R. A.NGN
The nurse is caring for an adult client in the primary care clinic. (case study 1 of 1). The nurse reviews the physician progress notes and documents today's visit in the nurse's note. which statement is a therapeutic response to the client's question? SATA
"The damage that constant high blood pressure causes to the small blood vessels in your heart, brain, kidneys and eyes is often invisible until it is irreversible." "Tell the physician and me about problems the medications are causing, then we can work with you to find alternatives". "You have made good progress with your blood pressure by changing your diet and losing weight. you can continue that success with different medications."
To locate the point of maximal impulse (PMI) of a client's heart, the nurse's hand (fingertips) should be placed over which location?
3. C
The neonatal intensive care (ICU) nurse has been called to attend the birth of a laboring client in the labor/delivery unit. (3-case study 6 part, 1). Click to highlight the findings from the client's history which concern the NICU nurse
30 weeks gestation following an auto accident. Airbag deployment noted at the accident scene. Slow fetal growth for dates. Symmetric fetal intrauterine growth restriction (IUGR). Low normal amniotic fluid volume (AFV).
The nurse prepares to administer the initial dose of oral enalapril 20 mg in the morning. Which medication should the nurse question giving to the client?
40 mg oral furosemide in the morning
A client receives an IV heparin infusion at 22 mL/hr through an infusion pump. The IV bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. How many unites of heparin is the client receiving during and 8-hour shift? round to whole number
8800 (500*22 =11,000* 8hr)
The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST?
A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema
A nurse from the surgical floor is reassigned to the pediatric unit. Which of the following client assignment is MOST appropriate for this nurse? 1. A 5-month-old infant after a cast application on the left extremity due to club foot. 2. A 4-year-old boy with right abdominal swelling and a decreased appetite. 3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C). 4. A 10-year-old girl with newly diagnosed type 1 diabetes.
A 5-month-old infant after a cast application on the left extremity due to club foot
The home care nurse performs a health screening at the local shopping center. The nurse knows that which client is at HIGHEST risk for developing a stroke?
A 69-year-old African-American male who has a history of hypertension and is 30 pounds overweight.
The home health nurse is planning client visits for the day. which client does the nurse see FIRST?
A client diagnosed with heart failure and who gained 3 lb in the last 24 hours.
The nurse assesses the fetal monitor of a client in labor. which fetal heart rate pattern requires an intervention by the nurse?
A heart rate that slows following the peak of the contraction and returns to baseline after the contraction ends
At 0700, the nurse administers 10 mg glipizide PO. At 1100, the nurse notes the client is lethargic and pale with cold, clammy skin. Which action does the nurse take FIRST?
Administer glucagon 1 mg subcutaneously
The health care provider prescribes furosemide and spironolactone. Before administering the furosemide and spironolactone, the nurse determines that the client's potassium level is 3.2 mEq/L. Which is the MOST important action for the nurse to take?
Administer only the spironolactone
The nurse is caring for an 85-year-old resident of a long term care facility who is a direct admit to the medical surgical unit (4-case study 6 part, 1) After receiving verbal report from the LTC staff and obtaining admission orders from the physician, the nurse performs a bedside assessment. The nurse knows which 4 assessment findings require immediate follow up?
Altered mental status. Heart rate 110 beats per minute. Muscle twitching and spasms. Loose stools
The nurse cares for clients in the pediatric clinic. which client should the nurse see FIRST?
An 8-month-old infant who has 6 watery stools in the past 8 hours
The nurse reviews room assignments for clients just admitted to the unit. The nurse questions which assignment?
An adolescent diagnosed with cellulitis of the right leg in a semi-private room with a client diagnosed with type 1 diabetes
A nurse is presented with a group of clients in the emergency department. To which client does the nurse give IMMEDIATE attention?
An adolescent in respiratory distress.
For each assessment finding below, click to specify whether the finding is consistent with the disease process of urinary tract infection, hypernatremia, or heart failure (4-case study 6 part, 2)
Apical pulse 110 beats/minute- hypernatremia and HF. Responds to name only, appears lethargic- hypernatremia and HF. Loose stools- hypernatremia. Dry mucous membranes, poor skin turgor- hypernatremia Muscle twitching of the upper and lower extremities- hypernatremia
The nurse cares for the client with a patient controlled analgesia(PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take?
Ask the client to describe the pain
An older adult client is admitted to the hospital with a diagnosis of pneumonia. Upon arrival to the unit, which action should the nurse take first?
Assess mental status
The nurse cares for the client 4 hours after admission to the neuroscience unit due to a closed-head injury. Which is the MOST important action for the nurse to take?
Assess pupil shape and reactivity.
Following surgery and recovery in the post anesthesia care unit, the client is transported back to the orthopedic unit. (1-case study 6 part, 5) for each body system below, click to specify the potential nursing intervention that is appropriate for the care of the client upon return to the orthopedic unit.
Assess the client apical rate and cardiac rhythm monitor breath sounds and pulse oximetry every hour reorient the client frequently
The nurse cares for the client diagnosed with Alzheimer disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take?
Assist the client to a bedside commode every 2 hours
The nurse cares for the client with chronic kidney disease who has an arteriovenous fistula in the left arm. which action should be included in the care of the client? SATA
Auscultate for "whooshing" sound over the fistula palpate for warmth and tenderness over the area of the fistula instruct the client to avoid carrying heavy objects with the left arm
The nurse cares for the client 3 days after a stroke. It is MOST important for the nurse to take which action?
Auscultate the client's lungs every 4 hours
The NICU nurse transports the client to the NICU for further stabilization and care management. (3-case study 6 part, 4). For each assessment finding, click to specify the potential nursing intervention that is appropriate for the care of the client. Pulse 170 bpm----- Respiration 64/minute, O2 saturation 87%------ Skin color pale
Avoid stimulation of crying. Apply oxygen by mask. Dry and warm infant.
An older adult client awakens frightened and agitated. The client climbs out of bed, removes the indwelling urinary drainage catheter, and runs down the hall screaming. Which is the FIRST action the nurse should take?
Check for injuries
Following a transurethral prostatectomy (TURP), the client has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30 mL balloon tip. Tension has been applied to the catheter. The client reports pressure in the bladder and rectum, and states, "I feel as though I have to urinate." Which action should the nurse take FIRST?
Check the patency of the catheter.
A client is prescribed haloperidol 5 mg IM every 4 hours PRN agitation. Which observation requires an IMMEDIATE intervention by the nurse?
Client has tongue protrusion and muscle rigidity
Six weeks after the event, the mental health nurse attends a court hearing for the client about the event. (2-case study 6 part, 6). for each assessment finding below, click to specify whether the finding indicates the clients condition has improved, not changed, or declined.
Client is clean, hair brushed, and wearing fresh clothes- Improved Client states, "I am taking fluphenazine every day and meeting with my counselor weekly." - Improved Client apologizes for behavior at the governor's residence- Improved Client slap self and mutters, "stop it. they'll see you" -no change
Based on the client's statements and behavior, the nurse believes the client is in an active phase of schizophrenia. (2-case study 6 part, 2). For each observation below, click to specify whether the observation of the client's behavior is consistent with delusion of grandeur, paranoia, or hallucination.
Client states, "God gave me all the answers."- delusion of grandeur and hallucination. Client states, "I am the only one who can give the plan to the governor!"- delusions of grandeur. Client shouts, "They are watching me all the time!"- paranoia and hallucination.
The nurse is caring for an older adult client newly diagnosed with colon cancer requiring creation of a permanent colostomy. (Bowtie). The nurse is reviewing the client's assessment data to prepare the client's plan of care.
Condition- Hemorrhage. Actions to take- administer morphine sulfate 3 mg IV push as ordered PRN pain, Notify the surgeon. Parameter to monitor- pulse rate and blood pressure, Skin assessment
The nurse is caring for an obese adult client who comes to the physician's office with mobility concerns. (Bowtie). The nurse is reviewing the client's assessment data to prepare the client's plan of care.
Condition- Rheumatoid arthritis Action to take- Teach client to pace activities. Refer to a dietician. Parameter to monitor- Pain level. Activities of daily living.
The nurse in the dialysis center is caring for an adult client undergoing hemodialysis. the client has a history of chronic kidney disease and has been on HD for 8 years. (Bowtie) The nurse is reviewing the nurse's notes and vital signs to prepare the client's plan of care.
Condition- hypervolemia Actions- start the HD treatment, obtain a wheelchair Parameters to monitor: weight, lung sounds.
The NICU nurse assesses the infant after birth and determine that the Apgar score at 1 minute is 5 and at 5 minutes is 6. (3-case study 6 part, 3) The nurse knows which physical finding is HIGHLY associated with the presence of a patent ductus arteriosus? SATA
Continuous "machinery" murmur. Tachycardia. Full, bounding pulses. Tachypnea
An adult client at full term comes to the hospital in labor. Two hours after admission, the client remains 4 centimeters dilated, and contractions are weak. The healthcare provider orders oxytocin. Which finding would require and intervention by the nurse?
Contractions every 2 minutes, lasting 90 seconds
The nurse prioritizes the needs of a client who has been raped. Which nursing action is MOST important? 1. Observe the client for withdrawn, tearful behavior. 2. Determine if the client sustained any injuries. 3. Obtain information about events which preceded the rape. 4. Accurately document the client's comments about the rape.
Determine if the client sustained any injuries.
Heparin 5,000 units subcutaneously is ordered every 12 hours for a client. The result of the client's most recent PTT is 55 seconds. Which action by the nurse is MOST appropriate? 1. Document the result and administer the heparin. 2. Withhold the heparin. 3. Notify the healthcare provider. 4. Have the test repeated.
Document the result and administer the heparin
The nurse returns to work the next morning, receives report, and performs and assessment. (4-case study 6 part, 6)
Drowsy, opens eyes to voice and touch- Improved Apical heart rate 92 bpm- Improved Serum sodium 147 mEq/L- Improved Skin warm, dry with positive tenting-No change serum glucose 47 mg/dL- Declined
A client had a gastric bypass procedure 4 hours ago. Vital signs are BP 92/68 mm Hg, P 112/min, and RR 22/min. which prescription does the nurse question?
Epinephrine 1 mg IV push
A young adult client is admitted to the labor unit for delivery. During the transition phase of labor, the client begins to scream and grab the side rails with each contraction. Which nursing action is MOST effective?
Establish eye contact with the client and breathe with the client
The nurse cares for an older adult client diagnosed with Alzheimer disease. it is MOST important for the nurse to take which action?
Frequently inform the client of the room and bathroom location
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?"
Have you ever had chest pain?
Complete the following sentences by choosing from the list of options. (3-case study 6 part, 5) The nurse suspected PDA is ------- It is priority for the nurse to request an order for -------. The nurse anticipates the client's need for -------. The nurse prepares to manage the symptoms of fluid overload through the administration of ------- The nurse expect to stimulate the closure of the PDA through IV administration of ------
Heart failure. An echocardiogram Insertion of an umbilical IV. Diuretics. Indomethacin
The NICU nurse reassesses the client one hour after diagnostic studies confirm the presence of a PDA and IV diuretics have been administered. (3-case study 6 part, 6) For each assessment finding below, click to specify whether the finding indicates the client's condition has improved, not changed, or declined.
Heart rate 160 bpm- improved. Respiratory rate 62/minute-No change Color acrocyanosis- Improved. Muscle tone: some flexion-No change. Reflexes: weak cry- No change
A client comes into the outpatient rheumatology clinic for follow-up care after an episode of an acute gout attack. The nurse is MOST concerned by which client statement?
I am dieting and drinking fewer fluids every day
The nurse teaches older adult residents of an assisted living facility about wellness and health promotion. The nurse is MOST concerned about which resident's statement?
I got a pneumonia vaccine about 6 years ago
The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement?
I have been sleeping 6 hours at night
The nurse cares for a client who is to receive thrombolytic therapy with tissue plasminogen activator. the nurse is MOST concerned if the client makes which statement?
I hit my head and lost consciousness during a car accident 2 months ago.
The nurse cares for a client with Addison disease who is taking 20 mg hydrocortisone daily. Which statement by the client requires an intervention by the nurse?
I may have episodes of low blood pressure while taking this medication.
The nurse teaches the client who had an above-knee amputation (AKA) 2 days ago about how to care for the residual limb. which statement, if made by client, indicates to the nurse that teaching is effective?
I should rewrap my residual limb with elastic bandages 3 times a day
The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further is needed?
I should take polyethylene glycol with a large glass of water
The nurse provides care for a client diagnosed with type 2 diabetes mellitus. The client undergoes a renal CT scan wit contrast media at 1000. The nurse is MOST concerned if the client makes which statement?
I took my metformin at 0600 this morning
A news reporter and camera person arrive on the nursing unit to videotape an interview of a client. When the nurse refuses their request, the reporter references his First Amendment rights. Which statement, if made by the nurse, is MOST appropriate? 1. "Why do you want to talk with the client?" 2. "I'll ask the client if he is ready to speak with you." 3. "I will need to call the nurse manager about your request." 4. "Does the client know that you are coming?"
I will need to call the nurse manager about your request
A school-age child is brought to the emergency department following a bicycle fall. An xray reveals healed fractures of the ribs. The child's parent states, "my child is careless and is always having accidents." which response by the nurse is the HIGHEST priority?
I will need to perform a thorough head-to-toe assessment and possibly take pictures for documentation
The nurse begins to implement the physician's orders. which order does the nurse need to clarify with the physician? (4-case study 6 part, 5)
IV fluid therapy
The spouse of an older adult client who is incontinent asks the nurse whether the client will have to wear adult briefs. Which response is MOST appropriate?
Let's discuss your specific concerns about your spouse
The nurse prepares to administer medication to a confused client and observes that the client's armband is missing. Which is the MOST appropriate action for the nurse to take?
Look in the medical record at the picture of the client
The nurse prepares to administer gentamicin to an older adult client. Which is the MOST important action for the nurse to take prior to administration of the medication?
Monitor the serum BUN and creatinine
A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is MOST appropriate? 1. Get Doppler studies to check the pulse. 2. Notify the healthcare provider. 3. Determine if the cast is dry. 4. Check the client's vital signs.
Notify the nealthcare provider
A client is prescribed prednisone and ask about possible adverse effects. the nurse teaches the client about which common adverse effect of prednisone? SATA
Osteoporosis low serum potassium fluid retention
Which nursing intervention is a PRIORITY to include in the plan of care? SATA (4-case study 6 part, 4)
Perform hourly rounding. Provide oral care. Monitor neurologic status. Monitor laboratory test result. Assess number and characteristics of stools Monitor capillary blood glucose
A client with suspected active tuberculosis is scheduled for a chest x-ray. Which action, if taken by the nurse, is MOST appropriate? 1. Instruct the staff transporting the client to wear a gown and mask. 2. Place a face mask on the client. 3. Request that the x-ray be postponed. 4. Give the client an emesis basin and tissues.
Place a face mask on the client
A client with gastroesophageal reflux disease (GERD) reports difficulty sleeping. Which is a priority topic for the nurse to teach?
Place pillow to elevate the head during sleep
A client is admitted with a diagnosis of acquired immune deficiency syndrome(AIDS). The lab results are hemoglobin 9.3 h/dL, hematocrit 25%, platelets 50,000/mm, white cell count 1,500/mm. Which order does the nurse implement FIRST?
Place the client on neutropenic precaution
The nurse provides care for a client in the labor unit. During the transitional phase, the umbilical cord becomes prolapsed. Which action is MOST important for the nurse to take?
Place the client on the knee and forearms with face down.
The nurse discusses an appropriate diet with a client diagnosed with iron-deficiency anemia. which meal selection indicates to the nurse that teaching is effective?
Pork chop, baked potato, and tossed green salad
The nurse is caring for an adult client in the emergency department. (case study 1 of 1). The nurse continuously assesses the client, documents, and reports findings. The nurse anticipates which order from the physician?
Prepare the client for an abdominal ultrasound
The nurse is caring for an adult client on the surgical unit. (case study 1 of 1) the nurse reviews the clients assessment and vital signs and calls the surgeon. which intervention does the nurse anticipate the physician will order? SATA
Prepare the client to return to surgery Type and cross match client for 2 units of packed red cells Increase the IV rate to 100 mL/hr
The nurse on the orthopedic unit cares for an older adult client being admitted from the emergency department. (1-case study 6 part,1) The nurse reviews the clients history and physical and obtains the clients vital signs, which finding does the nurse associate with normal aging? SATA
Reports decreased hearing Scattered scabbing and bruising on hands and forearms Wears bifocals
A client admitted to the hospital has chest pain when taking deep breaths and peripheral edema. The health care provider (HCP) prescribed "digoxin 0.25 mg orally now. Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse is BEST?
Review the client's serum digoxin level
The nurse observes a student nurse assigned to a client with a tracheostomy and humidified oxygen. which action requires an intervention by the nurse?
Setting the wall suction to 160 mm Hg pressure before suctioning
The nurse prepares to assign the client requiring a capillary blood glucose test to a newly hired unlicensed assistive personnel (UAP). Which action should the nurse take FIRST?
Show me how you check a capillary glucose level
The client remains agitated and insisting the governor must hear the message. (2-case study 6 part, 4). when planning the client's care, which 4 methods of verbal or non-verbal communication does the nurse consider?
Stand with relaxed posture a few feet away, arms loose. Ask open-ended questions about the client's life and family. Let the client have time to speak and listen carefully. Tell the client, "i know this must be frustrating for you.
A unit of packed red blood cells is prescribed for a client who has an intravenous infusion of dextrose 5%. Which is the MOST important action for the nurse to take?
Start a separate infusion of normal saline and use a Y connector to infuse the blood
The nurse cares for the client diagnosed with Parkinson's disease. The nurse notes that the client is ambulating with short, accelerating steps. Which action is the MOST appropriate for the nurse to take?
Teach the client to walk with a broad-based gait
The nurse cares for the client scheduled for a femoral popliteal bypass procedure. when the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know everything I need to know about it." Which response by the nurse is BEST?
Tell me what the healthcare provider told you about the risk and benefits of this operation
The nurse counsels a client at 36 weeks gestation who has attended childbirth class in preparation for labor and delivery. which statement by the client requires an intervention by the nurse?
The breathing pattern I learned in class will decrease the amount of time I spend in labor
The home care nurse visits the client diagnosed with Parkinson disease. The nurse is MOST concerned if which is observed?
The client is drooling
The mental health nurse is working with the police response unit to care for an adult client. (2-case study 6 part, 1). The mental health nurse receives the EMS call and accompanies the police response unit. which client behavior indicates the situation is likely a mental health crisis rather than a criminal event? SATA
The client was disheveled and dressed inappropriately to enter the governor's office. The client is acting "irrationally," pacing, and frantically yelling. The client states there is a message from God which must be relayed. The client states, "I am the only one who can give the plan to the governor"
The school nurse teaches accident-prevention to the parents of school-aged children. Which statement, if made by a parent to the nurse, indicates teaching is effective? 1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his bike." 2. "I keep my guns and ammunition in a locked cabinet in the basement." 3. "The next time we go to the park, I will teach my child the correct way to climb on the monkey bars." 4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."
The next time we go to the park, I will teach my child the correct way to climb on the monkey bars.
The nurse presents a seminar on herbal supplements at a community event. Which statement should be included in the seminar? SATA
The potency of herbal supplements varies between manufacturers. Herbal preparations are classified as dietary supplements. Ma huang contains ephedra and can be dangerous for people with high blood pressure.
An adolescent is admitted tot he hospital with a diagnosis of bacterial meningitis. which action, if observed by the nurse, would require an intervention?
The unlicensed assistive personnel (UAP) leaves the client room with the face mask hanging from the neck
The nurse identifies self and slowly approaches the client. the client asks the nurse to come closer and says, "I can prove that God provided the message. will you help me get in? The governor needs to hear the message!" (2-case study 6 part, 3). which response by the nurse is BEST?
This is not the way to give your message. come with me and we will get you some help
The nurse plans care for a client receiving disulfiram. which statement require an IMMEDIATE intervention by the nurse?
This medication will prevent me from drinking alcohol
The nurse teaches a client who is lactose intolerant about some alternative ways to maintain an adequate diet. The nurse will suggest the client include which food items in the diet?
Tofu and green leafy vegetables
The nurse identifies the client with which diagnosis as at risk of developing metabolic acidosis? SATA
Type 1 diabetes Salicylate toxicity Acute kidney failure Severe diarrhea
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500 mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours. 4. Blood pressure of 100/82.
Urinary output of 1,500 mL in 24 hours.
The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching is successful if the family makes which statement? 1. "We wear a fresh pair of clean gloves with each diaper change." 2. "We are not allowing our other children to be in the same room with the baby." 3. The grandmother wears a mask when changing the baby's diaper. 4. The mother wears an apron when changing the baby's diaper.
We wear pair of clean gloves with each diaper change
A client is admitted to the hospital following recent surgery and chemotherapy. The client has no appetite and has lost 10 lb in the past 4 weeks. Which statement is MOST important?
What are your favorite foods and beverages?
The home care nurse makes an initial visit to the 80-year-old client. The client's adult child states that the parent has a history of colon cancer and has been restless and confused for about a week. It is MOST important for the nurse to obtain an answer to which question?
What medication is your parent taking?
A 50-year-old client with a history of alcohol use disorder is treated in the emergency room for acute alcohol intoxication. it would be MOST important for the nurse to obtain the answer to which question?
When did you have your last drink?
The home care nurse cares for the client who is diagnosed with hypertension and mild depression. The client's adult child states that the client has been falling frequently. Which response by the nurse is BEST?
When does your parent fall?
The nurse receives a phone call from the parent of a school-age child taking methylphenidate daily. The parent reports the child has lost 2 pounds in the past 2 weeks. Which is the MOST appropriate response by the nurse?
When was the last time you contacted your child's health care provider?
Levodopa is prescribed for a middle-age client. Which statement would indicate further instruction is needed?
While I take this medication, I should eat a high-protein diet
The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate? 1. A 38-year-old client with a diagnosis of systemic lupus erythematosus. 2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer. 3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg. 4. A 74-year-old client who has received intravenous antibiotics for 7 days.
a 38-year-old client with diagnosis of systemic lupus erythematosus
The nurse teaches a wellness class to a group of women. The nurse knows that which of the following clients is MOST at risk for developing cervical cancer? 1. A woman who began menstruating at age 9. 2. A woman who used oral contraceptives for 8 years. 3. A woman diagnosed with endometriosis at age 20. 4. A woman who has had approximately 10 sexual partners.
a client who has had approximately 10 sexual partners
The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. the client's capillary blood glucose is 480 mg/dL. the postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. which is the FIRST action the nurse should take?
administer the 6 units of regular insulin subcutaneously
The nursing team consist of one RN, one LPN/LVN and two unlicensed assistive personnel (UAP). Which assignment is most appropriate for the LPN/LVN?
an older adult client diagnosed with a thrombotic cerebrovascular accident 5 days ago
The nurse cares for the client 4 hours after admission to the hospital for treatment of an anterior wall myocardial infarction. the client suddenly reports difficulty breathing and appears very anxious. which action should the nurse take FIRST?
auscultate the client's posterior lung fields
The nurse observes a student nurse examining a client's chest. which action by the student requires an intervention by the nurse?
auscultating heart sounds and then palpating for tacticle fremitus
The client diagnostic studies are complete, and the nurse reviews the clients result and laboratory findings. (1-case study 6 part, 2) The nurse understands the clients is at greatest risk to develop
cardiac dysrhythmias pneumonia rhabdomyolysis
During a paracentesis, 1500 mL of fluid is removed from a client. Which action should the nurse take IMMEDIATELY following the procedure? 1. Measure the client's abdominal girth. 2. Weigh the client. 3. Assess the client's level of pain. 4. Check the client's blood pressure.
check the client's blood pressure
The nurse is caring for an elderly client admitted for type 1 diabetes mellitus. the nurse notes that the client appears to have difficulty understanding what is said. which action, if taken by the nurse, is MOST appropriate?
check the client's ear canals for cerumen
The client diagnosed with a stroke develops dysphagia. Beforea allowing the client to eat, which action should the nurse take FIRST?
check the client's gag reflex
The following day, the nurse returns and is assigned to provide care for the client. The nurse reviews the hands-off report from the previous shift. (1-case study 6 part, 6) Which findings from the previous nurse's documentation indicate the client's condition has deteriorated since admission?
client-oriented to person only, and is agitated and combative striking out at nursing staff RR 22 with Sp02 94% on2 L oxygen/minute per nasal cannula temp(axillary) 100.2 F (37.88 C)
A 25-year-old multigravida is 22 weeks gestation. The client calls the clinic and inform the nurse, "I was exposed to rubella 2 days ago". which statement, if made by the nurse, is most appropriate?
come in this afternoon for your regularly scheduled appointment
The client adult child arrives at the hospital and provides a list of the clients home medications. the adult child speaks with the orthopedic surgeon. the client is scheduled for an open reduction and internal fixation of the left hip the following morning. the nurse plans the clients care (1-case study 6 part, 4) the nurse ensures the client
continues to take levothyroxine as scheduled if the client has an advance directive request a case manager to speak with the client child
The nurse provides care for a client diagnosed with chronic bronchitis. which is the best description of expected breath sounds heard during auscultation?
deep, low-pitched rumbling sounds heard during expiration
A client contaminated with an unidentified hazardous material from work arrives by ambulance at the hospital. which action does the nurse perform FIRST?
determine if decontamination occurred at the site
An older client is scheduled for a magnetic resonance image (MRI). The history indicates the client suffered an injury during the Vietnam war. which question is MOST important for the nurse to ask the client?
did your injury involve shrapnel
The nurse provides care for a client 2 hours after a renal angiogram is accessed via the right femoral artery. which finding requires an immediate intervention by the nurse?
diminished right dorsalis pedis pulse
A client comes to the outpatient clinic to receive the influenza vaccine. which is the BEST question the nurse would ask the client?
do you have any food allergies?
The health care provide orders hydralazine 25 mg IM on call for the client before surgery. the LPN/LVN administers hydroxyzine 25 mg IM to the client. which is the MOST appropriate action for the nurse to take?
document "hydralazine 25 mg ordered; hydroxyzine 25 mg given; HCP notified; blood pressure 130/84; pulse 86; respiration 12"
The nurse provides care for a client immediately after an ileostomy procedure. which is the best INITIAL action for the nurse during client teaching?
encourage the client to discuss any concern and ask question
A client calls the healthcare provider's office reporting a rash, intermittent fever, headache, fatigue, muscle pain, and stiff neck. It is MOST important for the nurse to ask which question? 1. "Have you ever felt this way before?" 2. "Have you noticed any swollen areas on your neck?" 3. "Have you recently noticed any flea bites?" 4. "Have you noticed any tick bites recently?"
have you noticed any tick bites recently
After the unexpected death of a client, the nurse observes the spouse standing with the adult children. Which statement by the nurse is MOST appropriate?
his must be a difficult time for you; I will stay with you
The home care nurse visits the client with a halo fixator traction device. which client statement MOST concerns the nurse
i drove to the library yesterday
The nurse teaches reality orientation to the spouse of a client with diagnosis of Alzheimer disease and moderate hearing loss. which statement, if made by the client's spouse, indicates understanding this technique?
i should place a calender and clock in an obvious place.
The nurse instructs a client about taking 100 mg losartan and 25 mg hydrochlorothiazide tablets once daily. which statement requires and intervention by the nurse?
i understand that i may develop a dry cough while taking this medication
A 12-year-old boy diagnosed with a fractured right femur is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse is MOST concerned by which client statement?
i will experience more muscle spasm and pain while my leg is in traction
The nurse teaches a client with spinal cord injury how to perform self-catheterization at home. which statement , if made by the client, indicates that teaching has been successful?
i will not reuse a single-use catheter when catheterizing myself
The nurse cares for an 80-year-old client taking medication for the treatment of hypertension and heart failure. which action is MOST important for the nurse to take?
instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising
The nurse provides care for the client with a cuffed tracheostomy tube. before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. which is the MOST appropriate action for the nurse to take?
leave the cuff inflated and suction through the tracheostomy
The nurse is called to the bathroom of a woman who delivered an 8 lb 4 oz male 12 hours ago. The nurse notes that there is blood running down the client's leg. Which statement, if made by the nurse, is BEST? 1. "Leave your perineal pad in the bathroom so I can evaluate the lochia." 2. "Why don't you go back to bed so you can rest?" 3. "Let me help you back to bed so I can check your fundus." 4. "Sit in this chair so I can check your blood pressure."
let me help you back to bed so i can check your fundus
A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram? 1. Observe the color of the client's fingernail beds. 2. Assess the client's blood pressure in both arms. 3. Listen to the client's breath sounds. 4. Assess for intercostal retractions.
listen to the client's breath sounds
The spouse of a client at 39 weeks gestation calls the clinic nurse and states, "my spouse's water just broke, and i think the baby is coming now!" which statement, if made by the nurse is best?
look at your spouse's vaginal area and tell me what you see
A parent brings a 15-month-old infant to the pediatric clinic for immunizations. the parent tells the nurse that the infant has been diagnosed with cancer and is being treated with chemotherapy. the nurse should question the administration of which immunization?
measles/mumps/rubella
Select the 3 priority actions the nurse considers at this time (1-case study 6 part, 3)
notify the physician of abnormal labs and diagnostic results place the client on a continuous cardiac monitor obtain a list of the clients home medications
The nurse instructs a client about furosemide, spironolactone, and a low-sodium diet. Which statement by the client indicates the need for further instruction?
now that i have to limit my sodium intake, i plan to use salt substitutes
A friend brings a young adult to the emergency department and states the client has been using heroin. Which action by the nurse is MOST appropriate?
obtain oxygen saturation levels
The nurse documents the client's care. The NICU nurse cares for the viable male newborn weighing 2 lbs 10 ounces (1190 grams) born via emergency cesarean birth (3-case study 6 part, 2). complete the following sentence by choosing from the list of options. The newborn is at risk for developing ------ related to ------- and ----
patent ductus arteriosus. Prematurity. Persistent fetal Circulation.
The nursing team consists of two RNs, one LPN/LVN, and one unlicensed assistive personnel (UAP). The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which task?
perform a dressing change on a client 3 days after a cholecystectomy
The nurse cares for the client after a lumbar laminectomy. which action by the nurse is MOST important?
place a pillow between the client's legs and then turn the client
The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to compression fractures of the 5th and 6th cervical vertebrae. the client reports a sudden onset of sweating and has a flushed face and chest. which action should the nurse take FIRST?
place the client in high-fowler position
A pregnant client receives an epidural anesthetic. After administration of the epidural, the client's blood pressure changes from 120/84 to 94/50. which action by the nurse is MOST appropriate?
place the client on the left side with legs flexed
In preparation for a total laryngectomy, the nurse teaches an adult client to prevent aspiration after surgery. which activity by the client indicates to the nurse that teaching is successful?
raising the head of the bed to 30 degrees before laying down
complete the following sentences by choosing from the list of options (2-case study 6 part, 5) The nurse helps the client----------. it is a priority for the nurse to-----------
relax and feel safe have the responding officers approach the client slowly and calmly
The nurse assesses an IV site before administering vancomycin. the nurse notes that the area around the site is pale and feels cool. which action will the nurse perform?
remove the intravenous catheter, elevate the arm, and insert an intravenous catheter at another site
The home care nurse visits an alert, oriented, malnourished older adult client with some bruising who lives with an adult child. the nurse reports the situation, but the client decides to remain living with the adult child. which action by the nurse is MOST appropriate?
respect the client's decision to stay in the adult child's home
The nurse reviews the client's laboratory results. (4-case study 6 part, 3). The client is at risk for developing -------due to -------as evidenced by--------
seizures. excessive fluid loss. hypernatremia
The nurse cares for a young adult client admitted to an outpatient treatment unit with a diagnosis of purging-type bulimia. it is MOST important for the nurse to take which action?
sit in silence as the client discusses daily life and eating habits
A client has become confused, and the urinary output has decreased during the previous 24 hours. which finding most concerns the nurse?
sodium 128 mEq/L
The nurse performs an assessment of a newborn. The nurse is MOST concerned by which observation?
stroking the outer sole of the infant's foot upward causes the toes to curl downward
The nurse triages clients in the emergency department. which client does the nurse see FIRST?
the client with burns on the face, chest, and hands, BP 120/80 mm Hg, P 100, R 24, T 98.8F (37.C)
The nurse cares for clients on an acute-care surgical area. which client should the nurse see FIRST?
the family of a client who has a small bowel resection 48 hours ago reports the client is more confused than yesterday
The nurse cares for clients in the pediatric clinic. The nurse would be MOST concerned if which was observed?
the hem of the skirt on a 10-year-old is longer on one side than the other
The nurse provides care for a client with suspected Neisseria meningitidis. which action is MOST important for the nurse to take?
wear a face mask while assisting with activities of daily living
The home care nurse visits a client terminally ill with pancreatic cancer. The client wishes to die at home. Which question is MOST appropriate for the nurse to ask?
who will take care of you?
The client takes 200 mg carbamazepine orally twice daily. The client asks the nurse about future pregnancies. which statement by the nurse is MOST appropriate?
you should contact your health care provider and discuss your concerns about pregnancy
A middle-age adult client scheduled for a vasectomy report being in a monogamous relationship. Which response by the nurse is MOST appropriate?
you will need to wear a condom when having sexual intercourse for 4 to 8 weeks following the vasectomy
