Exit retake questions

A nurse is reinforcing teaching about preventing Dental caries with the parent of a 12 month old toddler. Which of the following instructions should the nurse provide?

"Clean the teeth with a small, soft-bristled toothbrush"

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 reinfording discharge teaching|with a cliant who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?

"should throw away my used tissues in a closed plastic bag.

The nurse is continuing to care for the client Vital signs dav 1, 0900 Temperature (oral) 36.9 C (98.4 F) Heart rate 72/min Respiratory rate 16/min BP 162/112 mm Hg Oxygen saturation 97% on room air.

*Hemoglobin. HELLP syndrome *Alamine aminotransferase (ALT) HELLP syndrome Blood pressure Preeclampsia

Pulmonary edema

- High fowlers - monitor respiratory - Provide o2 - Check pt or inr - Dietary precaution with vitamin k - med furosemide (helps decrease pressure & fluid in the lungs)

A nurse is using a glucometer to measure a client's capillary blood glucose level, Which of the following actions should the nurse take? -Testa First drop of blood that forms after the Puncture - Wear Sterile Gloves - Keep the finger in Dependent Position - Select The Centrality Of The Finger

- Keep the finger in Dependent Position

Knee arthroplasty interventions

- Passive motion CPN machine to promote joint mobility - Monitor for pain rotation & extremity shortening, indication of infection - Ambulate day of survey - toilet seat extender

Trache care

- Provide care every 8 hr as needed - Monitor respiratory distress - suction as clinical indicated

Evisceration

- The displacement of organs outside of the body. - sterile saline damp dressing

Gentamicin

- antibiotic do not mix with aminoglycoside or penicillin in same Iv - hearing loss, dizziness, ringing in the ear

Prenatal care - edema interventions

- avoid standing for long period - Comfortable shoes and socks - Avoid anything that might make feet swell - rest your feet as much as possible - drink plenty fluids

C Diff

- contact - watery diarrhea - brat diet

Restraints

- emergency prescription within an hour - remove 1 at a time - 2 fingers - rom - prescription allow only 4 hr - provider can renew prescription within a maximum of 24 hrs - remove restraints & monitor every 2 hours

Rest and sleep

- identify sleep patterns - history & any recent changes - ask about sleep problems - establish bedtime routine - limit waking client - quiet environment - exercise 2 hours before bedtime - limit fluids 2 - 4 hrs before bedtime

Steps on providing postmortem care

- notify provider / Chaplin / mortuary - remove tubes or lines - clean or prepare for viewing as family desires - provide family/significant other participate - be aware of gender - identify culture values and religious beliefs - verify death certificate & facility documentation - prepare the client for transportation - ensure identification tags are present

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? -The client wants to talk about the diagnosis with nursing staff -The client has a Decreased Energy Level -The Client Makes Funeral Arrangements - The Client Requests A Second Opinion

-The client has a Decreased Energy Level

Suctioning

10-15 seconds on rotation motion, recover 20-30secs & document

A nurse is reinforcing dietary teaching with a client who's pre-pregnancy BMI was 30.5 the nurse should recognize that the client understands the teaching when she states she should expect to gain how many pounds during her pregnancy

16 pounds

A nurse is receiving change of shift report on 4 clients which of the following clients should the nurse plan to see first

A client who has a femur fracture and reports numbness of the toes

And charge nurse assigned a nurse to care for a group of clients which of the following client should the nurse ask the charge nurse to reassign to an RN

A client who has a new diagnosis of diabetes mellitus and needs to learn self administration of insulin

A nurse is assisting with the plan of care for a group of clients which of the following client should the most recommend for an interprofessional conference

A client who has a spinal cord injury

advance directives

A legal document designed to indicate a person's wishes regarding care in case of a terminal illness or during the dying process

A nurse is reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching? A. The client's extremity should be elevated after the cast is applied B. The client should keep the cast covered until it is dry C. The client can shower with the cast after 24 hours D. The client should use a hair dryer on a warm setting to relieve itching inside the cast

A. The client's extremity should be elevated after the cast is applied

A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. which of the following should the nurse include in the teaching?

Alert the staff if any of your identification bands are missing

A nurse is preparing to administer eyedrops to a child which of the following actions should the nurse take ?

Apply pressure to the lacrimal punctum after administering drops

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse do? Tie the gown with the gloves on. Push the gown sleeves up to the elbows. Apply the gown before the gloves. Tuck the glove cuffs under the gown sleeves.

Apply the gown before the gloves.

A nurse is observing an assistive personnel apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

Applying the stocking before the client gets out of bed

A nurse is caring for a client who has depressive disorder the client states everyone will be better off if I were not around which of the following responses should the nurse make

Are you thinking of hurting yourself?

A nurse is reinforcing teaching with a client who is in 16 weeks of gestation and has a prescription for fear is Sophie to treat I am deficiency anemia which of the following recommendations should the nurse week to improve the absorption of the medication

Avoid drinking milk with the iron supplement

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological therapy to manage pain when changing positions. Which of the following responses should the nurse make? A. "You can apply counterpressure to your back with each position change." B. "You can splint the incision with a pillow when changing positions." C. "You should use patterned-paced breathing when changing positions." D. "You should change positions as little as possible."

B. "You can splint the incision with a pillow when changing positions."

A nurse is caring for a client who has terminal cancer. which of the following responses by the client's school-age brother should the nurse expect?

Believes that his behavior is causing his death

A nurse is caring for a client who is 12 hours postpartum and has deep vein thrombosis of the left leg. The client is receiving an anticoagulant. Which of the following actions should the nurse take? A. Administer aspirin for pain B. Massage the affected extremity every 4 hr C. Apply an ice pack to the affected extremity for 20 mins every 2 hr D. Initiate bed rest

C. Apply an ice pack to the affected extremity for 20 mins every 2 hr

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions? A. Dorsal recumbent B. Left lateral C. Semi-fowler's D. Supine

C. Semi-fowler's

A charge nurse in a long-term care facility notices the smell of alcohol on a nurses breath which of the following actions should the nurse take first

Call the supervisor to ask for another nurse

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation . The nurse notes that the client's vagina and vulva purplish color. The nurse should docket this finding as which of the following? - Ballottement - Chadwick's sign - Chloasma - Hagar's sign

Chadwick's sign

A nurse is implementing a bladder training program for a client who had a stroke which of the following intervention should the nurse take

Check for residual urine after voiding

A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization which of the following findings in the clients record should the nurse recognize as a contra indication

Chemotherapy treatments

A nurse is assisting with the admission of a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for the client?

Chlordiazepoxide rationale: The nurse should expect to administer chlordiazepoxide to decrease anxiety and the risk for seizures associated with alcohol withdrawal.

A nurse is preparing to perform a wet to dry dressing change for a client who has an infected abdominal wound which of the following techniques should the nurse use when performing the dressing change

Clean the wound from center to outer edges

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation? - The client fell because the assistive personnel did not place non skid slippers on the client. - Client stated, I lost my balance and fell when I got out of bed to go to the bathroom. - An incident report has been completed and sent to risk management. - The client does not appear to have any injuries resulting from the fall.

Client stated, I lost my balance and fell when I got out of bed to go to the bathroom.

A nurse in an acute care setting is preparing to administer medications to a client which of the following information should the nurse obtain to identify the client

Client's telephone number

The hours sis preparing the postoperative clients closed wound drainage system which of the following actions should the nurse plan to take

Compress the container before replacing the drainage plug

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. 1 tablet every 3 to 4 hr PRN for pain inadvertently administer 2 tablets to the client. In which of the following locations should the nurse document this client care incident? - Incident report - Nursing care plan - Controlled substance inventory record. - Provider's progress notes

Controlled substance inventory record

A nurse is caring for a client who has an abdominal surgical incision and notices an evisceration which of the following actions should the nurse take ?

Cover the one with a transparent dressing

A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following should the nurse take? - Hold gentle, direct pressure on the protruding organ. - Place the client's knees in an extended position. - Raise the head of the bed to a 45 angle. - Cover the wound with sterile, saline- soaked gauze.

Cover the wound with sterile, saline- soaked gauze.

Acetaminophen contradiction

Diarrhea

A nurse is assisting with the care of a client following electroconvulsive therapy for the use of the expected finding should the nurse expect 15 min following the procedure.? - Paresthesia - Tonic- clonic-seizures. - Disorientation - Sleep apnea

Disorientation

furosemide therapeutic effects

Diuresis and subsequent mobilization of excess fluid (edema, pleural effusions). Decreased BP.

A nurse is transcribing a transcription from the prescription from the provider. The prescription reads Gentanmicin 2 gtt OD q4h. WOTF informatikngvshuukd the nurse clarify

Dosage

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching? - Assume responsibility for making the client's decisions. - Limit the client's social interactions - Maintain a verbal no harm contract with the client. - Encourage the client to be assertive.

Encourage the client to be assertive.

A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take? Use a 12- point front size Write the information at an 8th grade reading level. Present information from complex to simple. Explain medical terminology using basic, one -syllable words.

Explain medical terminology using basic, one -syllable words.

A nurse is caring for a client who is 4 as postpartum following a cesarean birth

Foul smelling lochia. Endometritis. Painful tender breast Mastitis. Temerature Mastitis and Endometritis. Chills Mastitis.

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which should the nurse include? Corn Potatoes Grapes Oranges

Grapes

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5 C (90.5 F). Which of the following data is the priority for the nurse to monitor? Muscle strength Pain sensation Heart rhythm Urinary output

Heart rhythm

A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include? Wash hands under running water for at least 10 seconds. Dry hands thoroughly from fingers to wrist. Clean hands with alcohol- based hand gel for 15 seconds. Hold the hands slightly higher than the elbows when using running water.

Hold the hands slightly higher than the elbows when using running water.

A nurse is reinforcing discharge instructions with a client who had a myocardial infarction. Which of the following statements indicates an understanding of the teaching

I can take a nitroglycerin pill every pill every 5 minutes up to 3 times to relieve chest pain

A nurse in an inpatient medical health facility is reinforcing teaching with a client who signed a consent form for electro convulsive therapy which of the following statements about a client indicates an understanding of the procedure

I might have short term memory loss after the procedure

A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new prescription for timolol eye drops. which of the following statements by the client indicates an understanding of the teaching

I should check my heart rate while taking this medication

A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new prescription for timilol Eyedrops which of the following statements by the client indicates an understanding of the teaching

I should check my heart rate while taking this medicine

A nurse is reinforcing teaching about # healthy lifestyle changes with a female client who has mild hypertension, which of the following statements by the client indicates an understanding of the teaching?

I should decrease my salt intake to 2g per day

The nurse is reinforcing teaching about advance directives with a client who has end stage heart failure

I should discuss this document with my family after I sign it

A nurse is reinforcing with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates understanding of the teaching? - I should practice pursed-lip breathing exercises. - I should do aerobic exercises once per day. - I will consume low protein, low calorie foods. - I will increase my fluid intake to 1,700 milliliter per day.

I should practice pursed -lip breathing exercises.

A nurse is reinforcing teaching with a parent of a newborn about home safety percolation which of the following statements by the parent indicates an understanding of the teaching

I will make sure that I can fit one finger between the mattress and the side of my newborns crib

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statement indicate understanding of the teaching? - I have to take this medication on an empty stomach. - I will need to remain upright for 1 hour after taking the medication. - I can take antacids at the same time as this medication.? - I should expect to have diarrhea while taking this medication.

I will need to remain upright for 1 hour after taking the medication.

A nurse in a mental health facility is reinforcing teaching with a client about panic attacks which of the following statements by the Client indicates an understanding of the instructions?

I will use abdominal breathing at the first sign of a panic attack

A nurse is caring for a client who is 2 days postoperative following a total bilateral. mastectomy. The client is tearful and looks away when surgical dressing is removed. The nurse should place the priority on which of the following actions? - Providing the client with information on community resources that will strengthen her coping skills. - Encouraging the client to write about her feelings in a journal each day. - Identify the client's perception of the changes in her physical appearance. - Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds.

Identify the client's perception of the changes in her physical appearance.

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? - Administer aspirin if the client develops a fever. - Assign the client to a negative pressure airflow room. - Initiate contact precautions for the client. - Have visitors remain at least 0.91 m (3feet) away from the client

Initiate contact precautions for the client.

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Insertion of a nasogastric tube

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

Instruct the client to hold the drainage bag a waist height when ambulating

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? Instruct the client to hold the drainage bag at waist height when ambulating. Secure the tubing with adhesive tape to the lower abdomen. Coil the tubing on the bed above collection bag. Collect a sterile specimen from the urinary drainage bag.

Instruct the client to hold the drainage bag at waist height when ambulating.

A nurse is reinforcing teaching about hand hygiene with newly licensed nurses. Which of the following information should the by included in the teaching? Interlace the finger while rubbing hands together. Dry hands starting from arms to fingers. Apply friction to hands for 10 seconds. Use hot water to wash hands.

Interlace the finger while rubbing hands together.

A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

Irrigate the bladder using sterile technique

phytonadione injection (vitamin k)

It's an injection that helps blood clot

Hopeless

Lack of energy

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation? - Cause of the client's death. - Location of the identification tag on the client's baby - Copy of the client's advance directives. - Last set of the client's vital signs.

Last set of the client's vital signs.

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following should the nurse include? - Use written signs to assist the client with locating the bathroom. - Use confrontation to manage the client 's behavior. - Limit the number of choices for the client. - Provider a stimulating environment for the client.

Limit the number of choices for the client.

A nurse is collecting data from a client who has heart failure the nurse notices the client has crackles in the bases of the lungs shortness of breath and a respiratory rate of 24 bom which of the following actions should the nurse take

Maintain the client and high Fowlers position

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

Maintain the drainage system below the level of the clients chest

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend including in the plan? - Measure the client's abdominal girth daily. - Restrict the client's sodium intake to 3 g per day. - Keep the client's daily protein intake below o.8g/kg - Position the client supine with legs elevated.

Measure the client's abdominal girth daily.

A home health nurse is conducting a home inspection for a client who is it was for falls which of the following instruction should the nurse provide for the client

Move the clients bed to the main floor on the house

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for management which of the following statements by the partner indicates an understanding of the teaching

Music will distract my husbands awareness of the pain

COPD (chronic obstructive pulmonary disease)

Nasal cannula

A nurse is reinforcing discharge teaching with a client who states. I don't feel confident driving to my follow- up appointment. The nurse obtain a referral for which of the following members of the health care team? Physical thermal therapist Occupational therapist Social worker Primary care provider

Occupational therapist

A nurse enters the room of a school- age and finds them on the floor experiencing a tonic - clonic. Which of the following actions should the nurse take? Turn the child onto their back. Place a pillow under the child's head. Restrain the child's upper extremities. Place a padded tongue blade in the child's mouth.

Place a pillow under the child's head.

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphasia. Which of the following instruction should the nurse include in the teaching? - Place oral suction equipment next to the client's bedside. - Give the client a straw to use for drinking - Provide thin liquids to help the client swallow - Use a needless syringe to instill feedings.

Place oral suction equipment next to the client's bedside.

A nurse is reviewing the pain of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures? - Administration of an iron injection using Z- track technique. - Placement of a central venous catheter. - Insertion of a nasogastric tube. - Irrigation of a wound with antibiotic solution.

Placement of a central venous catheter.

A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior which of the following actions should the nurse take after applying physical restraints to the Client

Plan to remove the restraints as soon as the client is calm

isosorbide dinitrate adverse effects

Postural hypotension, tachycardia, headache (To prevent angina)

A nurse is reviewing the medical record of a client who has COPD which of the following laboratory findings indicates a need to request a dietary referral for the client ?

Pre-albumin 13 mg /dL

A nurse is administering pancrelipase to a child who a child who has cystic fibrosis. Which of the following outcomes should the nurse expectation effect of the treatment? - Improved respiratory function. - Improved absorption of vitamin B and C. - Reduced fat in the stools. - Decrease sodium excretion.

Reduced fat in the stools.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. The nurse notes bright red urinary drainage after notifying the surgeon which of the following actions should the nurse take?

Request a prescription to obtain the clients bun level.

A nurse is assigned an assistive personnel to perform a Gastroatomy Feeling for a client who has been receiving feedings at homeWhich of the following actions should the nurse take to monitor the APs performance of the task

Request the AP to provide a return demonstration of the task

Following a kosher diet which of the following on the menu is OK

Roasted salmon

A nurse is caring for a client who has end stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take? Tell the client she should discuss this decision with her family. Ask the facility chaplain to visit the client. Support the client's decision to stop the treatment. Discuss alternative treatment methods with the client.

Support the client's decision to stop the treatment.

A nurse overhears two assistive personnel AP in the nurse station discussing a client who was recently admitted. Which of them should the nurse take? - Document the event in the client's progress notes. - Tell the APs to stop the conversation. - Submit an incident report to the risk manager. - Inform the client of the APS actions.

Tell the APs to stop the conversation.

A nurse is observing assistive personnel check the tympanic temperature. Which indication that the AP understands how to perform the procedure. - The AP pulls the pinna up and back. - The AP inserts the probe with a straight, forward motion. - The AP points the probe posteriorly. - The AP positioned the client facing her.

The AP pulls the pinna up and back.

A nurse is reinforcing teaching with a client who is to habe their plaster cast applied to his right arm Which of the Following information should the nurse include in the teaching

The client's extremity Should be elevated after the cast is applied

A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following should the nurse use to verify the identities of each client? - The names of the clients nearest relatives - The telephone numbers of the clients. - The room numbers of the clients - The diagnoses of the clients

The telephone numbers of the clients.

A nurse is caring for a client who is why her newborn is receiving phytonadione injection which of the following statements shiuld the nurse make

This medication prevents your baby from developing bleeding problems

A nurse is preparing to give change of shift report on a client who is 2 day postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? Time of the last pain medication Admission vital signs Steps required for dressing change. Preferred bath time.

Time of the last pain medication

A nurse is assisting in providing postmortem care to a client who was a devout follower of Hinduism. Which of the following request should the nurse anticipate from the client's family? - To bury the client's body within 24hr of their death. - To cremate the client's body pg 25 - To stay with the client's body for 8hr following their death - To prohibit medical personnel from touching the client's body

To cremate the client's body pg 25

A nurse in an adult daycare facility is contributing to the plan of care for a client whose family reports recent confusion and memory lOSs which of the following strategies should the nurse include in the plan

Use symbols in the communal room signage

A nurse is planning care for a 4 * client who is six hours postoperative following a right knee arthroplasty which of the following interventions should the nurse include in the clients plan of care?

Use the continuous passive motion machine intermittently

A nurse in a long term care facility is caring for a client who has methicillin -resistant Staphylococcus aureus MRSA. Which of the following actions should the nurse take? - Restrict the client client's visitors. - Remove personal protective equipment after leaving the client's room. - Ensure that the negative air pressure is active for the client's room. - Wear a gown when assisting the client with personal hygiene.

Wear a gown when assisting the client with personal hygiene.

Bucks traction's

Weights hang freely

UTI catherezation

Wipe front to back Cotton underwear Avoid bubble baths Male: retract foreskin Dominant hand sterile

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 is reinforcing teaching with a client who has a prescription for an antibiotic therapy the client tells the nurse that he always experiences diarrhea when he takes antibiotics which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea

Yogurt

A nurse is reinforcing teaching with a client who has diabetes Molite us about a 24 hour creatinine clearance test which of the following statements should the nurse include in the teaching?

You can begin collection of urine after discarding your first morning void

A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make. I am sure that everything will be all right, regardless of your decision. Making this decision is wrong. If I were you, I would contact your spiritual director. You have a right to change your mind.

You have a right to change your mind.

A nurse is delegating the collection of a sputum specimen to an AP. At which of the following times should the nurse instruct the AP to collect the specimen

as soon as the client awakens in the morning

A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staf. Which of the following responses should the nurse make? a. "Why do you feel the staf is the FBI?" b. "What makes you think the staf is following you?" c. "The psychiatric staff is not FBI. They are here to help you." d. "This must be very frightening for you. Let's talk more about it."

c. "The psychiatric staff is not FBI. They are here to help you."

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered dose inhaler. Which of the following instructions should the nurse include in the teaching?

close your mouth around the mouthpiece

A nurse is collecting data from a client who diabetic ketoaçidosis. Which of the following findings should the nurse expect?

fruity breath

atorvastatin adverse effects

headache, abdominal pain, joint pain, blood test

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage? o "Apply steady pressure with this tennis ball to her sacral area." o "Assist her to breathe in deeply at the beginning of each contraction." o Massage the client's fundus o Assist the client to empty her bladder o "Gently stroke her abdomen during contraction

o "Gently stroke her abdomen during contraction

A nurse is reinforcing teaching about advance directives with a client who has end- stage heart failure. Which of the following statements by the client indicates an understanding of the teaching? o "I am not allowed to change my mind once I sign this document." o "My partner needs to be present when I sign this document." o "I should discuss this document with my family after I sign it." o "An attorney will need to notarize this document for it to be valid."

o "I should discuss this document with my family after I sign it."

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching? o "You Should Have A Sputum Examination Every 4 Weeks." o "You Should Obtain Chest X-ray every 3 months." o "You should schedule a tuberculin skin test every 6 months." o "You should stop taking your anti tuberculin medication after 2 weeks."

o "You Should Have A Sputum Examination Every 4 Weeks."

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching? o "You Cannot Drink Fluids For 4 Hours After The Procedure." o "You Will Need To Urinate Before The Procedure." o "You will have legba to collect the urine." o "You will feel pressure when I Inflate The Catheter Balloon."

o "You Will Need To Urinate Before The Procedure."

A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching? o "A family member must witness your signature on the informed consent form." o "We require informed consent for all routine treatments." o "You can sign the informed consent form after the provider explains the pros and cons of the procedure." o "We can accept verbal consent unless the surgical procedure is an emergency."

o "You can sign the informed consent form after the provider explains the pros and cons of the procedure."

A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of Which of the following? o Boundary crossing o Countertransference o Veracity o Promoting trust

o Countertransference

A nurse is reinforcing teaching with a client who has arthritis.Which of the following instructions should the nurse include in the teaching? o Engage In Low-impact aerobic exercises o Apply Ice To The Inflamed Joint o Sleep On Soft Mattress o Use fingers to push off from bed or chair

o Engage In Low-impact aerobic exercises

A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority action on which of the following actions? o Providing the client with information community resources that will strengthen her coping skills o Identifying the client's perception of the changes her physical appearance o Demonstrating an non judgmental attitude toward the client when providing care for her surgical wounds o Encouraging the client to write about her feelings in a journal each day

o Identifying the client's perception of the changes her physical appearance

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? o Assign The Client To A Positive-airflow room o Have visitors remain at least 0.91m (3feet) away from the client o Administer Aspirin If The Client Develops A Fever o Initiate Contact Precautions For the Client

o Initiate Contact Precautions For the Client

A nurse is caring for an adolescent client who has bulimia nervosa.Which of the following actions should the nurse take first? o Instruct The Client About Effective Coping Strategies o Suggest That The Client Assist With Meal Planning o Observe The Client During And After Meals o Refer the client to support group for adolescents who have eating disorders

o Observe The Client During And After Meals

A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching? o Decreased Hemoglobin o Somnolence o Bradycardia o Decreased Blood Pressure

o Somnolence

A nurse is reinforcing teaching with a # parent of a child who has ADHD and is taking methylphenidate which of the following statements by the parents indicated the medication is effective

our child is able to complete his homework on time

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. which of the following recommendations should the nurse make?

perform pelvic rocking exercises several times per day

A nurse in an acute care setting is assisting in collecting client information To include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

physical assessment findings

A nurse is caring for a client who has anorexia nervosa and who has a behavioral management plan in place. which of the following findings should the nurse identify as an indication that the plan is effective

potassium 3.5/g dl

A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possi- ble latex allergy?

rhinorrhea

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy the nurse should explain to the client that which of the following adverse reactions can occur following the procedure

temporary memory loss