RN Comprhensive Online practice 2023 A

A nurse is caring for a client who has schizophrenia in an inpatient facility.

Client reports an increase in urination and had one episode of incontinence. Family noticed increased agitation and delusions.

A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mmHG. Which of the following medications should the nurse anticipate administering?

Flumazenil

A nurse on a mental health unit is caring for a client.

Fluoxetine 20mg PO daily -Contraindicated Low sodium diet- contrindicated Potassium 40 mEq PO daily- anticipated Initiate suicude precautions- anticipated

A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis?

Hematuria

A nurse is assessing a client who is scheduled for surgery.

Hemoglobin level Allergies Family history

A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

Hemorrhagic stroke Autonomic dysreflexia

A nurse is caring for a client who has bulimia nervosa

Hyponatremia cardiovascular abnormalities

A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching?

I should have my child avoid sun exposure between 10 am and 2 pm

A nurse is teaching the parent of a school age child about administering ear drops. Which of the following responses by the parent indicated an understanding of the teaching?

I should pull the top of the ear upward and back while instilling the medication.

A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching?

I will bend at my knees when picking an object up off the floor.

A nurse is caring for a client who has a terminal illness and request no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make?

I will provide you with information about medical treatment to include in your living will

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 clients indicates an understanding of the teaching?

I will wear a supportive bra overnight

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 precautions.

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Increase the clients dietary iron intake

A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?

Increased opacity of the lens.

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?

Initiate oral rehydration therapy for the toddler

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

An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN

Insertion of a nasogastric tube

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Inspection Auscultation Percussion Palpation

A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis?

Investigate environmental factors that might be contributing to client injury during these hours.

A nurse is caring for a client who has end stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make?

It seems like you feel your visits are a waste of time

A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to start the procedure?

Latex allergy

A nurse is administering cyclophosphamide orally to a school age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication?

Maintain hydration with liberal fluid intake.

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical sterile technique?

Maintain sterile object within line of vision.

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 caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure?

Mannitol

A nurse is caring for a client who is 4 postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first?

Massage the uterus to expel clots.

A nurse is caring for a client who has immunosuppression and continuous IV infusion. Which of the following actions should the nurse take?

Monitor the client's mouth every 8 hr.

A nurse is caring for a client.

Monitor the client's physical manifestations. Assess the client for a secondary gain from illness. Somatic symptom disorder Vital signs Pain

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity?

Subsernal pain

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 receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give?

There's a protocol for reviewing your medical record, and I can initiate the process.

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 clients medical record?

Time the medication was given.

A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take?

Use 0.9% sodium chloride for irrigation of the NG tube.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?

Use a reward system to modify the child's behavior

A hospice nurse is consulting with a client and their 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 assessing a client who is taking propranolol. Which if the following findings should indicate to the nurse that this client is experiencing adverse reaction to propranolol?

Wheezing

A nurse is assessing a client whose partner recently died. The client states "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?

You seem to be having a difficult time right now.

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?

Your body temperature might decrease slightly just prior to ovulation.

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory test should the nurse review prior to adjusting the client's heparin?

aPTT

A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?

observe the client and the situation.

A client who has high blood pressure is having difficulty following their treatment plan. Which of the following factory should the nurse recognize as being the greatest barrier to the client's ability to be compliant?

Absence of symptoms.

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 planning care for a client who has rheumatoid arthritis 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 fourth 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 community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a national notifiable infectious condition?

An adolescent client who has foodborne botulism

A nurse is caring for a client who has type 1 diabetes mellitus 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 clients ankle for 30 min every hour.

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel?

Arrange the lunch tray for a client who as a hip fracture.

A client who is 24 hr postoperative following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first?

Ask the client to rate their pain level

A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes?

Ask the nurse about their knowledge of the procedure.

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 is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first?

Assess the client for functional limitations

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider?

Axillary temperature 36.2 C (97.2 F)

A nurse is caring for a newborn whose parent ask why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following?

Bleeding

A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the following aPTT (30 to 40 seconds) values should the nurse expect?

45 seconds

A nurse on a pediatric unit has received change of shift report for four 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 in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism.

A client who channels their energy into a new hobby following the loss of their job.

A nurse is caring for a school age child. For each assessment finding, click to specify if the finding is consistent with ADHD or ID. Each finding my support more than 1 disease process

ADHD: Losing necessary things, interrupting others, intellectual impairment, and hyperactivity to sensory input.

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?

Abdominal bloating

A nurse is caring for a client who is receiving a transfusion of packed red blood cells.

Back pain Headache Anxiety

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 births.

Cervical lacerations

A nurse is preparing to administer a long-acting insulin to a client who had diabetes mellitus. Which of the following actions should the nurse plan to take first?

Check the insulin does with another licensed nurse.

A nurse is planning care for a client who had a deficit with cranial nerve II. Which of the following actions should the nurse plan to take?

Clear objects from the clients walking area.

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early deceleration on the monitor tracing. Which of the following actions should the nurse take?

Continue observing the fetal heart rate.

A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?

Decreased central vision

A nurse is caring for a client who has potassium level of 3 mEq/L (3 to 5mEq/L). For which of the following manifestations should the nurse monitor?

Decreased deep tendon reflexes

A nurse is caring for a client who has 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 caring for an older adult client. Which of the following findings should the nurse recognize as a physiological change associated with aging?

Decreased lung expansion

A nurse is caring for a newly admitted client. Select the 2 findings that require immediate follow up.

Decreased platelet count decreased hemoglobin

A nurse in a provider's office is caring for a client who had a new diagnosis of type 2 diabetes mellitus.

Delayed wound healing Glucose level

A nurse is teaching the parents of a toddler about snacks. Which is the following foods should the nurse recommend?

Diced steamed carrots

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend?

Double bag soiled dressings in plastic bags for disposal.

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 nurse is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Elevate the affected leg

A nurse on a medical surgical unit is caring for a client who is port operative following an emergency appendectomy.

Elevate the extremity and apply graduated compression stockings Varicose veins Edema of the right lower extremity and pruritis of the right lower extremity

A home health care nurse is developing a teaching plan for a client who had a ileostomy. Which of the following instructions should the nurse include?

Empty the appliance when it is one-third to one-half full.

A nurse is caring for a client in the inpatient psychiatric unit

Ensure that the client does not have access to sharp objects. Observe the client swallow all prescribed medications. Provide one-on-one observation. Assess the clients method of lethality.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?

Fever unresponsive to antipyretics

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

Fiber

A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first?

Move the client to a quiet place away from others.

A home health nurse is evaluating a school age child who has cystic fibrosis. The nurse should 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 teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching?

Nausea

A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan?

Notify the incident commander

A nurse is assessing a client who has multiple sclerosis. Which of the following manifestations should the nurse expect?

Nystagmus

A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect?

Partial-thickness skin loss

A nurse is caring for a client in the emergency department

Perform a CIWA-Ar Initiate seizure precautions Administer chlordiazepoxide Maintain a low stimulation environment Administer thiamine

A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan?

Provide a staff member to stay with the client continuously.

A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging?

Rapid decrease in blood pressure

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication?

Reduce environmental stimuli.

A nurse caring for a newborn. Complete the following sentence by using the lists of options.

Respiratory rate Heart rate

A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching?

Secure the retainer clip at the level of your baby's armpits.

A nurse is caring for a client who is 24 hr postoperative following a cesarean birth. Drag 1 condition and 1 client finding to fill in each blank in the following sentence

Seizures Blood pressure

A nursing is providing teaching to a client who is scheduled for electroconvulsice therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?

Short-term memory loss

A nurse is reviewing the laboratory report of a client who has end stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider?

Sodium 148 mEq/L (136 to 145 mEq/L)

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 nurse is caring for a client who has cancer and is deciding between two treatment plans. The client ask 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 charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take?

Tell the nurses to stop the discussion.

A nurse caring for a client during a follow up visit at a gastrointestinal clinic.

Temperature: all Weight: Crohn's disease and ulcerative colitis Bowel Pattern: Crohn's disease WBC: all Heart rate: Peritonitis Albumin level: Crohn's disease and ulcerative colitis Abdominal pain: Crohn's disease

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of a child sexual maltreatment?

The child exhibits discomfort while walking

A night shift nurse is giving change of shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the on coming nurse?

The client needs assistance when transferring from the bed to a wheelchair.