Version 1

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?

Monitor fetal heart tones.

The nurse is assessing a client with thigh high antiembolism stockings. Assessment findings include redness, swelling, and pain in the left calf. What is the priority action by the nurse?

Notify the healthcare provider.

Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?

Offer the client nutritious finger foods.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

Report the incident to risk management.

The nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. Which statement would indicate that the client has understood the instructions?

"I will avoid lying down after a meal."

While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response?

"I'm sorry, I can't disclose client information."

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse?

"If a wound heals on the surface but infection remains, it will open and drain."

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

"What does the pain feel like?"

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting

15 g of a simple carbohydrate.

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following?

A referral.

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?

Administer an analgesic.

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." What should the nurse do?

Allow the client to see and hold the baby for as long as she desires.

Which situation demonstrates correct principles of confidentiality?

An emergency department nurse reports suspected child abuse.

A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.

A client with an uncomplicated term pregnancy arrives at the labor- and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action?

Ask what time this happened and note the color, amount, and odor of the fluid.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit.

A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse?

Collaborate with the interprofessional team to make a referral to social services.

After an intravenous pyelogram (IVP), the nurse should include which measure in the client's plan of care?

Encourage adequate fluid intake.

The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client?

Enlist the help of a hospital interpreter; ask the son to translate if none is readily available.

Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make?

Evaluate the client for voluntary admission to a mental health facility.

A nurse is preparing to administer an I.V. containing dextrose 10% in 1⁄4 normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?

I.V. tubing with a volume-control chamber

A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene?

Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction.

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse?

Instruct the client to go to an emergency room for an urgent assessment.

The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the familyis most important to include in the plan of care?

Involve the client in usual at-home activities.

A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should the nurse take? Select all that apply.

Label the vial with the strength of the medication. Store the multi-dose vial in a secure place. Initial the vial as the person reconstituting the medication.

What should the nurse do when the client with a diagnosis of schizophrenia walks into group naked?

Lead the client to his room and help him dress if he needs assistance.

Bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, what should the nurse recommend to the client?

Maintain a regular program of weight-bearing exercise.

The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used.

Review medical record and medical orders for graduated compression stockings. Identify the client and explain procedure. Place the client in supine position. Apply powder or lotion to legs. Turn the stocking inside out and ease the stocking over the foot and heel. Smoothly pull the stocking over the ankle and calf.

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations?

Review nationally published immunization guidelines.

A client with depression states, "I'm still feeling nauseous after I take venlafaxine. Maybe I need something else." What should the nurse should tell the client to do?

Take the medication at mealtime.

A grandson calls the crisis center expressing concern about his grandmother, who lost her husband a month ago. He states, "She's been in bed for a week and is not eating or showering. She told me that she didn't want to kill herself, but it's not like her to do nothing for herself. She won't even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which reason?

The behaviors may reflect passive suicidal thoughts.

The parent asks the nurse about a 9-year-old child's apparent need for between-meal snacks, especially after school. What information should the nurse include in the teaching plan?

The child should help with preparing the snacks.

A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine 75 mg three times a day and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse should make which judgment about the client?

The depression is improving, and the suicidal ideation is lessening.

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?

The mother can bring the daughter any foods that she desires.

A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my computer at work all day?" Which over-the-counter medicine does the nurse consider to be safest for occasional use by a pregnant client with no known risks?

acetaminophen

Which mediation can the nurse administer through a nasogastric (NG) tube?

acetaminophen

A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate:

aggression.

The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the health care provider as an indication that the client has low cardiac output?

altered level of consciousness and thready pulse

After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel?

an 8-month-old with pneumonia who will be discharged today

A physician orders digoxin elixir for a client with heart failure. Immediately before administering this drug, the nurse must check the client's

apical pulse.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?

assessing present voiding patterns

In which maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior (LOA) position?

below the umbilicus on the left side

A client has been prescribed corticosteroids. The nurse would also anticipate an order for

blood glucose checks every 6 hours.

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?

cool, pale fingers

When caring for a client receiving haloperidol, the nurse should assess for which problem?

extrapyramidal symptoms

A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This action is an example of:

false imprisonment.

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on how much time the client spends in bed during the day.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

granulocytopenia

A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?

in the supine, sitting, and standing positions

A nurse is working on a surgical floor. The nurse must logroll a client following a

laminectomy.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution

For a client with Graves' disease, which nursing intervention promotes comfort?

maintaining room temperature in the low-normal range

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance?

metabolic alkalosis

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to

rest in an air-conditioned room.

A client has been diagnosed with metabolic alkalosis. The nurse should anticipate what finding from the client's arterial blood gases?

serum bicarbonate of 28 mEq/L

A client tells the nurse that she doesn't have funds to buy diapers and formula. The nurse should refer this client to a

social worker.

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should

take measures to ensure privacy during the counselor's visit.

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?

talking with the nurse

Which of the following clients should the nurse assess first?

the client who is a child with stridor and nasal flaring

The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is:

washing the hands frequently.

A client with diabetes is taking insulin lispro injections. At what time should the nurse advise the client to eat?

within 10 to 15 minutes after the injection.

Which finding is normal for a client during the icteric phase of hepatitis A?

yellowed sclera

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate?

"Gradually eliminate one feeding at a time."

A client with posttraumatic stress disorder states, "You don't know what I've been through. What can you do?" The nurse should respond

"I haven't been through what you have, but I'll be better able to understand if you tell me more about it."

A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client:

"It's frightening to have new people on the unit. We're here to talk about things like being afraid."

A client, with heart failure, is receiving furosemide, 40 mg IV. The provider orders 40 mEq of potassium chloride in 100 ml of dextrose 5% in water, to infuse over four hours. The client's most recent serum potassium level is 3.0 mEq/L. At which infusion rate should the nurse set the IV pump? Record your answer using a whole number.

25

A postpartum multiparous client diagnosed with endometritis is to receive intravenous antibiotic therapy with ampicillin. Before administering this drug, the nurse must take which action?

Ask the client if she has any drug allergies.

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first?

Discuss the breach of practice with the physician.

Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next:

Discuss the situation and possible courses of action with the dietitian and the client.

When developing the preoperative teaching plan for a 14- month-old child with an undescended testis who is scheduled to have surgery, which methodis most appropriate?

Explain to the parents how the defect will be corrected.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first?

Institute droplet precautions

Which client should the nurse assess first?

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency

Which of the following observations by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough

A well-known public official of a small community is admitted to the emergency department following an episode of chest pain. Several nurses from the medical unit are aware of the admission and access the official's electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation?

"Assessing the official's medical record is a breach of confidentiality."

The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could they do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder?

"Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety."

A nurse is teaching a pregnant client how to distinguish false labor contractions from true labor contractions. Which statement by the client indicates an understanding of this concept?

"False labor contractions are usually felt in the abdomen."

The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence?

"How safe do you feel in your home?"

Which client statement indicates an understanding of the risk of alcohol relapse?

"Stopping support groups and not expressing feelings can lead to relapse."

A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?

"Take a warm tub bath or shower before exercising. This may help with your discomfort."

A client comes to the clinic for evaluation. The client tells the nurse, "I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor." The client hands the nurse a printout of what the client found. Which response by the nurse would be mostappropriate?

"Tell me more about where you found this information that you gave me."

The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate?

"Tell me what you've found in your reading that's leading you to that conclusion."

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours."

A nurse is conducting an educational program about advanced directives for a group of adults at a local community center. The nurse explains what the directives entail and how they are used. After explaining this topic, the nurse determines that the teaching was successful based on which statement by the group?

"The document allows us to choose what we want to have happen."

A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client

"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain."

A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is thenurse's best response?

"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed."

The laboratory comes to draw an Hgb AIc. The client asks the nurse what this test represents. Which statement would be correct?

"This test reflects the average blood glucose over a period of approximately 2-3 months."

During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?

"This test will screen for spina bifida, Down syndrome, or other genetic defects."

A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse?

"What activities did you enjoy in the past?"

A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status?

"What did your child eat for breakfast?"

A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse's best response?

"Yes, a spacer is recommended because it increases the amount of medication that is delivered to the lungs."

A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response?

"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?

"You may experience progressive deterioration in all voluntary muscles."

A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next?

Administer the acetaminophen with codeine.

A 2-year-old is being seen in the outpatient department for a minor injury. The nurse places the child on the examining table, and the child begins to scream and cry. No attempts to comfort the toddler are effective. Which is the nurse's best action?

Allow the parents to hold the child in their lap for the assessment.

The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client?

Apply firm pressure on the site for 5 minutes after removal.

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priorityintervention?

Ask for additional information from the client.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

What is the priority nursing intervention in the postictal phase of a seizure?

Assess the client's breathing pattern.

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy.

A client with Parkinson's disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?

Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment.

The nurse is caring for a client with type 2 diabetes who has been admitted with hyperglycemia. What is the most important consideration when developing a teaching plan for this client?

Assess what the client already knows, then identify learning needs.

A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks' gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do?

Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?

Client's level of consciousness

A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation?

Contact the surgeon to explain that the client needs further clarification regarding surgery.

A client has several patches of vesicles over both arms. Which care should the nurse provide to this client?

Cover the draining areas with sterile gauze.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital?

Decrease the client's feelings of isolation and loneliness.

The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next?

Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.

A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is from a conservative faith and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. What should the nurse do?

Explore his or her own feelings about the issues of anencephaly and organ donation.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby?

Express a small amount of breast milk.

A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next?

Instruct the client to use a pant-blow pattern of breathing.

The nurse is teaching an adolescent how to self-administer insulin. Which of the following is a priority for the nurse to emphasize about insulin administration?

Insulin injections are administered in subcutaneous tissue.

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse's priority intervention?

Place the client on her left side and apply oxygen.

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What should the nurse do next?

Place the infant skin to skin with the mother.

A school-age client with diabetes is placed on an intermediate- acting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do?

Prevent late night hypoglycemia.

A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents?

Protect your child from infections because his resistance to infection is decreased

The team leader has noticed a sharp increase in medication errors associated with IV antibiotic administration over the last 2 months. The group that could offer resources for tracking medication errors and improving care outcomes is the:

Quality Improvement and Risk Management Department.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first?

The client admitted after a head injury in a motor vehicle who reports nausea

A client on the adolescent psychiatric unit was admitted with a diagnosis of body dysmorphic disorder. The client has not been able to attend school or their part-time work over the past year as a result of certain body obsessions. Recently, the client shaved the hair all over their body, claiming, "It is all growing weird." What component of therapy would be most important for the nurse to apply to this client?

The client's body image is real to the client.

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing.

An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written which prescription for taking the metformin before the procedure?

Withhold the metformin.

The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia?

a client with digoxin toxicity

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?

a middle-aged man with no injuries who has rapid respirations and coughs

A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client that if the medication isn't taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse's statement?

assault

When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?

assessing the vital signs and oxygen saturation levels

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?

chicken and orange slices

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by the abusers?

coercion as a result of the trusting relationship

A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should

collect the specimen in a sterile container.

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy?

cough and shortness of breath

The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory finding should the nurse report to the surgeon and anesthesiologist?

creatinine, 2.6 mg/dL (230 μmol/L)

Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?

daily weight

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to

distribute weight away from the involved side.

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

dyspnea, tachycardia, and pallor

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

elevated ST segment

A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?

extravasation

The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan? The client:

has a known history of sexually transmitted disease.

While taking an admission history, a client tells a nurse that they were a former IV drug abuser. Which test wouldbe most important for this client to undergo?

hepatitis C virus test

Which nifedipine-related side effect should the nurse be most concerned with when caring for a new stroke admission?

hypotension

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS?

identifying who will be responsible for making client care decisions

A client has been taking fluoxetine, 40 mg daily at 0900 for 1 week. The client states he feels nervous and has had diarrhea. What interpretation does the nurse make about the client's symptoms?

important, probably suggesting a decrease in dosage or change to another medication

After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom?

inability to extend the fingers on the right hand

A client rates the pain level of a migraine an 8 on a scale of 1-10. How would the nurse administer the medication to give the client the quickest relief?

intravenous (IV)

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

lung auscultation and measurement of vital capacity and tidal volume

The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP:

massages the client's legs.

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it

may induce bronchospasm

A medication nurse is preparing to administer 0900 medications to a client with liver cancer. Which consideration is the nurse's highest priority?

metabolism of the medication

A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is:

monitoring the blood glucose level closely.

A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care?

offering support by reviewing the short-pant form of breathing

A 44-year-old client has been experiencing spotting, nausea, vomiting, and fatigue. A positive pregnancy test and an ultrasound confirm a 13 week gestation. The client had three prior miscarriages with no term births. What does the nurse recognize as the greatest risk factor for the client at this time?

pregnancy loss

A 2 1/2-year-old child and his 2-month-old sibling are brought to the clinic by their father, who explains that the older child says "no" whenever asked to do something. The nurse should explain that the negativism demonstrated by toddlers is frequently an expression of which characteristic?

pursuit of autonomy

Which nursing intervention is essential in caring for a client with compartment syndrome?

removing all external sources of pressure, such as clothing and jewelry

A nurse is caring for a client who has end-stage chronic obstructive pulmonary disease receiving I.V. push morphine for pain management. During rounds, the nurse discusses with the physician the need to start the client on a continuous morphine infusion. The nurse bases this request on the fact that:

serving as a client advocate is an important role.

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?

to clear secretions from the tubing

A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, whichrationale best explains why a pregnant client would lie on her left side when resting or sleeping in the later stages of pregnancy?

to prevent compression of the vena cava

A client who is paralyzed after a spinal cord injury needs to be transferred to a stretcher. Which assistive device should the nurse use to facilitate this transfer?

transfer board

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

urinary retention

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply.

• Ask all family members, except the client's significant other, to wait outside when she's educating the client. • Use the hospital code for HIV when documenting care.

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? SATA

• Assess the client's skin integrity. • Maintain proper body alignment. • Assess client's neurological function.