after your baby is 24 hours old."
A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?' a. "You don't have to go through with the treatment." b. "Most people who have this procedure feel better following the treatment." c. "It's okay to be nervous before this treatment." d. "Your doctor wouldn't have ordered this treatment unless it was necessary."
a. "You don't have to go through with the treatment."
. A charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? a. A client who is receiving heparin for DVT b. A client who is 1 day postoperative following a vertebroplasty c. A client who has COPD and a respiratory rate of 44/min d. A client who has cancer with a sealed implant for radiation therapy
a. A client who is receiving heparin for DVT
Client with pneumonia gained 4.2 (9.3 lb.) over the last 5 days. Lab values this morning are: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team? a. Nephrologist b. Cardiologist c. Infectious control nurse d. Dietitian
a. Nephrologist
Client with acute glomerulonephritis. Which of the following food choices should the nurse recommend? a. Bagel b. Banana c. Eggs d. Smoked salmon
a. Bagel
A nurse is caring for a school age child who is postoperative and received morphine IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority? a. Bradypnea b. Sedation c. Euphoria d. Constipation
a. Bradypnea
. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. Client taking clozapine to treat schizophrenia and reports sore throat b. Client has OCD and is upset about a change in daily routine c. Client has narcissistic personality disorder and is mocking others during group therapy d. Client who has depressive disorder and requires assistance with ADLs
a. Client taking clozapine to treat schizophrenia and reports sore throat
A nurse in the ER is receiving report for four clients. Which should the nurse see first? a. Client who has HTN and reports severe headache b. Client who reports left arm pain following a fall c. Client who has heart failure and received diuretic 30 min ago d. Client who reports frequent and painful urination
a. Client who has HTN and reports severe headache
A home health nurse is completing screenings for elder abuse during client visits. Which of the following findings should the nurse identify as an indication of potential elder abuse? a. Client who reports being given sedative medications by family members b. Client who is taking warfarin and has several small bruises on her shins and hands c. Client who schedules multiple visits with his provider every month d. Client who lives with family members and begins to take more responsibility for self-care
a. Client who reports being given sedative medications by family members or b. Client who is taking warfarin and has several small bruises on her shins and hands
. Client who has bipolar disorder and is experiencing mania. Which of the following should the nurse include in the plan? a. Encourage the client to take frequent rest periods b. Encourage the client to spend time in the day room c. Place the client in seclusion when he exhibits signs of anxiety d. Withdraw the client's TV privileges if he does not attend group therapy
a. Encourage the client to take frequent rest periods or c. Place the client in seclusion when he exhibits signs of anxiety
Client in postpartum taking methylergonovine. The nurse should recognize that which of the following is a contraindication for this medication? a. HTN b. Polyuria c. Confusion d. Chlamydia
a. HTN
Client receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration? a. History of GERD b. Sitting in a high-Fowler's position during the feeding c. A residual of 65 mL 1 hr. postprandial d. Receiving a high osmolarity formula
a. History of GERD
Client presented with fine hair, exophthalmos, and reports intolerance to heat. Which of the following endocrine disorders is associated with these findings? a. Hyperthyroidism b. Hyperparathyroidism c. Hypothyroidism d. Hypoparathyroidism
a. Hyperthyroidism
A nurse is caring for a newly client who has bacterial meningitis. Which of the following actions should the nurse take? a. Implement seizure precautions b. Place the client in high-Fowler's position c. Perform ROM exercises once per shift d. Monitor the client for hypoglycemia
a. Implement seizure precautions
A nurse is developing plan of care for a newborn mother tested positive for heroin during pregnancy. Newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Minimize noise in the newborn's environment b. Swaddle the newborn with his legs extended c. Administer naloxone to the newborn d. Maintain eye contact with the newborn during feedings
a. Minimize noise in the newborn's environment
. Lab results s/p surgery. Which should be reported to the provider? a. Na 160 mEq/L b. Cl 100 mEq/L c. Bicarbonate 26 mEq/L d. K 3.8 mEq/L
a. Na 160 mEq/L
A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. Which of the following actions should the nurse take? a. Reset the vacuum by compressing the container b. Secure the drain to the bedding c. Position the affected extremity below the level of the client's heart d. Maintain the client in a supine position for the first 24 hr
a. Reset the vacuum by compressing the container
A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Restrict the client's total fluid intake to 250 mL/hr. b. Measure the client's urine output every hour c. Give the client protamine if signs of magnesium sulfate toxicity occur (antidote: calcium gluconate) d. Monitor the FHR via Doppler every 30 min
a. Restrict the client's total fluid intake to 250 mL/hr.
Crohn's disease. Which of the following diagnostic procedures should the nurse plan to teach the client regarding pernicious anemia? a. Schilling test b. Oral glucose tolerance test c. D-dimer test d. Thyroid scan
a. Schilling test
Reviewing client's lab results. Which of the following should the nurse review to evaluate the client's nutritional status? a. Serum albumin b. Serum sodium c. Troponin d. ESR
a. Serum albumin
A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder. Which of the following should the nurse expect? a. Suspicious of others b. Exhibits separation anxiety c. Ritualistic behavior d. Preoccupied with aging
a. Suspicious of others or d. Preoccupied with aging
A newly LPN working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention? a. Using an electronic massaging system to remind clients when to take medications b. Educating clients about contraindications to specific immunizations c. Helping clients understand health screenings covered by their insurance plans d. Providing clients with info about the benefits of exercise
a. Using an electronic massaging system to remind clients when to take medications
Admitting a client who is in labor and at 38 weeks of gestation. The client has a history of herpes simplex virus 2. Which of the following questions is most important for the nurse to ask the client? a. "Are you currently taking acyclovir?" b. "Do you have an active lesion?" c. "When did your labor begin?" d. "How long ago were you first diagnosed?"
b. "Do you have an active lesion?"
Client who has depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicators an understanding of the teaching? a. "I can continue to take St. John's wort while taking this medication." b. "I know it will be a couple of weeks before the medication helps me feel better." c. "I expect this medication to raise my blood pressure." d. "I should take this medication on an empty stomach."
b. "I know it will be a couple of weeks before the medication helps me feel better."
Teaching for a client undergoing radiation therapy and has stomatitis. Which of the responses by the client indicates an understanding of the teaching? a. "I should limit my intake of dairy products to prevent nausea." b. "I should use a soft-bristle toothbrush to clean my teeth after meals." c. "I should moisten my lips with lemon-glycerin swabs." d. "I should gargle with an alcohol-based mouthwash to kill germs."
b. "I should use a soft-bristle toothbrush to clean my teeth after meals."
Nutritional teaching for an adult client who has seizure disorder and a new prescription for phenytoin. Which of the following instructions by the nurse is appropriate? c a. "You should expect a change in the color of your stool while taking this medication." b. "Increase your intake of vitamin D while taking this medication." c. "Plan to take this medication with antacids." d. "Limit foods that contain folic acid while taking this medication."
b. "Increase your intake of vitamin D while taking this medication."
A nurse is visiting a client whose partner states that she is overwhelmed by caring for him. When suggesting respite care, which of the following explanations should the nurse provide? a. "Respite care provides clinicians to work with you in caring for your husband." b. "Respite care allows for time away from caring for your husband." c. "Respite care includes volunteers who will perform household tasks." d. "Respite care offers financial resources to help care for your husband."
b. "Respite care allows for time away from caring for your husband."
. Client in psychiatric unit. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse? a. "That can't be true. The only voices in this room are yours and mine." b. "You shouldn't be afraid when you think the voices are telling you to hurt yourself." c. "I understand the voices are frightening you, but I do not hear any voices." d. "Do you recognize the voices as belonging to anyone you know?"
b. "You shouldn't be afraid when you think the voices are telling you to hurt yourself." or d. "Do you recognize the voices as belonging to anyone you know?"
Child with sickle cell anemia. The nurse should emphasize the importance of which of the following factors to prevent sickle cell crisis? a. A low-protein diet b. Adequate hydration c. Calorie restriction d. Increased iron intake
b. Adequate hydration
Parent of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching? a. Position the nipple at the front of the infant's mouth b. Burp the infant frequently during feedings c. Use feeding devices without nipples d. Hold the infant in a supine position
b. Burp the infant frequently during feedings
. Nurse accidently punctures IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a bio hazardous material spill? a. Phenytoin b. Doxorubicin hydrochloride c. Metronidazole d. Ampicillin sodium
b. Doxorubicin hydrochloride
Assessing client in ER. Which of the following actions should the nurse take first? a. Obtain ABG levels b. Elevate the head of the client's bed to 30° c. Place client on a coating blanket d. Administer an analgesic
b. Elevate the head of the client's bed to 30°
. A nurse is caring for a client who has ESRD. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure? a. Osteoarthritis b. HTN c. Amputation d. Primary glaucoma
b. HTN
Client asks about acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment? a. HTN b. Herpes zoster c. Obesity d. Hypothyroidism
b. Herpes zoster
A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse plan to assess first? a. DM and HbA1C of 6.8% b. Hip fracture and a new onset of tachypnea c. Epidural analgesia and weakness in lower extremities d. Sinus arrhythmia and is receiving cardiac monitoring
b. Hip fracture and a new onset of tachypnea
A nurse in the emergency department is assessing client who has major depressive disorder. Which of the following actions should the nurse take first? [View Exhibit] a. Administer Zofran to the client for nausea b. Implement seizure precautions for the client c. Encourage the client to verbalize feelings d. Obtain the client's weight
b. Implement seizure precautions for the client
A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse assess first? a. DM and HbA1c of 5.2% b. Leukemia and platelet level of 95,000/mm3 c. Received IV Lasix and K of 3.6 mEq/L d. Hepatitis B and total bilirubin of 1.2 mg/dL
b. Leukemia and platelet level of 95,000/mm3
A nurse is planning care for a client who is scheduled to receive a PICC in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care? a. Administer sedation for the procedure b. Measure the arm circumference above the insertion site daily c. Use gauze to secure an arm board to the involved extremity d. Schedule and MRI postprocedure to verify placemen
b. Measure the arm circumference above the insertion site daily
. A nurse is caring for several clients on a med surg unit. For which of the following nursing activities is it required that the nurse use sterile gloves? a. Initiating IV assess b. Performing tracheostomy care c. Inserting an NG tube d. Administering total parenteral nutrition through a central venous assess device
b. Performing tracheostomy care
Nurse is developing care plan for client on Buck's traction and is schedules for surgery for a fractured femur of the right leg. Which should the nurse delegate to an AP? a. Observe the position of the suspended weight b. Remind the client to use the incentive spirometer c. Check the client's pedal pulse on the right leg d. Ask client to describe her pain
b. Remind the client to use the incentive spirometer
Postpartum client with a language barrier. Which of the following actions should the nurse take to gather the client's admission data? a. Allow client's partner to translate b. Request female interpreter through the facility c. Have client's child translate d. Ask nursing student who speaks the same language as the client to translate
b. Request female interpreter through the facility
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take? a. Instruct the client to lift her chin when swallowing b. Sit at or below the client's eye level during feedings c. Talk with the client during her feeding d. Discourage the client from coughing during feedings
b. Sit at or below the client's eye level during feedings
A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? a. There is a loop of tubing below the drainage system b. The system is working properly c. The lung has re-expanded d. The tubing is partially obstructed by clots
b. The system is working properly
Circumcised newborn. Which of the following instructions should the nurse include in the teaching? a. "Wrap sterile gauze around the penis if bleeding occurs." b. "Use soap to cleanse the site." c. "Apply petroleum jelly to the glans with diaper changes." d. "Remove yellow exudate around the penis."
c. "Apply petroleum jelly to the glans with diaper changes."
A nurse is assessing the growth and development of a 3 y/o child. Which of the following questions should the nurse ask the parent to determine if the child is exhibiting typical developmental expectations? a. "Can your child draw a stick figure?" b. "Can your child catch and throw a small ball?" c. "Can your child ride a tricycle?" d. "Can your child name five colors?"
c. "Can your child ride a tricycle?"
A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following statements by a client indicates an understanding of the teaching? a. "I will limit my alcohol use to one drink daily while taking disulfiram." b. "I will avoid foods containing tyramine while taking fluoexetine." c. "I will take the sustained-release methylphenidate every morning." d. "I will take my lithium on an empty stomach." (pharm pg. 64: taking lithium with food will help decrease GI distress)
c. "I will take the sustained-release methylphenidate every morning."
A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding? a. Type 2 DM and a blood glucose of 250 mg/dL b. Pneumonia with a productive cough and a fever of 38.8° C (101.8° F) c. 2 hr. post cast placement and has 2+ pitting edema and pallor d. First-degree heart block and a heart rate of 62/min
c. 2 hr. post cast placement and has 2+ pitting edema and pallor
. A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to assess the port? a. An angiocatheter b. A butterfly needle c. A noncoring needle d. A 25 gauge needle
c. A noncoring needle
A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary intention? a. Infected laceration b. Stage II pressure ulcer c. Approximated surgical incision d. Partial-thickness burn
c. Approximated surgical incision
Client with schizophrenia and experiences auditory hallucinations. Which actions should the nurse include in the plan? a. Refer to the hallucinations as if they are real b. Encourage the client to lie down in a quiet room c. Ask the client directly what he is hearing d. Avoid eye contact with the client
c. Ask the client directly what he is hearing
A nurse is assessing a client who has hypervolemia. Which of the findings should the nurse expect? a. Urinary frequency b. Decreased BP c. Bounding pulse d. Bradycardia
c. Bounding pulse
A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the following actions should the nurse take? a. Document administration of the medication upon removal from the medication dispensing system b. Withhold the medication if the client does not appear to be in pain. c. Count the current number of unit doses available in the medication dispensing system d. Withhold the medication if the client has a fever
c. Count the current number of unit doses available in the medication dispensing system
Client becomes unconscious and monitor displays v-tach. Which action should the nurse take first after determining the client does not have a palpable pulse? a. Establish IV access b. Administer epinephrine c. Defibrillate d. Assess heart sounds
c. Defibrillate
A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the following actions should the nurse take first to manage her time effectively? a. Develop an hourly time frame for tasks b. Schedule daily activities c. Determine goals of the day d. Delegate tasks to the AP
c. Determine goals of the day
Which of the following lab findings should the nurse recognize as indicative of rheumatic fever? a. Decreased hgb and platelet count b. Decreased myoglobin and antinuclear antibody titer c. Elevated sedimentation rate and C-reactive protein d. Elevated creatine kinase and troponin
c. Elevated sedimentation rate and C-reactive protein
Nurse manger observes two staff nurses reviewing the computer records of a client who is not under their care. Which of the following should the nurse manager take first? a. Request the nurses present an in-service on client confidentiality b. Place documentation of the nurses' actions in the personnel file c. Instruct the nurses to close the client's computer record d. Advise the nurses to read the facility's confidentiality policy
c. Instruct the nurses to close the client's computer record
A nurse is reviewing the preadmission lab tests results of a client who is to undergo hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider? a. Na 142 mEq/L b. Blood glucose 80 mg/dL c. K 3.3 mEq/L d. PT 11.5 seconds
c. K 3.3 mEq/L
A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (SATA) a. Foul perineal odor b. Fundus displaced to the right c. Lochia serosa d. Fundus 4 cm (1.6 in) below the umbilicus e. Postpartum chill
c. Lochia serosa d. Fundus 4 cm (1.6 in) below the umbilicus
. Client placed in seclusion and restraints. Which of the following actions should the nurse plan to take? a. Ensure that the prescription for restraints be renewed every 6 hr. b. Have a provider evaluate the client in person within 1 hr. c. Plan to monitor the client every 30 min while restrained d. Complete a written record regarding the seclusion and restraint every 2 hr
c. Plan to monitor the client every 30 min while restrained
A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? a. Measure the fundal height to determine the placement of the ultrasound stethoscope b. Perform Leopold maneuvers prior to auscultating the FHR c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR d. Place the client in a side-lying position prior to assessing the FHR
c. Position the ultrasound stethoscope above the symphysis pubis to assess the FHR
A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing? a. Morphine b. Digoxin c. Prednisone d. Omeprazole
c. Prednisone
Older client transferred from another facility. Nurse notes ulcers on the coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse? a. Notify risk management b. Inform the transferring agency of the client's condition c. Privately interview the client about her condition d. Contact the family regarding the client's condition
c. Privately interview the client about her condition
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's CPM device. Which of the following actions should the nurse take first? a. Report the defect to the equipment maintenance staff. b. Ensure the device inspection sticker is current c. Remove the device from the room d. Initiate a requisition for a replacement CPM device
c. Remove the device from the room
A nurse is caring for a client who is febrile. To reduce fever, the nurse applies a cooling blanket. Which of the findings indicates the client is having an adverse reaction to the cooling? a. Tachycardia b. Flushing c. Shivering d. Restlessness
c. Shivering
Discharge teaching to a client who does not speak the same language as the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take? a. Use gestures to convey meaning b. Speak slowly when talking to the interpreter c. Speak directly to the client d. Pause in the middle of the sentences
c. Speak directly to the client
A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? a. Administer nitroglycerin 0.4 mg SL 30 min before the procedure b. Draw blood specimens for culture and sensitivity c. Transport the client to radiology for a CT scan d. Obtain CBC with differentia
c. Transport the client to radiology for a CT scan or d. Obtain CBC with differentia
New prescription for carbidopa-levodopa. Which of the following instructions should the nurse include? a. "Take with a protein shake." b. "Report dark-colored urine." c. "Monitor for hyperglycemia." d. "Change positions slowly.
d. "Change positions slowly.
Teaching the parent of an infant who has positional plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? a. "I should place my baby in the left side-lying position at night when using the helmet." b. "I should avoid tummy time when my baby is wearing the helmet." c. "I should expect to have my baby wear this helmet for 10 months." d. "I should keep the helmet on my baby for 23 hours a day.
d. "I should keep the helmet on my baby for 23 hours a day.
. A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy obtain a copy of the therapist's notes. Which of the following responses should the nurse make? a. "Are you not happy with your treatment?" b. "Why are you interested in seeing your therapist's notes?" c. "I don't think you will benefit from reviewing your therapist's notes right now." d. "We can provide a copy of your records, but the therapist's notes are not included."
d. "We can provide a copy of your records, but the therapist's notes are not included."
Teaching for misoprostol. Which information should be included in the teaching? a. "You will have a urinary catheter inserted prior to the placement of the medication." b. "You will lie on your side for 30 min after the medication is inserted." c. "You will have oxytocin initiated within 3 hours of administration of the medication." d. "You will have intermittent fetal monitoring while you receive the medication."
d. "You will have intermittent fetal monitoring while you receive the medication."
A nurse is planning to administer 2 units of packed RBCs to an older adult who has anemia. Which of the following actions should the nurse plan to take? [SATA] a. Prime the infusion tubing with 0.45 NaCl b. Infuse blood over 4 hr. c. Don sterile gloves to prepare blood administration setup d. Assess the client's lung sounds prior to the infusion e. Verify with another nurse that the unit of blood is compatible with the client's blood type
d. Assess the client's lung sounds prior to the infusion e. Verify with another nurse that the unit of blood is compatible with the client's blood type
A nurse is caring for a client who has Cdif. Which of the following actions should the nurse take? (SATA) a. Wash hands with alcohol based b. Wear N95 c. Remove thermometer from client's room for use on another client d. Change gloves after contact with infectious material e. Wear a gown when providing care
d. Change gloves after contact with infectious material e. Wear a gown when providing care
. A nurse is creating a care plan for a client who is postoperative following a CABG. To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care? a. Administer atropine to the client if tachycardia is present b. Maintain the indwelling urinary catheter until the client is ready for discharge c. Prepare for fluid volume replacement if the central venous pressure steadily increases d. Check the client's hemoglobin level if chest tube drainage is 300 mL in the first 1 hr
d. Check the client's hemoglobin level if chest tube drainage is 300 mL in the first 1 hr
Which of the following clients should the nurse recommend referral to a dietitian? a. Older adult who has BMI of 24 b. Client with albumin of 3.7 g/dL c. Older adult who has presbyopia d. Client who has a nonhealing leg ulcer
d. Client who has a nonhealing leg ulcer
Postoperative client following appendectomy and receiving gentamicin. Which is an adverse effect of this medication? a. Respiratory rate 22/min b. Hgb 8.7 g/dL c. 2+ pitting edema of the ankles d. Creatinine 2.3 mg/dL
d. Creatinine 2.3 mg/dL
. Protocols for belt restraints. Which of the following guidelines should the nurse include? a. Remove the client's restraint every 4 hr. b. Request a PRN restraint prescription for clients who are aggressive c. Attach the restraint to the bed's side rails d. Document the client's condition every 15 min
d. Document the client's condition every 15 min
Adverse effects of sertraline a. Dry cough b. Increased urinary frequency c. Metallic taste in mouth d. Excessive sweating
d. Excessive sweating
Client in ER experiencing stimulant withdrawal. Which finding should the nurse expect? a. Decreased appetite b. Runny nose c. Muscle spasms d. Fatigue
d. Fatigue
Education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching? a. Fibrocystic breast disease b. Fibromyalgia c. Renal calculi d. HTN
d. HTN
A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal? a. Acrocyanosis b. Bulging fontanels c. Bradycardia d. Hypertonicity
d. Hypertonicity
Support group for clients whose family have committed suicide. Which of the following should the nurse plan to use during the group session? a. Encourage clients to establish a timeline for their grieving process b. Assist clients in identifying ways suicide could have been prevented c. Discourage clients from sharing negative aspects of their relationship with the deceased persons d. Initiate a discussion with clients about ways to cope with changes in family dynamics
d. Initiate a discussion with clients about ways to cope with changes in family dynamics
A nurse is assessing a client who presents to the L&D unit reporting the onset of contractions. Which of the following findings should the nurse identify as a manifestation of false labor? a. Presence of bloody show b. Contraction intensity increased by ambulation c. Slow change in dilation and effacement d. Intermittent, painless contractions
d. Intermittent, painless contractions
Inserting indwelling urinary catheter to a male client. Which of the following actions should the nurse take? a. Cleanse the tip of the penis in a side to side motion b. Pick up the catheter 13 cm (5 in) from its tip c. Perform the cleansing procedure with a fresh swab two times d. Lift the penis so that it is perpendicular to the client's body
d. Lift the penis so that it is perpendicular to the client's body
A nurse received change of shift report. Which of the following actions should the nurse take to manage time effectively? a. Focus on several client tasks at a time b. Document client care at the end of the shift c. Skip breaks until client tasks are completed d. Make a client to-do list for the day
d. Make a client to-do list for the day
Client with Alzheimer's disease. Which of the following should the nurse include in the plan of care? a. Encourage physical activity prior to bedtime b. Replace the carpet with hardwood floors c. Wear clothing with zippers instead of buttons d. Place locks at the top of exterior doors
d. Place locks at the top of exterior doors
. A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following action should the nurse take? a. Ensure that the client checks the gauge weekly b. Store the oxygen tank wrench in a locked cabinet c. Have the client store smaller tanks under his bed d. Place the oxygen tank away from curtains or drapes
d. Place the oxygen tank away from curtains or drapes
Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. A history of being in prison c. Male gender d. Previous violent behavior
d. Previous violent behavior
Client on bed rest. The nurse should recognize that which of the following findings is a complication of immobility? a. Decreased serum calcium levels b. Increased BP c. Urinary frequency d. Swollen area on calf
d. Swollen area on calf
