Comp

A home health nurse is caring for a client who has type 2 diabetes mellitus. The client reports feeling lightheaded and is experiencing mild hypoglycemia. Which of the following dietary selections the nurse recommend?

2 tbsp of raisins

A nurse is assisting with a community educational program for a group of caregivers about car restraints. Which of the following caregiver statements indicates an understanding of the teaching?

A 12 year old child should place the shoulder lap safety belt low across their hips

A nurse at a local health department is screening clients for the shingles (herpes zoster) vaccine. The nurse should identify that which of the following clients should receive this immunizations

A 52-year-old client Who has a history of childhood chicken pox

A nurse on a mental health unit is reinforcing teaching about client rights to a group of newly licensed nurses. Which of the following statements should the nurse include?

A client can refuse to take prescribed medication

A nurse is caring for a group of clients at a long-term care facility. Which of the following clients should the nurse see first?

A client who was witnessed falling while getting out of bed

A nurse is reinforcing teaching about advance directives with a client. Which of the following client statements indicates an understanding of the teaching?

A living will is a legal document that expresses a client's wishes regarding medical treatment. The living will is used when the client becomes unable to make decisions.

A nurse is caring for a client who has leukemia and had a bone marrow transplant 72 hr ago. The nurse should identify that which of the following increases the client's risk for infection?

A visitor brings the client a bouquet of fresh flowers

A nurse witnesses a client collapse. After establishing that the client is unresponsive and breathless, which of the following actions should the nurse take next?

Activate emergency response team

A nurse is caring for a client who has had a cerebrovascular accident. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Apply barrier cream to the client's sacral area

A nurse is caring for a client who has a new prescription for compression stockings. When assisting the client to apply the stockings, which of the following actions should the nurse take?

Apply the stockings before the client gets out of bed in the morning

A nurse is caring for a postoperative client who is receiving opioid medication via patient-controlled analgesia (PCA) device. The client tells the nurse, "I'm still in so much pain so I don't think this machine is working." Which of the following actions should the nurse take?

Ask the client to demonstration his they have been using the PCA device

A nurse is providing care to a client who had a barium swallow 24 hours ago. The client reports that they have not had a bowel movement since the study was completed. Which of the following actions should the nurse take first?

Auscultate the client's abdomen for bowel sounds

A nurse is reinforcing discharge teaching with the guardian of a school-age child following a cardiac catheterization. Which of the following instructions should the nurse include?

Avoid giving your child tub baths for the next 3 days

A nurse is reinforcing dietary teaching with a client who has iron deficiency anemia. Which of the following food items should the nurse recommend?

Beef liver

A nurse is collecting data from a client who is at 36 weeks of gestation and is having contractions. Which of the following findings should the nurse identify as an indication of placental abruption?

Board-like abdomen

A nurse is reinforcing teaching with a client who has a new prescription for propranolol. Which of the following adverse effects should the nurse include in the teaching?

Bradycardia

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease and suddenly becomes aggressive. Which of the following actions should the nurse take first?

Call additional staff for assistance

A nurse is caring for a client who is receiving continuous IV fluids. The alarm on the IV pump begins to sound. Which of the following actions should the nurse take?

Check the tubing for kinks or obstructions

A nurse is caring for a 5-year-old child whose guardian reports that the child has been stuttering for the past 4 months. Which of the following statements should the nurse make?

Children who have persistent stuttering should see a speech therapist

A nurse is caring for a client who has hepatitis A. The nurse should recognize that hepatitis A can be transmitted through which of the following methods?

Contaminated food

A charge nurse is assigning tasks to a licensed practical nurse (LPN). Which of the following tasks should the charge nurse identify as outside the scope of practice for an LPN?

Develop a plan of care for a client who requires bladder training

A nurse is providing care for a client who has major depressive disorder. Which of the following should the nurse expect?

Difficulty making simple decisions

A nurse is reinforcing discharge teaching for a client who has a new prescription for Home oxygen therapy. Which of the following statements should the nurse make?

Do not allow smoking in your home

A nurse is reinforcing teaching with a client who is scheduled to have a mammogram. Which of the following statements should the nurse include?

Do not use deodorant prior to the test

A nurse is assisting with the admission of a client who had bacterial meningitis. Which of the following transmission precautions should the nurse implement?

Droplet precautions

Nurse is reviewing the health record of a female client. The nurse should recognize that which of the following factors in the clients medical history places them at an increased risk for developing breast cancer?

Early menarche

A nurse is reviewing the medical record of a client who has alcohol use disorder. Which of the following laboratory results of the nurse expect?

Elevated activated partial thromboplastin time (aPTT)

A nurse is reinforcing discharge teaching with a client who has a T-tube following a cholecystectomy. Which of the following instructions should the nurse include in the teaching?

Empty the drainage bag each day at the same time

A nurse is caring for a client who has schizophrenia and reports hearing voices that others cannot hear. Which of the following actions should the nurse take?

Encourage the client to focus on activities in the present

A nurse is preparing a client for a knee arthroplasty. The client tells the nurse, " i'm so anxious about the surgery." Which of the following strategies could the nurse implement to help decrease the clients anxiety?

Encourage the client to talk about concerns related to the procedure

A nurse is observing an assistive personnel (AP) feed a client who has left-sided weakness and dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Encouraging the client to place their chin to the chest before swallowing

A nurse is caring for a client who has epilepsy and has been experiencing seizure activity. Which of the following actions should the nurse take?

Ensure that suction equipment is available at the clients bedside

A charge nurse in a long term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first?

Give the AP's assignment to a coworker

A nurse is reinforcing teaching with the parent of a toddler who has acute otitis media. Which of the following instructions should the nurse include?

Give your child acetaminophen for discomfort

Nurse is caring for a client who is postoperative following a lumbar disco Tony and is having difficulty voiding. The nurse should identify that which of the following prescribed medications increases the client's risk for urinary retention?

Hydromorphone

A nurse is collecting data from a client who is taking digoxin for heart failure. Which of the following findings should the nurse identify as increasing the client's risk for developing dysrhythmias?

Hypokalemia

Nurse is caring for a client who is struggling to breastfeed their newborn. The client tells the nurse, " i'm embarrassed that I can't breastfeed my baby because I feel like it means I'm a bad mother." Which of the following responses should the nurse make?

I can make arrangements for a breast-feeding specialist to visit with you

A nurse is reinforcing teaching with an assistive personnel (AP) about caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a wound. Which of the following statements by the AP indicates an understanding of the teaching?

I should apply personal protective equipment before entering the client's room

A nurse is discussing the use of epidural analgesia with a newly licensed practical nurse LPN. Which of the following statements by the newly licensed nurse indicates an understanding of this method of pain control?

I should report leaking at the insertion site to the anesthesiologist

The nurse is reinforcing teaching with a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates an understanding of the teaching?

I shouldn't add salt to my food

A nurse is reinforcing teaching with a client who has cancer and a new prescription for fentanyl transdermal patches. Which of the following statements by the client indicates an understanding of the teaching?

I will fold the patch with the adhesive sides inward before discarding it

A nurse is reinforcing teaching with the guardian of a school-age child who has cystic fibrosis. Which of the following guardian statements indicates an understanding of the teaching?

I will give my child their enzymes whenever they eat a meal or a snack

A nurse is reinforcing discharge teaching about safety precautions with a client who is recovering from a stroke. Which of the following client statements indicates an understanding of the teaching?

I will have grab bars installed in my bathroom

A home health nurse is reinforcing teaching about food safety with a client who has gastroenteritis. Which of the following statements by the client indicates an understanding of the teaching?

I will wash tomatoes before putting them in a salad

A nurse is reinforcing teaching with the parent of a newborn about physical assessments. Which of the following statements by the parent demonstrates an understanding of the newborn hearing screening test?

If my baby fails the hearing test, there will need to be retesting as a part of follow-up care

A nurse is caring for a newly admitted client who has posttraumatic stress disorder PTSD. The client appears withdrawn and reports feelings of worthlessness and increased alcohol use. Which of the following actions should the nurse take first?

Initiate continuous observation of the client

A nurse is contributing to the plan of care for a client who needs nasopharyngeal suctioning for pulmonary secretions. Which of the following interventions should the nurse include in the plan of care for this procedure?

Insert the catheter when the client inhales

A nurse is caring for a client who has a new prescription for amitriptyline. After 1 week, The client calls a providers office and states, I'm not taking these pills anymore. They aren't doing anything. Which of the following responses should the nurse make?

It can take a few weeks before you feel a difference when taking this medication

A nurse is facilitating a support group discussion for a group of clients. The nurse notes that one of the clients is monopolizing the conversation, which is preventing the other clients from participating. Which of the following statements should the nurse make?

Let's speak privately about your concerns after the session

A nurse is reinforcing teaching about long-term prednisone therapy with a client who has rheumatoid arthritis. Which of the following statements should the nurse include?

Long-term use of this medication can result in the development of gastric ulcers

A nurse on a medical surgical unit is providing care for four clients. For which of the following scheduled procedures should the nurse check the client's medical record to verify that there is a completed informed consent document?

Lumbar puncture

A nurse is contributing to the plan of care for a client who is receiving continuous enteral feedings via a nasogastric tube. Which of the following interventions should the nurse include in the plan?

Measure the pH of gastric aspirate prior to administering feeding

A nurse in an urgent care clinic is collecting data from a client who is exhibiting agitation, paranoia, and visual hallucinations after ingesting an unknown substance. The nurse should identify that the client is likely experiencing intoxication from which of the following substances?

Methamphetamines

A home health nurse is collecting data from a client who has generalized anxiety disorder. Which of the following statements by the client's partner is the priority for the nurse to investigate further?

My partner's prescription isn't generic, so we can't afford it anymore

A nurse is collecting client data from an older adult client. Which of the following client statements should the nurse recognize as a possible indication of elder abuse?

My son puts my retirement checks in his bank account and provides me with an allowance

A nurse is contributing to a client's plan of care. Which of the following actions should the nurse include?

Note the time that each intervention should be performed

A nurse is assisting with the care of a client who had an open reduction with internal fixation of the ankle. The nurse notes that the affected extremity is cool with a weak pulse. Which of the following actions should the nurse take first?

Notify the registered nurse

A nurse is caring for a client who has Parkinson's disease. The client reports tremors and has difficulty getting food from the plate to their mouth. Which of the following referrals should the nurse recommend?

Occupational therapist

A nurse is reinforcing dietary teaching with the parent of a three-year-old toddler at a well child visit. Which of the following instructions should the nurse include?

Offer your child 3 cups of low-fat milk each day

A home health nurse is reinforcing teaching with a client who has active tuberculosis (TB). Which of the following statements should the nurse make?

People who live with you do not need to wear masks in the home

A nurse is assisting in the plan of care for a client who has a nasogastric sump tube attached to suction for gastric decompression. Which of the following interventions should the nurse include in the plan of care?

Position the blue air vent above the level of the client's stomach

A nurse is caring for a client who reports 12 liquid stools in the past 8 hours. Which of the following findings should the nurse expect?

Potassium level 2.5 mEq/L

A nurse in a long-term care facility is caring for an older adult client who reports taking over-the-counter pseudoephedrine for nasal congestion. For which of the following adverse effects should the nurse monitor?

Prolonged QT interval

A nurse is caring for a client who has a terminal diagnosis. The nurse should identify that which of the following interventions will assist the client to make decisions related to end of life care?

Providing information about nutrition management options if the client becomes unable to tolerate oral intake

A nurse is preparing to remove intermittent sutures from a client's incision. Which of the following actions should the nurse take?

Pull from the opposite side of the suture after clipping it

A nurse is caring for a client who has a respiratory infection and a temperature of 39.6°C (103.3°F). Which of the following actions should the nurse take?

Remove the client's blanket

A nurse is reinforcing teaching with the parents of a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following instructions should the nurse include?

Remove the newborn's eye mask for the duration of feeding time

A nurse is caring for a preschooler who has a spiral fracture. The preschooler's parent tells the nurse that the injury occurred a couple of days ago. Which of the following actions should the nurse take?

Report suspected maltreatment of the preschooler too local authorities

A nurse is caring for a client who is on bed rest and has reddened area on the coccyx. Which of the following action should the nurse take to help prevent further skin breakdown?

Reposition the client at least every 2 hours

A nurse in an urgent care clinic is collecting data from an adolescent who has a spiral fracture of the arm. The clients Guardian refuses to allow the adolescent to answer the questions. Which of the following actions should the nurse take?

Request that the guardian go to the waiting room

A nurse is caring for a client who has bowel obstruction and who has an NG tube placed and connected to a wall section. Which of the following actions should the nurse to take?

Secure the NG tubing to the client's gown

A nurse in a long-term care facility is discussing stool specimen collection techniques with a group of assistive personnel (AP). Which of the following instruction should be included in the discussion?

Send a 3-cm (1-in) section of former stool to the laboratory

A nurse is reinforcing discharge teaching with a client following cataract surgery. Which of the following instructions should the nurse include in the teaching?

Sleep on the non operative side for 2 weeks

A nurse is caring for a client who has vision loss. Which of the following strategies should the nurse plan to use while caring for the client?

Stand just ahead of the client and offer an arm for guidance during ambulation

A nurse in a pediatric clinic receives an urgent phone call from a parent who states, "My child just drank a full bottle of liquid acetaminophen. What should I do?" Which of the following responses should the nurse make?

Take your child to the emergency department immediately

A nurse is caring for a client who is postoperative following a thyroidectomy reports frequent leg cramps which of the following actions should the nurse take?

Tap over the facial nerve to observe for twitching

A nurse is observing an assistive personnel (AP) perform blood glucose monitoring for a client. Which of the following actions by the AP requires intervention by the nurse?

The AP uses the first drop of client's blood as the sample

A nurse is observing an assistive personnel (AP) caring for assigned clients. Which of the following actions by the AP should the nurse identify as assault?

The AP yells obscenities and threatens to restrain a client who is agitated

A nurse is reinforcing teaching about self-administration of insulin with a client who has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching?

The abdomen is the recommended injection site for fastest absorption

A nurse is caring for a client who has an NG tube for gastric decompression. Which of the following data should the nurse recognize as an indication that the NG tube is in the correct position?

The aspirated tube contents have a pH of 4.0

A nurse is caring for a client who has chronic venous insufficiency. For which of the following client behaviors should the nurse intervene?

The client is sitting with her legs crossed

A nurse is caring for a client who has a prescription for an intramuscular injection of vitamin B12. Which of the following should the nurse identify as a contraindication for the administration of this medication?

The client is taking warfarin PO

A nurse is collecting data from a client who was treated with oxycodone for acute pain 1 hr ago. Which of the following data should the nurse recognize as the most reliable indication that the medication has been effective?

The client reports a lower number on a numeric pain scale of 0 to 10

A nurse working at a local health department is preparing to administer the human papilloma virus (HPV) vaccine to a client. Which of the following should the nurse identify as a contraindication for administering the vaccine?

The client reports being 4 months pregnant

A nurse is assisting in the care of a client who is at 20 weeks so just station. Which of the following findings should the nurse identify as a potential complication of pregnancy?

The client reports daily headaches

A nurse is collecting data from a client who is 24 hr postoperative following an open colon resection. The client has a clamped NG tune and a new prescription to begin a clear liquid diet. Which of the following findings should the nurse report to the provider?

The client reports vomiting green-tinged fluid

A nurse is reinforcing teaching with an adolescent client. Which of the following factors should the nurse identify as a barrier to learning?

The client speaks a different primary language than the nurse

A nurse is assisting with the care of a client who had an unwitnessed fall. Which of the following should the nurse document in the client's medical record?

The client's mental status

A nurse is caring for a 16-year-old client who was recently diagnosed with syphilis. The client expresses concern about keeping their diagnosis private. Which of the following statements should the nurse make?

The health department will be notified of this infection

A nurse collecting data from 2-week-old infant. Which of the following findings should the nurse expect?

The infant turns their head towards the right when their right cheek is stroked

A nurse is observing a newly licensed nurse assist a client who has dysphagia to eat. Which of the following actions by the newly licensed nurse required intervention by the nurse?

The newly licensed nurse provides liquids to the client using a straw

A nurse is collecting the health history for a client. Which of the following findings should the nurse identify as a risk factor for a cerebrovascular accident (CVA)?

Total cholesterol 250 mg/dL

A nurse is assessing a client who received a dose of amoxicillin 1 hr ago. Which of the following findings should the nurse identify as a potential adverse effect of the medication?

Urticaria

A nurse at a college health fair is reinforcing teaching about skin cancer prevention. Which of the following instructions should the nurse include?

Use a sunscreen with a sun protective factor of at least 15

A nurse is preparing to administer a prescribed Schedule II opioid to a client for pain management. Which of the following actions should the nurse take first?

Verify the medication and dosage on the medication administration record

A nurse is reinforcing teaching about growth and development with the guardians of a preschooler. Which of the following statements should the nurse make?

You should provide 1 hour of physical activity for your child each day

A nurse is reinforcing teaching with a client who has influenza. Which of the following statements should the nurse include in the teaching?

You should wash your hands before coming in contact with other people

A nurse is reinforcing teaching for a client who is scheduled to have a liver biopsy. Which of the following statements should the nurse include?

You will be lying on your right side immediately following the procedure

A nurse is preparing to witness a client's signature on an informed consent document. Which of the following statements should the nurse make?

Your signature indicates that you are aware of the risks associated with the procedure