Ati

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?A.SodiumB.CalciumC.PotassiumD.Magnesium

sodium

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"Ill wash my hands before I remove the old dressing and again before putting on the new one"

A nurse is talking with a parent of a preschool age child who tells the nurse my child has suddenly become disinterested in certain foods which of the following statements should the nurse make ?

"Keep a diary of the foods your child eats each day "

A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

A 10-month-old infant can pull up to a standing position.

For tuberculosis what contact precautions should be used?

Airborne

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states "It's too late for me to quit". Which of the following actions should the nurse take?

Assist the client in finding local smoke-cessation assistance programs

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term weight loss goal?

Attempt to increase the clients self-motivation

A nurse is preparing to insert an indwelling urinary catheter for a female client. As the catheter is inserted, which of the following instructions should the nurse give the client?

Beardown

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all)

Black beansWhole-grain bread

A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance

C. Depression

A nurse is caring for a client who is unstable and has vital signs measure every 15min by an electronic BP machine. The nurse notices the machine begins to measure the BP at varied intervals and the readings are inconsistent. Which of the following action should the nurse take?

Disconnect the machine and measure the BP manually every 15 min

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique clarifying? A. Now that we have talked about your medications, let's talk about your pain. B. Are you having other symptoms? C. It sounds like your pain is intermittent D. It seems as though you have really had a rough time these past few weeks

C. It sounds like your pain is intermittent

A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?

Discuss the meaning of a common proverb

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer?

Chest the clients vital signs

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching?

Clients who are age 65 or older are reluctant to report pain

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures?

Compare the medical record number and name on the MAR with the client's identification band

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client?

Death is viewed as an interruption of what might have been.

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is communicating with a group pf clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?---

Feedback is provided

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups?

Grains

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab values should the nurse expect for this client?

Hct 55%

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability to cry or speak

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following action should the nurse take?

Insert the tip of the tubing 8 cm (3.1 cm)

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial.

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?

Position the client for drainage of secretions by gravity

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?

Tell me more about how you feel about dying

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in bed during the day

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease.

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?

WBC 15,000 mm3

A nurse is evaluating the development of a group of clients. according to erikson, the developmental task of intimacy vs isolation occurs during which of the following stages of development?

Young adulthood

A nurse is beginning a therapeutic relationship with a client. which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?

assume an open position

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

check the clients pain level

A nurse is preparing to administer a partial dose of prefilled opioid analgesic parenterally to a client. Which actions should nurse take?

record the amount of medication wasted on the controlled substance inventory record

When caring for a client with anorexia and nausea due to cancer treatment, the nurse should prioritize the intervention of

limiting drinking liquids with food