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A nurse is performing a skin assessment for a client who expresses concern about skin cancer which of the following findings should the nurse identify as a potential indication of skin malignancy

A mole with an asymmetrical appearance

A nurse is providing discharge teaching to a client about self administering heparin which of the following instructions should the nurse include in the teaching

Administer the medication into the abdomen

A nurse is caring for a client who has COPD select three findings that require a follow up

Breath sounds, oxygen saturation, temperature

A nurse is admitting a client who is having an exacerbation of heart failure. in Planning this clients care where should the nurse initiate discharge planning

During the admission process

a nurse is assessing for adult clients which of the following physical assessment techniques should the nurse use

Ensure the bladder of the blood pressure cuffs around 80% of the clients arm

A nurse is reviewing a clients fluid and electrolyte status which of the following findings should the nurse report to the provider

Potassium 5.4 meq/L

A nurse is preparing a change of shift report which of the following tools or documents should the nurse use to communicate continue to healthcare

SBAR

A nurse is caring for a client who has a terminal illness and is approaching death the client and short of breath and has noisy respirations from secretions in the airway which of the following actions should the nurse take

Turn the client every two hours

A nurse is admitting a client to a healthcare facility the nurse is placing the client on isolation precautions which of the following interventions should the nurse include

Where in N 95 masks, place a container for solar linens, please decline in a negative airflow Road, remove mask after exiting

a nurse is caring for a client who is receiving a unit of packed RBCs

allergic reaction, itching

A nurse is admitting a new client which of the following actions should the nurse take while performing medication reconciliation

compare the client's home medications with the provider's prescriptions

A nurse is caring for a client who has pneumonia The nurse should identify that the client might be experiencing_as evidenced by the client_

extravasation,iv cath

A nurse on a medical surgical unit is caring for a client who has a new prescription for a wrist restraints which of the following actions should the nurse take

pad a client's rest before applying the restraints

a nurse is assessing an older client's risk for falls. which of the following assessments should the nurse use to identify the clients safety needs

pupil clarity visual acuity visual fields

A nurse is caring for a client who ask about the purpose of advance directives which of the following statements should the nurse make

they indicate the form of treatment a client is willing to accept in the event of a serious illness

A nurse is caring for a client who has dementia which of the following intervention should the nurse take to minimize the risk of injury to the client

use bed alarm system

A nurse is teaching a client and his family how to care for the clients tracheostomy at home which of the following instructions should the nurse include in the teaching

use tracheostomy covers when outdoors

A nurse is providing discharge instructions to a client who will be using a walker which of the following client statements indicates an understanding of the teaching

"I will hire someone to trim the tree that hangs low over the stairs of my front porch."

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses which of the following statements should the nurse manager plan to include in the teaching

"Use the complete name of the medication magnesium sulfate."

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the clients body 4. ask the clients family members if they would like to view the body 5. place a name tag on the body

a nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over seven hours he nurse should set the infusion pump to deliver how many milliliters per hour

107

A nurse is preparing an education program for staff about advocacy which of the following information should the nurse include

Advocacy ensures clients' safety, health, and rights.

a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include

Advocacy ensures clients' safety, health, and rights.

Show a nurse is caring for a client who is receiving a unit of packed RBCs the client has manifestations of_as evidenced by the clients_

Allergic reaction, itching

A nurse is preparing to administer an injection of an opioid medication to a client the nurse draws out 1 mL of the medication from a 2 mL vial which of the following actions should the nurse take

Ask another nurse to observe the medication wastage.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is administering 1 L of 0.9% sodium chloride to a patient who is postoperative and has fluid volume deficit which of the following changes should the nurse identify as an indication that the treatment was successful

Decreasing heart rate

A nurse is caring for a client who has pancreatitis select the three task the nurse to delegate to an assistive personnel

Document vital signs, measure clients intake and output, transfer the client from wheelchair to bed

A nurse is caring for a client who requires an NG tube for stomach decompression which of the following actions should the nurse take when inserting the NG tube

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

A nurse is caring for a client who has an aggressive form of prostate cancer they provide her briefly discuss this treatment options and leaves the clients room when the nurse asked if the client would like to discuss any concerns the client declines which of the following statements should the nurse make

I am available to talk if you should change your mind

A client who is postoperative is verbalizing pain as a two on a pain scale of 0 to 10 which of the following statements are the nurse identify as an indication that the client understands the preoperative teaching she received about pain medication

It might help to listen to music while I'm lying in bed

A nurse is taking with an older adult client who is complementing retirement money the current states I keep thinking about how Much I enjoy my job I'm not sure I want to retire which of the following responses should the nurse take

Let's talk about how the change in your job status will affect you

A nurse is initiating a protective environment for a client who has had an allergenic stem cell transplant. Which of the following precautions should the nurse plan for the client

Make sure the client wears a mask went outside her room if there is construction in the area

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical surgical unit listen to the audio clip of what the nurse auscultates through the stethoscope and identify breath sound

Normal breath sounds

A nurse is caring for a client who has a new diagnosis of seizure disorder The nurse should first address to clients_followed by the clients_

Physical safety, positioning

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer which of the following actions should the nurse take

Reassure the client that this is an expected response to grief.

A nurse is talking with a partner of a client who has dementia clients partner expresses frustration about finding time to manage household responsibilities while caring for their partner the nurse should identify that the partner is experiencing which of the following types of real performance stress

Roll overload

A nurse is lifting her bedside cabinet to move it closer to the client who is sitting in a chair to prevent self injury which of the following actions should the nurse take when lifting this object

Stand close to the cabinet when lifting

A nurse is caring for a client who is postoperative following abdominal surgery click to highlight the assessment findings below that the nurse should report to the provider

Urinary output, reported pain level, vital signs

A nurse is planning strategies to manage time effectively for a client care which of the following strategies should the nurse implement

Use the planning step of the nursing process to prioritize client care delivery.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living wheel the client ask what would happen if I arrived at the gym or emergency department and I had difficulty breathing which of the following responses should the nurse make

We will give you oxygen through a tube in your nose

A nurse is preparing to administer enoxaparin subcutaneously to a client which of the following actions should the nurse take

administer the medication with the needle at a 45 degree angle

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which of The following types of transmission precautions should the nurse initiate

contact precautions

A nurse is caring for a client who is post operative and refuses to use an incentive spirometer following major abdominal surgery which of the following actions is the nurses priority

determine the reasons why the client is refusing to use the device

a nurse is caring for a client who has pharyngeal diphtheria. which of the following types of transmission precautions should nurse initiate

droplet

A nurse in a providers clinic is caring for a client who has diarrhea. select instructions that the nurse should include in the teaching

eat probiotic foods, avoid alcohol, avoid caffeine, follow a low carb diet

A nurse is caring for a client who has a terminal illness and is at the end of life the nurse should recognize that which of the following statement by the client's partner indicates effective coping

i am relying on support from our family during this time

a nurse is providing discharge instructions to a client who will use a walker. which of the following client statements indicates an understanding of the teaching.

i will hire someone to trim the trees hanging from my front porch

A nurse is assessing a client who reports increased pain following physical therapy which of the following questions should the nurse ask when assessing the quality of the patient's pain

is your pain sharp or dull

A nurse and a provider's office is assessing the deep tendon reflexes of a client which of the following images should the nurse identify as indicating the correct technique for eliciting the clients patellar reflex

knee photo

a nurse using an open irrigation technique to irrigate a clients indwelling urinary catheter which of the following actions should the nurse take

subtract the amount of irrigant used from the clients urine output

a nurse is Caring for a client who has herpes zoster and ask the nurse about the use of complementary and alternative therapies for pain control the nurse should inform the client at this condition is a contraindication for which of the following therapies

Acupuncture

A nurse is preparing to apply addressing for a client who has a stage two pressure injury which of the following types of dressing should the nurse use

Hydrocolloid

A nurse in a providers clinic is caring for a client who has heart failure a nurse is evaluating teaching for a client who has heart failure which of the following through statement by the client indicates an understanding of the teaching

Limiting my sodium intake to 2 g, if you were potato chips, I know to call my doctor if I gained 3 pounds

a nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh length sequential compression sleeves. which of the following actions should the nurse take

Make sure two fingers can fit under the sleeves.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock the nurse notifies the surgeon who tells the nurse to continue to measure the clients vital signs every 15 minutes into report back in one hour which of the following actions should the nurse take next

Notify the nursing manager

A nurse in a providers clinic is caring for a client who has diarrhea the nurse is providing teaching for a client who has diarrhea select the floor instructions the nurse should include in teaching

Probiotic foods, avoid alcohol, avoid caffeine, low fiber diet

A nurse in an emergency department is caring for a client complete the following sentence by using a list of options The nurse shit first_followed by_

Review medication's that might cause confusion, using other methods to get the client safe

Nurse is caring for a client who has a peripheral IV inserted for fluid replacement the nurse is assessing a client which of the following actions should the nurse take

Stop the IV infusion, evaluate the clients left arm, apply heat to the clients left hand

A nurse is evaluating a clients use of a cane which of the following actions should the nurse identify as an indication of correct use

The client holds the cane on the stronger side of her body.

A nurse is performing a home health assessment for a client who is receiving supplemental oxygen which of the following observations should the nurse identify as proper safety protocol

The client identifies the location of a fire extinguisher

a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should nurse take

examine personal values about the issue

a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notified the surgeon who notified the nurse to continue measuring the clients vital signs every 15 minutes and to report back in 1 hr.

notify the nursing manager

a nurse is reviewing evidence based practice principles about administering oxygen therapy with a newly licensed nurse

regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min