Exit B PN - 2017

A nurse assisting with a childbirth class is discussing non pharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

"I should use counterpressure for back pain during labor."

A nurse is caring for a client who requests information bout advance directives. Which of the following responses should the nurse make?

"Advance directives are written instructions regarding end-of-life care."

A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suctioning. Which of the following supplies does the nurse need to perform this task?

Yankauer catheter

A nurse notices an assistive personnel taking a nap in the break room during he meal time. The AP appears drowsy while performing routine tasks. Which of the following actions should the nurse take?

Report the observations about the ap to the unit's nurse manager.

a Nurse is caring for a client who is post op following an open reduction with internal fixation of the ankle. The client report pain and the nurse notes that the affected extremity is cool, pale, and has a weak pulse. The nurse calls the surgical assistant who responds "it has always been like that" Which of the following actions should the nurse take first?

Notify the nursing supervisor.

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 a newborn's parents about umbilical cord card. Which of the following statements by a parent indicates an understanding of the instruction?

"I will give our baby sponge baths until the cord falls off."

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the teaching about the acute phase of diverticulitis?

"I will receive the nutrient I need through my IV Fluid"

A nurse is speaking with the adult daughter of a client who has Alzheimer's disease. The daughter states, "I love my dad, but caring for him is wearing me out." Which of the ff response should the nurse make?

"Let's discuss how caring for your father is affecting your health.

a school nurse is having a conversation with the parents of an adolescent. The nurse should identify which of the following situations as an ethical dilemma for the parents?

"We can't decide whether to try to homeschool our child or move her to a private school."

A nurse is collecting data from who is severe pain. Which of the ff questions should the nurse ask first?

"Where is your pain located?"

A nurse is assisting with performing a non stress test for a client who is at 39 weeks of gestation which of the following instructions should the nurse reinforce with the client?

"You should depress the button on the handheld marker when you feel your baby move."

A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching?

"You will need to take the medication for the rest of your life."

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take?

Offer the client headphones to listen to music.

a Nurse in maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

Wear a surgical mask within 3 feet of the client.

A nurse is assisting with the admission of a client who has major depressive disorder. Which of the ff communication technique should the nurse use to establish a trusting relationship with the client?

Offering general leads

A nurse is preparing to administer prednisone 1mg/kg PO to a preschooler who weights 20kg (44lb). Available is prednisone oral solution 5mg/1mL. How many mL should the nurse administer? Round

4 mL

a nurse is contributing to the plan of care for a client who is on suicide precautions. Which of the following interventions should the recommend?

Encourage the client to sign a no-harm contract.

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client whose urinary output was 100mL for the past 12 hrs

A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the ff clients should the nurse identify as being at risk for urinary retention?

A school-age child who has allergic rhinitis and is taking diphenhydramine.

A nurse is caring for a client who took an overdose of acetaminophen. Which of the following medications should the nurse plan to administer to the client?

Acetylcysteine

A licensed practical nurse on a medical surgical unit is working with an RN and an Assistive personnel. Which of the following assignments should the LPN expect to receive?

Administering an NG tube feeding to a client who had a stroke

A nurse is reinforcing teaching with a client who is bottle feeding he full-term newborn with formula. Which of the following instructions should the nurse include in the teaching?

Although is is unnecessary to be rigid about feeding times, six to eight feedings every 24 hrs should support a full-term newborn's nutrition adequately. Fewer feedings in the initial weeks could delay the estabilment of an adequate weight-gain pattern.

A nurse is collecting data from a middle adult female client who is taking melatonin. Which of the ff responses to the med should the nurse expect?

Improved sleep

A nurse is observing an AP caring for a client. For which of the ff actions should the nurse intervene?

An AP reports client information to the oncoming AP in the hallway

a Nurse is reinforcing teaching for a client who has a coronary artery disease and is taking low-dose aspirin daily. The nurse should include that this medication has which of the following therapeutic effects for CAD?

Antiplatelet

A nurse is assisting with monitoring a client who is in labor and has spontaneous rupture of membranes following a vaginal examination. The provider reports the client's cervix is dilated to 1 cm with an unengaged presenting part. Which of the following actions should the nurse take?

Apply the external fetal heart rate monitor.

A nurse delegates the collection of a sputum specimen from a client who has tuberculosis to an assistive personnel. At which of the following times should the nurse instruct the ap to collect the specimen?

As soon as the client wakes up.

A nurse is preparing to administer an influenza virus immunization to a client by the intradermal route. Which of the following actions should the nurse take?

Avoid massaging the site after injecting the vaccine

A nurse is contributing to the plan of care for a client who is newly diagnosed with iron deficiency anemia. Which of the ff foods should the nurse include in the plan as having the highest amount of iron?

Boiled spinach

A nurse is caring for a client following a bronchoscopy procedure. Which of the following actions should the nurse perform first?

Check for a gag reflex.

A nurse is contributing to the discharge plan for a client who had a knee arthroplasty. Which of the following actions should the nurse identify as the priority?

Check the client's mobility

A nurse is reviewing a client's electronic medical record and finds that an assistive personnel recorder the client's temperature as 35.3 degrees Celsius (95.5 degrees F) 2 hrs earlier. Which of the following actions should the nurse take firsT?

Check the client's temperature.

A nurse is reinforcing teaching with a client who has a fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving?

Cherry tomatoes

A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

Client reports during with urination.

A nurse is collecting data from a client who is 24 hr post op from an open colon resection, has a clamped NG tube, and is resuming a clean liquid diet. Which of the following findings should the nurse report to the provider?

Client reports vomiting green-tinged fluid.

A nurse is assisting in teaching a group of staff nurses about hepatitis A. Which of the following modes should the nurse include as a method of transmitting hepatitis A?

Consumption of contaminated food.

A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the ff actions should the nurse take?

Cover the exposed area with sterile, saline-soaked dressings.

A nurse is reviewing laboratory reports for a client who has an Escherichia Coli infection and is receiving gentamicin. Which of the following results should the nurse report to the provider before administering the next dose?

Creatinine 2.5 mg/dL

A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

Demonstrate assertiveness.

A nurse is collecting data from a client who has iron deficiency anemia. Which of the following findings should the nurse expect?

Difficulty concentrating.

A nurse manager is preparing to complete a performance analysis for a group of assistive personnel. The manager asks a staff nurse for feedback on each assistants abilities. Which of the following actions should the staff nurse take?

Discuss how each AP's actions measure against the job description.

a nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally 3 times a day at home. Which of the following components of the prescription should the nurse question?

Dosage

A nurse is reinforcing teaching with a client who has a type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. which of the following information should the nurse provide to help the client manage his symptoms?

Eat a bedtime snack

A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected TB. Which of the ff actions should the nurse plan to take?

Ensure the injection produces a wheal on the skin

A nurse is working with an interpreter to explain a diagnostic procedure to a client who doesn't speak the same language as the nurse. Which of the following actions should the nurse take?

Ensure the interpreter is culturally compatible with the client.

A nurse is contributing to the plan of care for an older adult client who has difficulty sleeping. Which of the following interventions should the nurse include in the plan?

Establish a regular exercise routine 2 hr or more before bedtime.

A nurse is collecting data from a client who sustained spinal cord injuries from fractures to the t1 and t2 vertebrae. Which of the following client outcomes should the nurse expect?

Flexes and extends the shoulders

A nurse is observing a stable preterm newborn who develops apnea for longer than 20 sec, with a decrease heart rate of 20/min. Which of the ff actions should the nurse take first?

Flick the sole of the newborn's foot

A nurse is talking with a client whose son died in a motor-vehicle crash 2 weeks ago. The client states "I really thought I;d be back to my usual routines by now, but I can't think of anything else except my son is gone" Which of the following responses should the nurse make?

Grieving for your son is hard work. It will take as much time as you need to come to terms with your loss.

A nurse is collecting data from a client who has an unprepared femur fracture and rates his pain as 8 on a scale of 0 to 10. The client is talking and caught with a visitor. Which of the following of the prescribed medication should the nurse administer?

Hydromorphone 5 mg orally.

A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance. Which of the following statements by the parent indicates an understanding of the teaching?

I should offer my child yogurt that has a probiotic as a snack.

A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

I will rinse my mouth after taking this medication.

A nurse is instructing an assistive personnel on the use of proper body mechanics when moving a client. which of the following statements by the assistive personnel should the nurse identify as an understanding of the teaching?

I will use a pull sheet to help slide the client toward me.

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

If I forget to take a dose, I can take it later on the same day."

A nurse is preparing to administer a medication to a client when the client states " I'm sick of all there medication. I'm not taking any more today!" Which of the following actions should the nurse take?

Inform the client of the possible consequences of the medication refusal.

A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the ff should the nurse include as an example of assault?

Informing a client the nurse is going to administer an injection even though the client refuses.

A nurse is administering lorazepam to a client who is scheduled for surgery within 1 yr. Which of the ff actions should the nurse take after administering the medication ?

Instruct the client not to get out of bed.

A nurse is assisting in the plan of care for a female client who is to undergo a 12-lead ECG. Which of th off actions should the nurse include in the plan of care?

Instruct the client to remain still while the test is performed.

A nurse is contributing to the plan of care for a client who had a vaginal delivery 4 hours ago and has a 4th degree perineal laceration. Which of the following actions should the nurse recommend?

Instruct the client to use a sitz bath at least twice a day.

A nurse at a clinic is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

Lack of change in pupil size when the client looks from a far to a near object.

A nurse in reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk of cancer?

Lamb

The nurse is position a client who is scheduled for a lumbar puncture. The nurse should assist the client into which of the following positions?

Lateral Recumbent.

A nurse is contributing to the plan of care for a care for a client who has chest tube connected to a closed drainage system. Which of the ff actions should the nurse include in the plan of care?

Maintain the drainage system below the level of the client's chest.

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the ff actions should the nurse take to promote the client's venous return?

Maintain the sequential compression device.

A parent brings her adolescent son to an urgent care center and states. "He is high on something and needs help" The client is exhibiting agitation and paranoia and reports visual hallucinations. The nurse should suspect intoxication with which of the following substances?

Methamphetamines

A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the ff prescription should the nurse clarify with the provider?

Metoprolol ER 50mg per NG tube BID

A nurse in an acute mental health facility is caring for a client who has borderline personality disorder and reports. "I am going to kill my girlfriend when I get out of here." Which of the ff actions should the nurse take?

Notify the client's care team of the threats against the partner

A nurse is collecting data from a female client who has a new diagnosis of genital herpes. Which of the following findings should the nurse expect?

Painful erythematous vesicles.

A client who is diagnosed with Parkinson's disease verbalizes frustration due to increase difficulty with ambulation. Which of the ff responses should the nurse take?

Perform active ROM with your arms and legs two times a day.

A nurse is contributing to the plan of care for a client who is at risk of developing pressure ulcers. Which of the following actions should the nurse include in the plan of care?

Place the client in a 30° lateral position.

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late deceleration on the fetal monitor tracing. Which of the following actions should the nurse take?

Place the client in the lateral position.

A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?

Place your baby's crib away from heat vents.

A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. For which of the ff results should the nurse notify the provider?

Platelet count 95,000 mm3

A nurse manager is providing an in-service on hand hygiene to assistive personnel. which of the following information should the nurse manager include in the in-service?

Remove reigns when washing hand with soap and water.

While administering a medication to a client, a nurse notices a frayed electrical cord connecting the client's continuous passive motion machine to the electrical outlet. Which of the following actions should the nurse take?

Remove the device from the client's room.

A urse in a pediatric clinic is collecting the data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the ff actions should the nurse take?

Report the suspected abuse to a appropriate agency.

A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity?

Scan the facility identification board.

A nurse is admitting a client who is at high risk for suicide. Which of the ff actions is the nurse's priority?

Search the client's personal belongings

A nurse working in a community clinic is caring for an adolescent who has infectious mononucleosis. The client asks the nurse to explain how the disease was acquired. The nurse should explain that an individual acquires this disease by which of the following.

Sharing eating utensils with an infected person

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 nonoperative side for 2 weeks.

A nurse who is facilitating a support group notices that one client in the group is extremely talkative, to the point where others in the group have difficulty sharing their own ideas. Which of the following strategies should the nurse use to facilitate the group process with this client?

Speak privately to the client about this behavior.

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets Which of the following instructions should the nurse include in the teaching?

Take up to three tablets during a single angina episode.

A nurse is reinforcing reaching for a preoperative client on how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

The client attempts to elevate the cylinder by inhaling deeply.

A Nurse is collecting data from an older adult client who is 48 hr postoperative following abdominal surgery. The provider writes a prescription to advance the client to a regular Diet. For which of the following findings should the nurse notify the provider?

The client has absent bowel sounds.

A nurse is caring for a female client who has an indwelling urinary catheter. which of the following actions should the nurse take?

Wipe the drainage port with an antiseptic wipe after emptying urine from bag.

A nurse at a long term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?

The facility had 12% fewer urinary tract infections over the past 6 months.

A nurse is assisting with the plan of care for a client following a transurethral resection of the prostate. Which of the following interventions should the nurse include in the plan of care?

The nurse should irrigate the bladder using strict sterile technique and maintain closed catheter drainage system to minimize the rick of infection.

A nurse is caring for a client who is 4 hr postoperative ff a total thyroidectomy. Which of the ff manifestations should the nurse report to the provider as indicating possible hypocalcemia?

Tingling of fingers

A nurse is preparing to administer a rectal suppository to a school-age child. Which of the following action should the nurse plan to take?

Use one finger to insert the suppository past the anal sphincters.

A nurse in a long term care facility is using validation therapy with a client who has dementia. The client becomes agitated and asks why his wife who died several years ago has not visited him. Which of the following responses should the nurse make?

You must miss your wife. Let's take a walk and you can tell me about her.

A nurse is collecting data from a client who has type 2 diabetes mellitus and is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

You weight gain should be the same as for someone without diabetes.

A nurse is reinforcing reaching with a client about a planned thoracentesis. Which of the following information should the nurse include in the teaching?

You will need to be monitored for 1 hour after the procedure."

A nurse is reinforcing teaching with a client who has a new prescription for prednisone for the treatment of Addison's disease. which of the following instructions should the nurse include in the teaching?

You will need to schedule a bone density test.

A nurse is caring for a client who is 16 hr postoperative following a total hip arthroplasty. the client reports numbness, pain, and tingling in the affected leg. Which of the following actions should the nurse take first?

compare capillary refill in toes bilateraly

A nurse in reinforcing teaching about weight loss with a female older adult client who is overweight. Which of the following statements should the nurse include in teaching?

keep fat intake to no more that 30% of daily caloric intake.

A Nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

lack of sleep

A nurse is reinforcing preoperative teaching with a client scheduled for a bowel retention with ileostomy. which of the following descriptions should the nurse give of the expected output from a mature ileostomy?

liquid with little odor

A nurse is reinforcing discharge teaching with a client who is postoperative following transurethral resection fo the prostate. Which of the following instructions should the nurse include in the teaching?

perform Kegel exercises daily.

A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevate cholesterol level. which of the following strategies should the nurse include in the teaching?

purchase beef that is a loin cut.