Comprehensive Practice 2023A

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 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 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 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 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 community health nurse is reviewing the medical records for four newly diagnosed clients. the nurse should idenitfy which of the following clients as having a nationally 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 client's 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 (AP)?

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

a nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. the client suddenly becomes restless and reports feeling lightheaded. which of the following actions should the nurse take?

Check the client's oxygen saturation level.

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

Clear objects from the client's walking area.

a nurse is caring for a newborn who has herpes simplex virus (HSV). which of the following isolation precautions should the nurse intiate?

Contact

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 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.

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 assessing a newborn following a vaginal delivery. which of the following findings should the nurse report to the provider?

Nasal flaring

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 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 working on an inpatient mental health unit is caring for a client who is experiencing active suicidal ideations. which of the following interventions should the nurse recommend including in the plan of care to ensure a safe client care environment?

Serve meals with plastic utensils.

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

Short-term memory loss

a nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. which of the following instructions should the nurse include?

Take the medication 15 min before playing sports.

a nurse is reviewing the medical record of a client who has schizophrenia and is scheduled to begin a new prescription for clozapine. which of the following findings should the nurse identify as a contraindication for this client to receive clozapine?

WBC count 2,800/mm3 (5,000 to 10,000/mm3)

a nurse is caring for a client who has a pulmonary embolism. the client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. the morning laboratory values for the client at aPTT 98 seconds and INR 1.8. which of the following actions should the nurse take?

Withhold the heparin infusion.

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

aPTT

a nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. which of the following precautions should the nurse implement?

contact

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 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

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 home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. which of the following statements by the client indicates an understanding of the teaching?

"I will walk for short distances throughout the day."

a nurse is caring for a client who has cancer and is deciding between two treatment plans. the client asks 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 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 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."

The nurse is continuing to care for the adolescent. Which of the following prescriptions should the nurse anticipate from the provider? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent.

Anticipated: Prepare the adolescent for surgery. Remove the splint. Contraindicated: elevating the right leg above heart level, and applying ice to the affected extremity

A nurse on a mental health unit is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Anticipated: initiate suicide precautions. Potassium 40 mEq PO daily. Contraindicated: Fluoxetine 20 mg PO daily. Low-sodium diet.

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 expereince 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 caring for a client who is receiving a transfusion of packed red blood cells (RBCs). The nurse should suspect a transfusion reaction based on which of the following assessment findings? Select all that apply.

Back pain, anxiety, headache

A nurse is caring for a client who has schizophrenia in an inpatient facility. Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Client has involuntary tongue movement and foot tremor. Client reports an increase in urination and had one episode of incontinence. Family noticed increased agitation and delusions.

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 for the client.

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 manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 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 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 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 caring for a client. Complete the following sentence by using the list of options.

The client is exhibiting manifestations of anorexia nervosa and is at risk for arrhythmia.

A nurse is assessing a client who is scheduled for surgery. Click to highlight the assessment findings that the nurse should notify the provider about prior to the procedure.

hemoglobin level, latex allergy, and family history

a nurse manager is preparing to teach a group 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 is 4 hr 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 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 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 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 objects within the line of vision.

a nurse manager is on a planning committee to develop 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 caring for an adolescent. Select the 4 findings that require follow-up.

Pain, capillary refill, skim temp, pedal pulse

a nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. which of the following manifestations should the nurse expect?

strict adherence to routines

a nurse is caring for a client who has a potassium level of 3 mEq/L. for which of the following manifestations should the nurse monitor?

decreased deep tendon reflexes

a nurse is caring for a client who has a 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 teaching the parents of a toddler about snacks. which of the following foods should the nurse recommend?

diced steamed carrots

A nurse is caring for a preschooler on the pediatric unit. After reviewing the assessment findings, which of the following actions should the nurse take? Select the 4 actions the nurse should take.

discontinue the IV medication, administer 0.9% sodium chloride IV, administer epinephrine IM, monitor vital signs frequently

a client who is 24 hour 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 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 caring for a newborn whose parent asks 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 caring for a client during a follow up visit at a gastrointestinal clinic. For each assessment finding, click to specify if the assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis. Each finding may support more than one disease process.

Crohn's diesease: temperature, weight, bowel pattern, WBC, albumin, abdominal pain Ulcerative colitis: temperature, weight, WBC, albumin Peritonitis: temperature, WBC

a nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. which of the following activities is the nurse's priority?

Ensure that the client understands the medication regimen.

The nurse is assessing the adolescent 4 hr following fasciotomy. Click to highlight the findings below that indicate the adolescent's condition is improving.

Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10.

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?

Form a committee of staff members to investigate current staffing issues.

a nurse is caring for a client following vacuum-assisted birth. the nurse should monitor the client for which of the following complications related to vacuum-assisted births?

cervical laceration

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

The nurse should plan to first assess the newborn's respiratory rate, followed by the newborn's heart rate.

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 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 client's medical record?

Time the medication was given

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 decelerations 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 creating a plan of care for a newly admitted child. which of the following actions should the nurse include in the plan?

administer high-dose therapy

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 nurse is assessing a client for compartment syndrome. which of the following findings should the nurse expect?

edema

A nurse is caring for a school-age child. For each assessment finding, click to specify if the finding is consistent with attention deficit hyperactivity disorder (ADHD) or intellectual disability (ID). Each finding may support more than 1 disease process.

ADHD: losing necessary things, interrupting others, intellectual impairment, and hyper reactivity to sensory input. ID: Intellectual impairment, impaired language skills

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 assessing a 2-month-old infant during a well-baby examination. which of the following actions should the nurse take to assess the infant's rooting reflex?

stroke the infants cheek

A nurse is providing phone advice for a client who is pregnant. Complete the following sentence by using the lists of options.

The client is at risk for experiencing metabolic acidosis, due to the client's weight loss.

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?

substernal pain

a nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. the nurse should monitor the client for which of the following adverse effects of PEEP?

tension pneumothorax

A nurse s preparing to administer lactated Ringer's 1,500mL IV to infuse at 50mL/hr. The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

13gtt/min

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 assees first?

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain

a charge nurse is speaking with the partner of a client. the partner states that the client is not receiving adequate care. which of the following actions should the charge nurse take first to resolve the situation?

Ask the partner to list specific concerns.

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.

The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia.

The nurse is continuing to care for the adolescent. The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?

The adolescent's parents have concerns regarding the surgery.

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

The child exhibits discomfort while walking.

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

nystagmus

A nurse is caring for a client in the emergency department (ED). The nurse is planning care for the client. Select the 5 actions the nurse should plan to take.

perform a clinical institute withdrawal assessment for alcohol (CIWA-Ar) initiate seizure precautions administer chlordiazepoxide maintain a low-stimulation environment administer thiamine

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

platelet count hemoglobin

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 assessing a client who has delirium. which of the following manifestations should the nurse expect?

rapid speech

a nurse is caring for a client who has a new prescription of 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 caring for an adolescent. Which of the following actions should the nurse take after the adolescent returns from surgery?

elevating the affected limb at chest level, performing neurovascular assessments every hour, and removing the indwelling urinary catheter when it is no longer indicated

A nurse is caring for a client in the inpatient psychiatric unit. Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

ensure that the client does not have access to sharp objects, provide one-on-one observation, assess the client's method of lethality, observe the client swallow all prescribed medications

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 immunosuppression and a continuous IV infusion. which of the following actions should the nurse take?

monitor the client's mouth every 8 hr

a nurse is providing discharge teaching to a new parent about car 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 teaching the parent of a school-age child administering ear drops. which of the following responses by the parent indicates 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 requests 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 client indicates an understanding of the teaching?

"I will wear a supportive bra overnight."

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 in a clinic receives a call from a guardian whose child has varicella. the guardian asks when the child can return to school. which of the following responses should the nurse make?

"When crusts have formed on every lesion."

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 nurse make?

"You seem to be having a difficult time right now."

a nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. which of the following information should the nurse include?

"You will receive fingersticks for blood glucose testing."

a nurse is providing client teaching about 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 providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? Select all that apply.

"a speech pathologist will be performing a swallowing study for you" "thicken your beverages before drinking" "you should rest before eating a meal"

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

Absence of symptoms

a nurse is preparing to replace a client's transdermal fentanyl patch 72 hr of use. after the nurse opens the packet containing the new puch, the client declines to accept it. which of the following actions should the nurse take?

Ask another nurse to witness the disposal of the new patch.

a nurse is assessing for correct placement of a client's NG feeding tube prior 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 plannign care for a client who has thrombocytopenia. which of the following instructions should the nurse include in the client's plan of care?

Avoid venipunctures when possible.

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 preparing to administer a long-acting insulin to a client who has diabetes mellitus. which of the following actions should the nurse plan to take first?

Check the insulin dose with another licensed nurse.

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 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 home health care nurse is developing a teaching plan for a client who has a new 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 preparing to administer 2 units of fresh frozen plasma to a client. which of the following actions should the nurse plan to take?

Enter the plasma product number into the client's medical record.

a nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. which of the following findings should the nurse report to the provider?

Irritability when being held

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 providing client education to a postpartum client who has decided to bottle feed the newborn. which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement?

Place ice packs on the breasts for 15 min several times per day.

an assistive personnel (AP) and a nurse are turning a client onto the right side. which of the following actions by the AP requires the nurse to intervene?

Places a pillow under the client's right arm

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 manager is assisting with the orientation of a newly licensed nurse. which of the following actions by the nurse requires the nurse manager to intervene?

Tells the hospital chaplain a client's diagnosis

an RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. for which of the following situations should the nurse intervene?

The LPN and the AP grasp the client under their arms to lift him up in bed.

A nurse is caring for a 3-year-old child who has a gastrostomy tube. Drag words from the choices below to fill in each blank in the following sentence.

The child is at risk for developing skin breakdown and an infection.

The nurse is continuing to care for the adolescent. Complete the following sentence by using the lists of options.

The client is at highest risk for developing compartment syndrome as evidenced by the client's paresthesia.

A nurse is caring for a client who is on 24-hr observation. Complete the following sentence by using the lists of options.

The client is at risk for hemorrhage due to thrombocytopenia.

A nurse is caring for a client who has bulimia nervosa. Drag words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing cardiovascular abnormalities and hyponatremia.

A nurse in a provider's office is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Complete the following sentence by using the lists of options.

The client is at risk for developing delayed wound healing due to glucose level.

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.

The client is at risk for developing seizures as evidenced by blood pressure.

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 oncoming nurse?

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

a charge nurse is planning an educational session for staff nurses about working with parents whose children have a terminal illness and are candidates for donating their organs. which of the following information should the nurse plan to include?

The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body.

A nurse is caring for a client who is in the spinal cord injury (SCI) unit. Complete the following sentence by using the list of options.

The nurse should first address the client's oxygen saturation followed by the client's urinary output.

A nurse is caring for a client who is 1 hr postpartum. Select the 6 actions the nurse should take.

firmly massage the uterine fundus, administer methylergonovine, weigh the perineal pads, provide emotional support, insert an indwelling urinary catheter, administer oxygen

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

flumazenil

a charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. which of the following actions should the charge nurse take first?

gather more information about the staff nurse's actions

a nurse in an outpatient mental health clinic is working with a client who ha spost-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress?

guided imagery

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

maintain hydration with liberal fluid intake

a nurse is teaching a client who has a new prescription for estradiol. for which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider?

headaches

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 client's 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 performing an abdominal assessment on a client. identify the sequence of actions the nurse should take.

inspection, auscultation, percussion, palpation

A nurse is caring for a 68-year-old client who is 2 days postoperative following surgical repair of a left hip fracture. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor for that condition.

intestinal obstruction assist client to semi-fowler's position, prepare to administer IV fluids bowel sounds urine output

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

latex allergy

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 nurse is caring for a school-age child who is taking valproic acid. the nurse should expect the provider to order which of the following diagnostic tests?

serum liver enzyme levels

A nurse is caring for a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

somatic symptom disorder monitor the client's physical manifestations assess the client for a preoccupation with illness stress level pain

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which os the following observations should the nurse identify as an indication for potential violence?

the client is pacing around the chair in which their partner is sitting

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 on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

varicose veins elevate extremity apply graduated compression stockings edema of RLE, pruritus of RLE

a nurse is assessing a client who is taking propranolol. which of the following findings should the indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

wheezing