predictor

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

a social worker who is assigned to an involuntary committed school age client ​

a nurse is reviewing the medical record of five clients. For which of the following events should the nurse write an incident report? SATA

a. a client fell when ambulating to the bathroom alone b. a client received an 0900 daily medication at 1000 c. an approximate amount of urine was recorded after the urine leaked from the client's catheter bag. d. a client who has an infection refused the evening meal. e. a client received the first dose of antibiotic 1 hour before the collection of blood for culture and sensitivity testing

a nurse on a medical surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admission ?

a. a client who had a radical mastectomy 36 hours ago and has a surgical drain b. a client who had a lobectomy and has a chest tube drainage system c. a client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy d. a client who has cervical cancer and an internal radioactive implant

a nurse is contributing to an in service for newly licensed nurses about situations requiring an incident report. WHich of the following expamples should the nurse include?

a. a nurse discovers that an electronic Iv pump delivered twice the prescribed amount of fluid to a child

a nurse on a hospice unit is caring for a client who has a cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse/

a. an ap is encouraging intake of oral fluids

a nurse is providing pre op care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take?

a. assist with a referral to a home health care agency

a nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

a. believes the death is punishment for bad behavior

a nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. which of the following manifestations should the nurse expect?

a. bradycardia b. polyuria c. hypertension d. constipation

a nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

a. cover the wound with sterile saline soaked gauze

a nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

a. ensure that the client gave informed consent

a nurse is caring for a client who is on isolation precautions. Which of the following pieces of personal protective equipment should the nurse remove first?

a. gloves

a nurse is collecting data from a 9 year old during a well child visit. Which of the following findings should the nurse expect?

a. grasps concept of cause and effect b. demonstrates self centered control c. expresses conflict over independence and control d. displays emotional detachment from parents

a nurse is caring for a client who has toxoplasmosis and asks the cause of the infection. Which of the following responses should the nurse make?

a. handling cat feces

a nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. which of the following client statements indicate an understanding of the nurses instructions?

a. i will eat or drink something every 2 to 3 hours throughout the day

a nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicate an understanding of the teaching?

a. i will know my b/p is too high if i get a reading of 140 over 90 or higher

a nurse is reinforcing teaching with a client who is postop following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome?

a. include one serving of protein with each meal

a nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

a. inject 15 units of air into the regular insulin vial

a nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

a. it enhances quality of life by promoting comfort

a nurse is preparing to apply a thigh length sequential compression device for a client who is post op. Which of the following actions should the nurse take?

a. measure the circumference of the client's upper leg

a nurse is reinforcing teaching with the guardian of a 2 month old infant about immunizations. which of the following statements by a guardian indicates an understanding of the teaching

a. my baby will receive the rotavirus immunization orally b. i should expect my baby to have a high fever for 24 hours after an immunization c. i should not feed my baby anything for 2 hours prior to an immunization d. my baby will receive three doses of the meningococcal immunization before kindergarten

a nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

a. orange juice b. sweet potato c. canned green beans d. wheat bread

a community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?

a. present information from complex to simple b. use a 12 point font size c. explain medical terminology using basic one syllable words d. write the information at an 8th grade reading level

a nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

a. productive cough with pink, frothy sputum

a nurse is administrating pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

a. reduced fat in the stools

a charge nurse is monitoring a group of assistive personnel regarding the use of gloves in contact isolation. For which of the following actions by an AP should the charge nurse intervene/

a. removes gloves last after other personal protective equipment.

a nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

a. shortness of breath

a nurse is assisting with monitoring a client who is receiving a unit of packed rbcs. which of the following findings indicates the client is experiencing a transfusion reaction?

a. temp 38.8C (101.8F)

a nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings as the priority to report to the provider?

a. the client has a sudden increase in energy

a nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care requires reporting to the interprofessional team?

a. the client is unable to grasp eating utensils

a nurse is contributing to the plan of care for a client who is experiencing panic level anxiety and reports visual hallucinations. Which of the following actions should the nurse recommend including in the plan of care?

a. use a low pitched voice when speaking to the client

a nurse at a long term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

assist the client with range of motion exercises of the hands

a nurse is caring for a client who has dementia. which of the following findings should the nurse expect?

b. acute onset of confusion

a nurse is reinforcing teaching about preventing dental caries with the parent of a 12 month old toddler. Which of the following instructions should the nurse provide?

b. clean the teeth with a small soft bristled toothbrush

a nurse on a med surgical unit is assisting with the admission of a client who has advanced lung cancer. which of the following statements regarding advance directives should the nurse take?

b. document the clients decisions about end of life care in the med record

a nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

b. explain to the client that anxiety causes physical manifestations

a nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?

b. grandiose thinking

a nurse is reviewing medical record of a client who is taking acetaminophe to relieve headache pain. Which of the following conditions in the clients history should the nurse identify as a contraindication?

b. hep c

a nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicate an understanding of the teaching?

b. i have to take this medication on an empty stomach

a nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include?

b. leukorrhea

a nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

b. loss of taste

a nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

b. measure the client's vital signs

a nurse is collecting data from a client who has acute cholecystitis. which of the following findings should the nurse expect?

b. pain in the right upper abdomen

a nurse in an acute setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

b. physical assessment findings

a nurse is caring for a client who has recently died. which of the following actions should the nurse take?

b. place a pillow under the client's head

a nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. The client states I am thinking about stopping the treatment. which of the following responses should the nurse make?

b. tell me more about what you are thinking

a nurse is preparing to delegate the client care to an ap which of the following information should the nurse verify prior to delegations

b. the ap's job description

a nurse is preparing a vitamin k injection to give to a newborn. The newborns mother questions the purpose of the medication. Which of the following responses should the nurse make?

b. this medication will decrease the risk of hemorrhage in your newborn

a nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

b. urine output 12 ml/hr

a nurse is supervising an AP who is providing client care. The nurse should identify that which of the following actions by the AP demonstrate effective use of supplies?

b. wears clean gloves when performing oral care.

a nurse is caring for a child who has terminal cancer. Which of the following responses by the childs school age brother should the nurse expect?

believes his bad behavior is causing his brother's death.

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

c. a client who has a femur fracture and reports numbness of the toes

a nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?

c. avoid exposing the neck to the cold

a nurse is caring for a client who has a femur fracture with the leg in bucks traction. which of the following actions should the nurse take

c. compare bilateral pedal pulses

a nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

c. determine the client's level of consciousness

a nurse is assisting with the care of a client who is receiving a continuous iv infusion. which of the following indicates fluid volume excess

c. distended neck veins

a nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching?

c. i need to keep the cap in place for at least 6 hours after intercourse

a nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

c. i will wash my babys face with a warm wet washcloth without soap

a nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

c. irregular heart rate

a nurse is using a glucometer to measure a client's capillary blood glucose level. which of the following actions should the nurse take?

c. keep the finger in a dependent position

a nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "i can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

c. let me show you how to swaddle and cuddle him, then you try

a nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?

c. lets talk about what the voices are saying to you

a nurse is collecting data from a client who is at 12 weeks of gestation. The client states weve been trying to get pregnant for several months but now im not sure im ready. which of the following responses should the nurse make?

c. many women experience feelings of ambivalence during pregnancy

a nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

c. measure the client's abdominal girth daily

a nurse in a providers office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

c. neisseria gonorrhoeae

a nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via iv infusion. Which of the following manifestations should the identify as an adverse effect of the treatment?

c. new onset of hearing loss

a nurse is monitoring a client who is post op. Which of the following actions should the nurse take when collecting data about the clients respirations

c. observe the movements of the client's chest wall

a nurse enters a room of a school age child and finds them on the floor experiencing a tonic clonic seizure. Which of the following actions should the nurse take?

c. place a pillow under the childs head

a nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

c. potassium 3.5

a nurse is contributing to the plan of care for a client who is scheduled to receive ECT for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?

c. provide frequent reorientation after ECT

a nurse determines that clients who receive zolpidem post op have an increased fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings?

c. the risk manager

a nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this med?

c. urinary retention

a nurse is reviewing lab values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?

c. urine protein 3+

a nurse is collecting data from a client who received oxytocin 10 units IM 30 mins ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?

client report of uterine cramping

a nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

d. apply dressings with sterile gloves

a nurse is caring for a client who is 2 days post op following an above the knee amputation. which of the following actions should the nurse take to promote progression toward indepenedence and mobility for the client?

d. encourage the client to use the overbed trapeze

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

d. fruity breath odor

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

d. i will practice perineal exercises to decrease urinary leakage

a nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching?

d. ill have my friend drive me home after the procedure.

a nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take?

d. instruct the client to change positions frequently

a nurse is assisting with a community health program for caregivers of clients who have alzheimers disease. Which of the following information should the nurse include?

d. limit the number of choices for the client

a nurse is reviewing the home medications of a client who recently had a transient ischemic attack and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over the count medication interacts adversly with clopidogrel?

d. naproxen

a nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

d. our child is able to complete his homework on time

a nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

d. place the shoulder harness at the level of the infants shoulders

a nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

d. position the client on their left side

a nurse is reinforcing teaching about passive range of motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching?

d. support the extremity

a nurse is collecting data from a client who is 1 day post op following a TURP. which of the following findings should the nurse report to the provider?

dark red urine

a nurse is providing a client with IV fluids and finds that the iv pump screen is malfunctioning. Which of the following actions should the nurse take?

discontinue use and tag the iv pump

a nurse is caring for a client who suddenly develops chest pain and dyspnea. which of the following actions should the nurse take first?

elevate the head of the client's bed

a nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. WHich of the following instructions should the nurse include regarding effleurage?

gently stroke her abdomen during contractions

a community health nurse is assissting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

grapes

a nurse is caring for a client who has been given methylegonivine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effects?

hematuria

a nurse in a providers office is reinforcing teaching about skin care with a client who has new diagnosis of systemic lupus erythematousus. Which of the following statements by the client indicates an understanding of the teaching?

i will dry my skin by patting it with a towel

a nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parent indicates an understanding of the teaching?

i will make sure than i can fit one finger between the matress and the side of my newborns crib

a nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?

i will mix the medication with a full glass of water

a nurse is reinforcing teaching with a parent of a 4 month old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching?

i will use a cool mist vaporizer in my babys room

a nurse working in a clinic is reinforcing with a client who has hep a. which of the following client statements indicates an understanding of the teaching?

i will use different hand towels than others in my home

a nurse is caring for a client who was admitted for observation following a head injury. which of the following findings by the nurse indicates the client is experiencing increased ICP

irritability

a nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

location of the identification tag on the client's body

a nurse is assisting with the care of a client who is 6 hour postoperative following a right total knee arthoplasty. which of the following actions should the nurse take?

maintain the head of the bed in high fowlers position

a nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

monitor the client's range of motion every 60 min

a home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

move the clients bed to the main floor of the house

a nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?

nuchal rigidity

a nurse is collecting data from a client who is 12 hours post op following intestinual surgry. which of the following findings should the nurse report to the charge nurse prior to the clients ambulation?

oxygen sat 90%

a nurse is caring for a client who is unable to perform ADL's and wears dentures. Which of the following actions should the nurse take when providing denture care?

place a towel in the sink when cleaning the dentures

a nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching?

place oral suction equipment next to the client's bedside

a nurse is collecting data from a 4 month old infant at a well child visit. For which of the following findings should the nurse notify the provider?

presence of grasp reflex

a nurse is caring for a client who speaks a different language than the nurse. the client's partner tells the nurse that the client would like to go home against medical advice. which of the following actions should the nurse take?

request the services of an interpreter to determine the client's wishes

a charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

soiled dressings should be placed in a biohazard trash receptacle

a nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an xray, which of the following methods should the nurse use to verify placement

test the ph of the gastric asparate

a nurse is collecting data from a client who is 8 hours postoperative following an appendectomy. Which of the following manifestations is the best indications that the client needs a PRN analgesic

the client reports pain as 7 on a scale of 0-10