RN Comp Practice B 2019 with NGN
A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?
Strict adherence to routines
A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?
Support the client's left arm on a pillow while sitting
A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?
Survey the scene for potential hazards to staff and children
A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?
Take the medication 15 min before playing sports
A nurse is caring for a client who is receiving PEEP via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?
Tension Pneumothorax
A nurse working in the ED is triaging 4 clients. Which of the following clients should the nurse recommend for treatment first?
A middle adult client who has unstable vital signs
A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consents promotes which of the following ethical principles?
Autonomy
A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?
Avoid including raw fruits in the client's diet
A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?
"A client who requires airborne precautions should be placed in a negative-pressure airflow room."
A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?
"Have you had any stomach pain or bloody stools?"
A nurse is admitting a client to the psychatric unit after attempting suicide. The client states, "My father does not are whether I live or die." Which of the following responses should the nurse make?
"How does theis make you feel?"
A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?
"I can designate my partner as my health care surrogate."
A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?
"I told my doctor that I would like to start a support group for other women who are sick in my community."
A nurse is providing information to a client immediately before their scheduled Romberg test. Which of the following statements should the nurse make?
"I will be checking you once with your eyes open and once with them closed."
A nurse is providing education to the parent of a school-age child with has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
"I will make sure my child receives a yearly influenza immunization."
A nurse is teaching a client who has a new prescription for TPN through a central line. Which of the following information should the nurse include in the teaching?
"I will need to measure your weight daily."
A nurse is providing teaching to the guardians of a newborn about measures to prevent SIDS. Which of the following guardian statements indicates an understanding of the teaching?
"I will not allow anyone to smoke near my baby."
A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I will wear a supportive bra overnight."
A charge nurse notices that one of the nruses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?
"I would like to talk to you about the unit policies regarding break time."
A home health nurse is evaluating a school-ae child who has cystic fibrosis. The nurse initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?
"My child has only a small amount of mucus after percussion therapy."
A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?
"Tell me more about your understanding of the options."
A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?
"We can expect the hospice nurse to provide support for us after our mother's death."
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?
"You have the right to change your mind about this procedure at any time."
A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse should in the teaching?
"Your body temperature might decrease slightly just prior to ovulation."
A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? (SATA)
-"I will cover my baby's body when I wash her hair" -"I will use the bulb syringe first in her mouth and then in her nose"
A nurse is providing discharging teaching for the parents of a preschool-age xhild has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (SATA)
-"Shake the medication bottle well before each dose is given." -"Store the medication in the refrigerator." -"Report diarrhea to the provider immediately."
A nurse is caring for a client who is 1hr postpartum. Exhibit 1: Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus.Oxytocin 20 units being administered via continuous IV infusion. 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Exhibit 2: Vital Signs 1200: Temperature 37.5° C (99.5° F) Heart rate 92/min Respiratory rate 22/min Blood pressure 100/60 mm Hg SaO2 97% on room air 1215: Temperature 37.1° C (98.8° F) Heart rate 112/min Respiratory rate 26/min Blood pressure 90/52 mm Hg SaO2 92% on room air 6 actions the nurse should take?
-Administer methylergonovine -Firmly massage the uterine fundus -Insert indwelling urinary catheter -Provide emotional support -Administer oxygen -Weigh the perineal pads
A nurse is caring for an adolescent Exhibit 1: 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Weight 54.5 kg (120 lb) Heart rate 89/min Respiratory rate 20/min Blood pressure 124/82 mm Hg Oxygen saturation 98% on room air Exhibit 3: Provider Prescriptions 1415: X-ray of right leg Surgery consult Morphine 4 mg IV every 2 hr as needed for pain. Exhibit 4
-Elevate affected limb at chest level -Remove indwelling urinary catheter when no longer indicated -Perform neurovascular assessments every hr
A nurse in an outpatient mental health clinic is caring for a client. Exhibit 1: Vital Signs 3 months ago: Blood pressure 116/68 mm Hg Heart rate 82/min Respiratory rate 16/min Temperature 36.7° C (98.1° F) SaO2 97% on room air Today: Blood pressure 128/76 mm Hg Heart rate 104/min Respiratory rate 22/min Temperature 37.4° C (99.4° F) SaO2 97% on room air Exhibit 2: Nursrs' Notes 3 months ago: Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented x4. Responds appropriately to questions. Client reports sleeping well and working at a local retail store. Today: Client presents for follow-up visit. Pressured speech noted. Appears to be listening to unseen others. Client is restless. Frequently getting out of chair. Appears tired and disheveled. Exhibit 3: Graphic Record 3 months ago: 83.9 kg (185 lb) Today: 83 kg
-Speech -Restlessness -Auditory hallucinations
A nurse is caring for a client during a follow up visit at a GI clinic. Exhibit 1: Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Exhibit 2: Vital Signs 0600: Temperature 37.8° C (100° F) Heart rate 104/min Respiratory rate 26/min Blood pressure 88/56 mm Hg O2 saturation 90% on 2 L via NC Exhibit 3: Diagnostic Results 0645: Hematocrit 25% (37% to 52%) Hemoglobin 8.3 g/dL (12 to 16 g/dL) WBC count 18,000/mm3 (5,000 to 10,000/
-Use humidification with O2 therapy -Administer IV fluids -Assess the client's mouth every 8hr -Assess peripheral circulation hourly
A nurse is preparing to administer lactated Ringer's 1,500mL IV to infuse at 50mL/hrh. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min. (Round to whole number)
13gtt/min 50mL*15gtt=750 750gtt/60min=12.5
A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lbs. What is the amount in grams the nurse should administer? (round to a whole number)
18g 198 lbs/2.2kg=90kg 90kg*0.2g=18g
A nurse on a pediatric unit has received change-of-shift report for 4 children. Which of the following children should the nurse assess first?
A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
A nurse must recommend cleints for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?
A client who has cellulitis and is receiving oral antibiotics Q8hr
An antepartum nurse is caring for 4 clients. For which of the following clients should the nurse initiate seizure precautions?
A client who is at 33 weeks of gestation and has severe gestational hypertension
A nurse has just received change-of-shift report on 4 clients. Which of the following clients shuold the nurse assess first?
A client who is postoperative with abd distention and no bowel sounds.
A nurse has received change-of-shift report on 4 assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?
A client who is receiving an MAOI and is requesting a cheeseburger for dinner
A nurse at a mental health clinic is caring for 4 clients. The nurse should recognize that which of thefollowing clients is using dissociation as a defense mechanism?
A client who was abused as a child describes the abuse as if it happened to someone else.
A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?
A client whose caregiver requests adult day care services.
A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?
Aspirate contents from the tube and verify the pH level
A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?
Abd bloating
A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? Exhibit 1: H&P 8-year-old male admitted with cystic fibrosis Reports shortness of breath Wheezing throughout lung fields Productive cough with thick sputum Exhibit 2: Graphic Record Heart rate 108/min Respiratory rate 26/min Temperature 37.2°C (98.9°F) Blood pressure 100/62 mm Hg Oxygen saturation 92% Exhibit 3: Diagnostic Results Sputum culture: Burkholderia cepacia
Administer high-dose antibiotic therapy
A nurse manager is perparing an educational session about advocacy to a group nurses. The nurse manager should include which of the following information in the teaching?
Advocacy is a leadership role that helps others to self-actualize
A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?
Agency for Healthcare Research and Quality
A nurse is caring for an older client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following lab values indicates that the client needs additional nutrients added to the feeding?
Albumin 2.8g/dL
A nurse is planning care for a client who has rheumatoid arthritis (RA) and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
Allow for frequent rest periods throughout the day.
A nurse is caring for a client who is in the 4th stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?
Amount of vaginal bleeding
A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?
An older adult whi is nervous and attempting to pull out an IV line
A nurse is caring for a client who has type 1 DM and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?
Apply a cold pack to the client's ankle for 30 min every hour
A nurse is caring for 4 clients. Which of the following tasks should the nurse delegate to an AP?
Arrnge the lunch tray for a cleint who has a hip fracture
A nurse is preparing to replace a client's transdermal fentanyl patch after 72hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?
Ask another nurse to witness the disposal of the new patch
A charge nurse is speaking with the partner of a client. The partner states that this client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
Ask the partner to list specific concerns
A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?
Assign the cleint to a private room with negative air pressure
A nurse is caring for a client who had abd surgery 24hr ago. Which of the following actions is the nurse's priority?
Assist with deep breathing and coughing
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
Auscultate the apical pulse at least 1 min
A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of thef ollowing findings should the nurse identify as an adverse effect of the medication?
Blurred vision
A nurse in a mental health clinic is assessing a client who has a histroy of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders?
Borderline
A nurse is providing dietary teaching to a client who has a new prescription for phenalzine. Which of the following food recommendations should the nurse make? (SATA)
Broccoli Yogurt Cream cheese
A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD. (Picture)
C abd Assess for abd distention and visible peristalsis, manifestations for HD.
A nurse is caring for an adolescent Exhibit 1: 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Weight 54.5 kg (120 lb) Heart rate 89/min Respiratory rate 20/min Blood pressure 124/82 mm Hg Oxygen saturation 98% on room air 4 findings that require follow-up
Cap refill Skin temp Pain Pedal pulse
A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth?
Cervical laceration
A nurse is caring for a client. Exhibit 1: Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The client's symptoms started 1 hr prior to arrival at the ED. Client received fibrinolytic therapy and was transferred to the ICU. Day 2, 0800: Client is awake and alert to person, place, and time. Client has weak right-side hand grasp. However, this is improved from admission. Client to be evaluated by speech therapy due to aphasia. Day 2, 1930: Called to the client's room by a family member. Client is lethargic and restless, oriented to person and place. Client reports headache. The client's family member also reports that the client just vomited in an emesis basin. Client's speech is slurred. Exhibit 2: Vital Signs Day 1, 1000: Temperature 37.2° C (99° F) Heart rate 114/min Blood pressure 184/88 mm Hg Respiratory rate 24/min O2 saturation 97%
Cluster nursing care CONTRAINDICATED Keep the lights in the client's room dim ANTICIPATED Administer O2 therapy to keep O2 sat above 95% ANTICIPATED Maintain the client's hips in flexion CONTRAINDICATED Monitor BG Q4hrs ANTICIPATED Keep the client supine. CONTRAINDICATED
A nurse is caring for a 68-year-old client who is 2 days postoperative following surgical repair of a left hip fracture. Exhibit 1: Nurses' Notes 1300: Client reports intermittent abdominal pain as 5 on a scale of 0 to 10 on left side of abdomen. Last bowel movement 5 days ago. Client reports usual pattern is one bowel movement daily. Oral fluid intake 1,950 mL/24 hr. Urine output 1,820 mL/24 hr. 1900: Client reports nausea and constant abdominal pain as 5 on a scale of 0 to 10 throughout abdomen. Pain began after eating dinner. Exhibit 2: Physical Exam 1300: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive bowel sounds in lower quadrants. Skin warm and dry to touch in trunk and all extremities. Pedal pulses strong and equal bilaterally. Capillary refill less than 3 seconds in toes bilaterally. 1900: Abdomen distended, dull to percussion, firm and nontender on palpation. Hypoactive
Condition: INTESTINAL OBSTRUCTION Actions: -SEMI-FOWLER'S POSITION -IV FLUIDS Monitor: -BOWEL SOUNDS -URINE OUTPUT
A nurse is caring for a client who is postoperative following administration of general anesthesia Exhibit 1: Vital Signs 0830: Temperature 36.9° C (98.5° F) Heart rate 134/min Respiratory rate 28/min Blood pressure 92/52 mm Hg Pulse oximetry 89% on room air Exhibit 2: Nurses' Notes 0830: Client is postoperative following an inguinal hernia repair. Apical pulse 134/min and irregular Client reports dyspnea. Exhibit 3: Diagnostic Results 0835: Arterial blood gases (ABGs) pH 7.30 (7.35 to 7.45) PCO2 64 mm Hg (35 to 45 mm Hg) HCO3- 26 mEq/L (21 to 28 mEq/L) PO2 80 mm Hg (80 to 100 mm Hg)
Condition: MALIGNANT HYPERTHERMIA Action: -ADMINISTER DANTROLENE -ADMINISTER OXYGEN Monitor: -MUSCLE RIGIDITY -HYPERCAPNIA
A nurse in the ED is assessing a client. Exhibit 1: Medical History 1030: Diagnosed with schizophrenia 2 years ago Migraine headaches Unresponsive to second-generation medications (clozapine and risperidone), changed to first-generation medication 6 months ago Current medications: Haloperidol 5 mg PO TID Sumatriptan 50 mg PO every 2 hr PRN headache Exhibit 2: Vital Signs 1030: Heart rate 122/min Respiratory rate 28/min Blood pressure 182/85 mm Hg Temperature 39.7° C (103.5° F) Oxygen saturation 90% on room air Exhibit 3: Nurses' Notes 1030: Client arrived at ED via ambulance. Emergency medical technicians (EMTs) report being called to client's home by the client's partner.According to EMTs, partner stated they found the client with decreased responsiveness, muscle rigidity, posturing, and diaphoresis. 1045: Client unresponsive to questions, does not follow simple commands. Sinus tachycardia; S1S2 on auscultation; p
Condition: NEUROLEPTIC MALIGNANT SYNDROME Action: -HOLD ALL ANTIPSYCHOTIC MEDS -PROVIDE A COOLING BLANKET Monitor: -TEMP -HYDRATION STATUS
A nurse in an ED is assessing a school-age child who was bri=ought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?
Contact Child Protective Services
A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?
Cough
A nurse is caring for a client during a follow up visit at a GI clinic. Exhibit 1: Nurses' Notes Client arrived today for follow up. Client reports worsening gastrointestinal symptoms. Client was last seen 2 months ago and reported abdominal pain and bloating. Today, the client reports worsening abdominal pain in the right lower quadrant and abdominal bloating. Client reports frequent soft to loose stools today and denies tarry stools. Client also states that they have been experiencing a loss of appetite and some weight loss. Exhibit 2: Vital Signs 2 months ago: Temperature 37.2° C (99° F) Heart rate 78/min Respiratory rate 16/min Blood pressure 126/78 mm Hg Oxygen saturation 99% on room air Weight 89.2 kg (196.7 lb) Today: Temperature 37.8° C (100° F) Heart rate 105/min Respiratory rate 18/min Blood pressure 102/74 mm Hg Oxygen saturation 95% on room air Weight 84.8 kg (187 lb) Exhibit 3: Diagnostic Result Today:
Crohn's disease: -Abd pain location -Weight -Bowel pattern -Albumin level -Temp -WBC Ulcerative Colitis: -Weight -Albumin -Temp -WBC Peritonitis: -HR -Temp -WBC
A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?
Decreased hallucinations
A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?
D. moving leg away from midline of body
A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following medthods should the nurse include in the teaching?
Delegate non-nursing tasks to ancillary staff
A nurse is updating the plan of care for a client who is 48hr postopertative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?
Determine the client's reading skills
A nurse on a med-surge unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?
Difficulty performing ADLs
A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?
Droplet
A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?
Dry Mouth
A client is receiving IV fluids at 150mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
Dyspnea
A nurse is caring for a client who is pregnant. Exhibit 1: Nurses' Notes 1000: The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks. 1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus. 1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine. 1500: Client tolerating fluids well. Ate four graham crackers without emesis. Has voided 300 mL of amber-colored urine. Exhibit 2: Vital Signs 1000: Temperature 36.8° C (98.2° F) Heart rate 112/min Respiratory rate 20/min Blood pressure 100/65 mm Hg SaO2 97% on room air 1200: Temperature 37° C (98.6° F) Heart rate 102/min Respiratory rate 20/min Blood pressure 104/70 mm Hg SaO2 98% on room air 1500: Temperature 36.8° C (98.2° F) Heart rate 90/min Respiratory r
Eat every 2-3hr: RECOMMENDED Drink warm ginger ale when nauseated: RECOMMENDED Increase intake of high-fat foods: CONTRAINDICATED Alternate eating solid foods and liquids: RECOMMENDED
A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 DM. Which of the following activities is the nurse's priority?
Ensure that the client understands the medication regimen
A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?
Explore the client's reasons for refusing the treatment
A nurse is caring for an adolescent Exhibit 1: 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Weight 54.5 kg (120 lb) Heart rate 89/min Respiratory rate 20/min Blood pressure 124/82 mm Hg Oxygen saturation 98% on room air 1630: Temperature 38° C (100.4° F) Heart rate 94/min Respiratory rate 20/min Blood pressure 126/84 mm Hg Oxygen saturation 98% on room
Extremity pulse +3 Cap refill 2 seconds Right extremity is warm to the touch Adolescent reports no numbness or tingling Adolscent reports pain as 2 on a scale of 0 to 10
A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?
Facilitate an interdisciplinary conference at the new facility for the family.
A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According Nägele's rule, which of the following should the nurse document as the client's estimated date of birth (EDB)?
February 15
A nurse is perparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of thefollowing nutrients should the nurse instruct the client to decrease in their diet?
Fiber
A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using? (Audio Clip)
Flight of ideas
A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling precedure. Which of the following actions should the nurse manager take first?
Form a committee of staff members to investigate current staffing issues
A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease?
Have the client wear a surgical mask while being transported outside the room.
A nurse is assessing a client who received 2 units of PRBCs 48hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?
Hemoglobin 14.9g/dL
A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?
Hold the insulin pen device perpendicular to the client's skin to inject the medication
A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?
Implement fall percautions for the client.
A nurse is planning care for a client who has rheumatoid arthritis (RA). Which of the following interventinos should the nurse include in the plan?
Increase the client's dietary iron intake
A nurse on a mental health unit is caring for a client. Exhibit 1: Nurses' Notes Day 1, 1300: Client admitted following a suicide attempt. Client's family reports client has not left bedroom in 1 week. Client previously diagnosed with bipolar disorder. Client reports feeling excessively tired and light-headed. Allergies: Client's family reports allergy to SSRIs (angioedema) and penicillin (anaphylaxis). 1600: Client has been sleeping in their room since admission. Flat affect noted. Exhibit 2: Provider Prescription Day 1: Lithium 300 mg PO three times daily Acetaminophen 325 mg 1 to 2 tablets PO every 6 hr PRN pain or fever Exhibit 3: Lab Results Day 1, 1400: Sodium 140 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Chloride 110 mEq/L (98 to 106 mEq/L) BUN 11 mg/dl (10 to 20 mg/dL) Magnesium 1.3 mEq/L (1.3 to 2.1 mEq/L) Total calcium 10.1 mg/dL (9.0 to 10.5 mg/dL) Phosphate 3.7 mg/dL (3.0 to
Initate suicide precautions: ANTICIPATED Potassium 40mEq PO daily: ANTICIPATED Low-Sodium diet: CONTRAINDICATED Fluoxetine20mg PO daily: CONTRAINDICATED
A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?
Initiate continuous cardiac monitoring
A nurse in the ED is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?
Initiate transmission-based precautions
A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?
Insert a lubricated gloved finger and advance along the rectal wall
A nurse is perofmring an abd assessment on a client. Identify the sequence of actions the nurse should take.
Inspect Auscultate Percuss Palpate
A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?
Instruct the client to void
A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?
Making a list of activities to complete
A nurse is providing teaching to a client who has a new diagnosis of type 1 DM. The nurse shuld instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia?
Irritability
A nurse is caring for a client who is taking taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?
Jaundice
A nurse is preparing a sterile field to perofmr a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique?
Maintain sterile objects wihtin the line of vision
A nurse on a ned-surge unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
Make a referral for social services
A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an AP?
Measure the client's daily weight
A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy. Exhibit 1: Vital Signs 1100: Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min Blood pressure 128/68 mm Hg Pulse oximetry 97% on room air 1115: Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min Blood pressure 138/74 mm Hg Pulse oximetry 95% on room air 1130: Temperature 38.6° C (101.5° F) Heart rate 136/min Respiratory rate 16/min Blood pressure 154/86 mm Hg Pulse oximetry 95% on 2 L/min via nasal cannula Exhibit 2: MAR 1110: Morphine 4mg IV bolus Exhibit 3: Nurses' Notes 1100: The client is asleep, easily aroused. Rates pain at incision site as 8 on a scale of 0 to 10. Portable wound bulb suction device in place with scant serosanguinous drainage present. Dressing to neck dry and intact. 1115: Client asleep. Arousable with name called loudly multiple times. Client rates
Mental Status BP HR Temp
A nurse is caring for aclient who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?
Monitor the client's mouth Q8hr
During achange of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
Move the client to a room near the nurses' station
A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?
Nasal Flaring
A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?
Noting the progress of the group toward assigned goals
A nurse is caring for a client following a laparoscopic cholecystectomy. Exhibit 1: Nurses' Notes 1030: 33-year-old client is 1 hr postoperative following a laparoscopic cholecystectomy. Alert and oriented to x 3. Skin warm and dry. Lungs clear auscultated throughout all lung fields. Normal sinus rhythm. Denies nausea and vomiting, bowel sounds hypoactive in all four quadrants. Peripheral pulses +2 bilaterally. Incision dressing clean and dry, incision upon inspection intact, no redness, swelling, or drainage noted. Exhibit 2: Client Education 1230: Discharge instructions given to client. Instructions on incision/wound care and proper hand washing. Client to report swelling, redness, drainage, bleeding, or warmth at operative site to surgeon. Client expected to experience carbon dioxide retention in the abdomen. Instructed the client to rest for 24 hr following surgery. Client can bathe or shower the day after surg
Ondansetron 4mg PO for nausea: CONTRAINDICATED Apply heat for abd pain as needed: ANTICIPATED Change dressing when soiled: ANTICIPATED Encourage deep breathing exercises every hour: ANTICIPATED
A nurse is caring for a client who is postpoerative following an appendectomy. Exhibit 1: Nurses' Notes 1800: Client alert and oriented x 4 Skin warm and dry Lungs clear on auscultation Bowel sounds hypoactive in all four quadrants Urine clear yellow Incisional dressing clean and dry Client reports pain as 6 on a scale of 0 to 10 1815: Morphine administered as prescribed 2000: Client reports abdominal pain as 10 on a scale of 0 to 10. Client reports nausea, no vomiting. Incisional dressing is dry and intact with no breakthrough bleeding noted. Lung sounds are clear to auscultation. Hypoactive bowel sounds present in all four quadrants. Exhibit 2: Vital Signs 1800: Temperature 98.4° F (36.8° C) Heart rate 104/min Respiratory rate 22/min Blood pressure 142/80 mm Hg O2 saturation 97% on room air 2000: Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min Blood pressure 158/88 mm Hg O2 saturation 93%
Pain Nausea HR O2
A nurse is planning to delegate client care tasks to an AP. Which of the following tasks should the nurse plan to delegate to the AP?
Perform gastrostomy feedings through a client's established gastrostomy tube
A nurse in the ED is caring for a client who is unconious and requires emergency medical procedures. The nurse is unable to locate members of the client;s family to obtain consent. Which of the following actions should the nurse take?
Proceed with provision of medical care
A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Pink, frothy sputum
A nurse is caring for a client who had a stroke 6hr ago. Which of the following interventions should the nurse implement to reduce the risk of ICP?
Place the client in a quiet environment
A nurse is caring for an adolescent Exhibit 1: 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Weight 54.5 kg (120 lb) Heart rate 89/min Respiratory rate 20/min Blood pressure 124/82 mm Hg Oxygen saturation 98% on room air 1630: Temperature 38° C (100.4° F) Heart rate 94/min Respiratory rate 20/min Blood pressure 126/84 mm Hg Oxygen saturation 98% on room
Prepare the adolescent for surgery: ANTICIPATED Apply ice to the affected extremity: CONTRAINTICATED Elevate the right leg above heart level: CONTRAINDICATED Remove the splint: ANTICIPATED
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV four this client?
Radial vein of the inner arm
A nurse is assessing a client after administering epi for an anaphylactic reaction. Which of the following findings should the nurse identify as na adverse effect of this medication?
Report of CP
A nurse is reviewing the ABG vulues of a client. The client has a pH: 7.2 PaCO2: 60mmHg HCO3: 25 mEq/L The nurse should identify that the client has which of the following acid-base imbalances?
Respiratory acidosis
A nurse is developing a client education program about osteoporosis for old adult clients. The nurse should include which of the following variables as a risk factor fo osteoporosis?
Secondary lifestyle
A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style?
Seek input from the other nurses
A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of thefollowing diagnostic tests?
Serum liver enzyme levels
A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?
Start a task then determines what supplies are needed
An RN is observing a LPN and an AP move a client up in bed. For which of the following situations should the nurse intervene?
The LPN and the AP grasp the client under his arms to lift him up in bed
A nurse is caring for an adolescent Exhibit 1: 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Weight 54.5 kg (120 lb) Heart rate 89/min Respiratory rate 20/min Blood pressure 124/82 mm Hg Oxygen saturation 98% on room air 1630: Temperature 38° C (100.4° F) Heart rate 94/min Respiratory rate 20/min Blood pressure 126/84 mm Hg Oxygen saturation 98% on room
The adolescent's parents have concerns regarding the surgery.
A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?
The client exhibits discomfort while walking.
A nurse is caring for a client who is postoperative following CABG. Exhibit 1: Lab Results 0630: Sodium 145 mEq/L Potassium 3.2 mEq/L Chloride 116 mEq/L BUN 24 mg/dL Magnesium 1.5 mEq/L Total calcium 9.0 mg/dL Phosphate 4.6 mg/dL Glucose 95 mg/dL WBC count 9,500/mm3 Exhibit 2: I&O 0700: 4 hr input 400 mL 4 hr output 350 mL 1100: 4 hr input 475 mL 4 hr output 360 mL 1500: 4 hr input 350 mL 4 hr output 375 mL Exhibit 3: Vital Signs 0700: Temperature 37.6° C (99.6° F) Heart rate 86/min Respiratory rate 20/min Blood pressure 115/70 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1100: Temperature 37.2° C (99.0° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 110/72 mm Hg Oxygen saturation 100% on 2 L via nasal cannula 1500: Temperature 37.7° C (99.8° F) Heart rate 80/min Respiratory rate 20/min Blood pressure 108/70 mm Hg Oxygen saturation 100% on 2 L via nasal cannula Exhibit 4: Nurses' Note
The client is at greatest risk for developing DYSRHYTHMIAS as evidence by ELECTROLYTE IMBALANCE
A nurse is caring for an adolescent Exhibit 1: 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Exhibit 2: Vital Signs 1400: Temperature 37° C (98.6° F) Weight 54.5 kg (120 lb) Heart rate 89/min Respiratory rate 20/min Blood pressure 124/82 mm Hg Oxygen saturation 98% on room air 1630: Temperature 38° C (100.4° F) Heart rate 94/min Respiratory rate 20/min Blood pressure 126/84 mm Hg Oxygen saturation 98% on room
The client is at highest risk for developing COMPARTMENT SYNDROME as evidenced by the client's drop PARESTHESIA
A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Exhibit 1: Lab Results 0700: Sodium 143 mEq/L Potassium 3.5 mEq/L Chloride 104 mEq/L BUN 15 mg/dl Magnesium 1.5 mEq/L Total calcium 8.0 mg/dL Phosphate 4.6 mg/dL Glucose 95 mg/dL WBC 9,500/mm3 Exhibit 2: Nurses' Notes 0700: Client alert and oriented x 3. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client rates dull pain in neck of 2 on a 0 to 10 scale. Declines pain medication. 1100: Client alert and oriented to person, place, and time. Respirations even and unlabored with no adventitious sounds. Bowel sounds active in all 4 quadrants. Surgical dressing dry, slight edema at incision site noted. Client reports muscle cramps in legs as a pain level of 5 on a 0 to 10 scale. Morphine 5 mg IV administered. Encou
The client is at highest risk for developing HYPOCALCEMIA as evidence by the REPORT OF NUMBNESS AROUND LIPS
A nurse on the med-surge unit is caring for a client who was admitted from the ED. Exhibit 1: Vital Signs 1400: Temperature 38° C (100.4° F) Heart rate 110/min Respiratory rate 24/min Blood pressure 96/58 mm Hg Pulse oximetry 96% on room air 1500: Temperature 37.2° C (98.9° F) Heart rate 96/min Respiratory rate 20/min Blood pressure 100/70 mm Hg Pulse oximetry 97% on room air Exhibit 2: Nurses' Notes 1500: Client admitted from the ED for dehydration. Client alert and oriented to person, place, and time. Client reports they are feeling "weak." IV dextrose 5% in water (D5W) infusing at 100 mL/hr. Exhibit 3: Lab Results 1400: Calcium 10.2 mg/dL Magnesium 1.5 mEq/L Potassium 4.7 mEq/L Sodium 150 mEq/L 1700: Calcium 9.5 mg/dL Magnesium 1.5 mEq/L Potassium 4.1 mEq/L Sodium 164 mEq/L
The client is at risk for developing CONFUSION due to SODIUM LEVEL
A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Exhibit 1: Vital Signs 0700: Temperature 37.5° C (99.6° F) Heart rate 86/min Respiratory rate 22/min Blood pressure 115/70 mm Hg Oxygen saturation 100% on room air 0805: Temperature 36.6° C (98.0° F) Heart rate 88/min Respiratory rate 20/min Blood pressure 130/72 mm Hg Oxygen saturation 100% on room air 0910: Temperature 37.1° C (98.8° F) Heart rate 55/min Respiratory rate 26/min Blood pressure 185/105 mm Hg Oxygen saturation 90% on room air Exhibit 2: Nurses' Notes 0700: Client alert and oriented x 3. Denies pain. Client unable to move lower extremities. Urinary catheter draining clear amber urine. Client turned to right. 0805: Client alert and oriented x 3. Denies pain. Client unable to move lower extremities. Urinary catheter draining clear amber urine. Client turned to left. 0910: Client reporting headache as a 9 on 0 t
The client is at risk for developing HEMORRHAGIC STROKE due to AUTONOMIC DYSREFLEXIA
A nurse is caring for a client who has bulimia nervosa. Exhibit 1: Admission Assessment Day 1, 0630: Client admitted to inpatient unit for evaluation and treatment following report of binge eating and vomiting for over 1 year. Client reports feeling excessively tired and light-headed. Neuro: Client alert and oriented x 3. Respiratory: Lungs clear and equal bilaterally GI: Diminished bowel sounds noted x 4. Client reports vomiting three to four times per day. Integumentary: Small superficial lacerations and calluses noted on fingers bilaterally. Breakdown noted around edges of lips. Exhibit 2: Lab Results Day 1, 0730: Sodium 136 mEq/L (136 to 145 mEq/L) Potassium 3.4 mEq/L (3.5 to 5.0 mEq/L) Chloride 97 mEq/L (98 to 106 mEq/L) Total calcium 10.0 mg/dL (9.0 to 10.5 mg/dL) Glucose 74 mg/dL (74 to 106 mg/dL) Day 2, 0730: Sodium 135 mEq/L (136 to 145 mEq/L) Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L Chloride 95 mEq/L (
The client is at risk for developing HYPONATREMIA and CARDIOVASCULAR ABNORMALITIES
A nurse is providing phone advice for a client who is pregnant. Exhibit 1: Nurses' Notes Week 6 of gestation: Spoke with client over the phone. Client reports nausea and vomiting with a weight loss of 0.9 kg (2 lb) from their pre-pregnancy weight. Client reports no noted change in voiding pattern and denies dry mucus membranes. Advised client to eat small frequent meals of nongreasy, dry, sweet or salty foods, such as dry toast, crackers, and pretzels. Encouraged client to call back if nausea and vomiting worsens. Week 10 of gestation: Spoke with client over the phone. Client reports a 6.8 kg (15 lb) weight loss over the past month. Client states nausea continues, making it difficult to eat. They describe a diet of water, toast, and pretzels because other foods are unappealing. They report tolerating a cup of black coffee each morning. Advised client to be seen by the provider today.
The client is at risk for experiencing METABOLIC ACIDOSIS due to the client's WEIGHT LOSS
A nurse is caring for a client who is 24hr postoperative following a cesarean birth. Exhibit 1: Nurses' Notes 1500: Dressing dry and intact. Fundus firm midline at umbilicus. Scant lochia rubra. Client rates incisional pain as a 3 on a scale of 0 to 10, denies need for analgesia. Indwelling urinary catheter removed. 1700: Client reports headache with pain rated at 4 on a scale of 0 to 10. Analgesic administered. 1800: Client reports blurred vision and nausea. Rates pain from headache as a 6 on a scale of 0 to 10. Deep tendon reflexes 4+, clonus positive. Exhibit 2: Vital Signs 1500: Temperature 36.6° C (97.9° F) Heart rate 86/min Respiratory rate 18/min Blood pressure 155/90 mm Hg Oxygen saturation 98% on room air 1800: Heart rate 96/min Respiratory rate 22/min Blood pressure 185/115 mm Hg Oxygen saturation 96% on room air Exhibit 3: Lab Results 700: Capillary blood glucose (casual) 120 mg/dL (less than 200 mg/dL)
The client is at rsk for developing SEIZURES as evidence by BLOOD PRESSURE
A nurse is caring for a client. Nurses' Notes 0800: The parent of a young adult client expresses concern about the client's recent weight loss. Parent reports the client has stated multiple times that they are overweight and is significantly limiting how much they eat. Client states, "Nothing is wrong with me. I am not sure why I was brought here." Client noted to have yellowed sclera, lanugo, 2+ edema. Skin cool and dry to palpation. Exhibit 2: Vital Signs 6 months ago: Heart rate 63/min Respiratory rate 19/min Blood pressure 117/79 mm Hg Temperature 37.2° C (98.9° F) 0800: Heart rate 51/min Respiratory rate 18/min Blood pressure 98/51 mm Hg Temperature 36.5° C (97.7° F) Exhibit 3: Lab Results 6 months ago: Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Sodium 140 mEq/L (136 to 145 mEq/L) Calcium 9.7 mg/dL (9 to 10.5 mg/dL) Magnesium 1.6 mEq/L (1.3 to 2.1 mEq/L) 0800: Potassium 3.3 mEq/L (3.5 to 5 mEq/L) Sodium 133 mEq/L (
The client is exhibiting manifestations of ANOREXIA NERVOSA and is at risk for ARRHTHMIA
A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?
The client is pacing around the chair in which their partner is sitting.
A nurse is assessing a client who is at 11 weeks of gestations and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?
The client reports a decrease in episodes of nausea
A nurse is caring for a client who is in spinal cord injury (SCI) unit. Exhibit 1: Nursrs' Notes Day 1, 1700: Client admitted to SCI 3 days ago following C7 injury.Urinary output 800 mL in indwelling urinary catheter over last 12 hr. Day 2, 0600: Client has nonproductive cough.Urinary output 100 mL in indwelling urinary catheter over last 6 hr. Exhibit 2: Vital Signs Day 1, 2200: Temperature 37.2° C (99.0° F) Heart rate 74/min Respiratory rate 20/min Blood pressure 110/60 mm Hg Oxygen saturation 95% on room air Day 2, 0600: Temperature 37.8° C (100° F) Heart rate 54/min Respiratory rate 26/min Blood pressure 96/60 mm Hg Oxygen saturation 90% on room air Exhibit 3: Physical Exam Day 1, 1700: Lung sounds diminished in lower lobes. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Skin is cool, pale, and dry to touch. Day 2, 0600: Adventitious lung sounds auscultated in lower lo
The nurse should first address the client's OXYGEN SATURATION followed by the client's URINE OUTPUT
A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
The time of the client's last dose of pain medication
A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
Time the medication was given
A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?
Tremors
A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?
Turn off the CPM machine during mealtime.
A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?
Use a 3-point gait
A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of hte following instructions should the nurse include?
Use a reward system to modify the child's behavior
A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nnurse plan to take?
Use the ventrogluteal
A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
Verify the client and blod product information with another licensed nurse
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?
Wear clothing made with cotton fabrics while oxygen is in use.
A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?
Wheezing
A nurse is caring for a school-age child. Exhibit 1: First visit: A child is brought to the clinic accompanied by guardians. The guardians have received feedback from the child's teacher that the child has become disinterested in schoolwork and has difficulty paying attention during class. The child often loses their school supplies. The guardians report that the child demonstrates these behaviors at home as well. The child refuses to participate in household chores, keeps their room untidy, does not clean up when told to, and is generally careless and disinterested. On assessing, the child is found to be talkative, restless, and easily distracted. 2 weeks later: The child's guardians report that the child seems to be doing better at school. The child is improving at paying attention during class and completing assignments on time. Exhibit 2: Vital Signs First visit: Blood pressure 94/56 mm Hg Heart rate 90/min Resp
When analyzing cues, the nurse should identify that manifestations of ADHD include losing necessary things, interrupting others, intellectual impairment, and hyper reactivity to sensory input. In ADHD, the client often loses necessary things in daily life, such as pencils, erasers, and books. The client often interrupts others and has difficulty waiting for their turn in conversation. The client might have an intellectual impairment, which can lead to poor academic performance and difficulties with socialization. The client might exhibit hyperreactivity or hyporeactivity to stimuli.
A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparinvia continuous IV infusion at 1,200 units/hr and warfarin 5mg PO daily. The morning lab values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take?
Withhold the heparin infusion.
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?
aPTT
A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?
pH 7.31
