Final Review - 4-"C"

A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide

"Take your iron medication with fluids other than coffee or tea."

A nurses for Caring for four clients. Which of the following client should the nurse care for first?

A client is hypothyroidism and is stuporous

nurse receives report on a group of clients. Which of the following client should the nurse attend to first?

A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10

A nurse receives a change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse plan to assess

A client who had a hip arthroplasty reports pain and erythema in his calf

I nurse on the medical surgical unit is receiving reports on four clients. Which of the following client should the nurse assess first?

A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL

A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first?

A client who is having auditory hallucinations is becoming agitated

A nurse is caring for a group of clients. Which of the following client should nurse assess first?

A client whose abdominal pain and is vomiting coffee ground emesis

A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first?

A client whose chronic kidney disease with cloudy diasylate outflow

A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client should the nurse identify as the priority?

A client with indications of hypovolemic shock

A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?

A client's wrist restraints tied to the bed rails

The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned?

A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident.

A nurse is using Naegeles rule to calculate the expected delivery date for a newly pregnant primigravida. The first day of the clients last period was October. What is the expected delivery date?

0711 (July 7, 2011)

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

Administer calcium gluconate IV.

The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate nursing action? Click on the links of this below for additional client information

Administer oral rehydration solutions.

A nurse is caring for client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions is appropriate?

Place the client private room.

A nurse observes an AP providing care to a child who is in skeletal traction. Which of the following action requires intervention?

Placing weights as a child's bed

The nurse is assessing a client is receiving radiation therapy. Which of the following findings should the nurse expect?

Platelets 95,000 mm3

A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?

Poor problem solving ability

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following interventions should the nurse perform

Position the head of bed at 30 degrees during feeding.

A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection?

Profuse milky white discharge

A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply)

Syncope Vertigo

A nurse is assessing a client wasn't following vital signs: Oral temperature of 37.2°C (99 F). Apical pulse rate of 80/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood pressure of 132/40 mm Hg. What is the clients pulse pressure?

Systolic presssure subtracted by diastolic pressure (132 - 40) = 92

Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following instructions should the nurse include?

Take with a glass of orange juice

Addresses planning to provide teaching to young adult client who is insomnia. Which of the following should the nurse include in the teaching?

Consume a high carbohydrate snack at bedtime.

A charge nurse is discussing the use of applying ice to a client's injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?)

Decreased capillary permeability

A nurse is interviewing an older adult client about the physiological changes he has been experiencing. Which of the following changes should the nurse recognize is normally associated with the aging process?

Decreased sense of taste

A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus. Which of the following action should the nurse take?

Determine if the AP is qualified to perform the test.

A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions should nurse take?

Discontinue oxytocin infusion

A nurse is assessing a client that has had a long arm cast. Which of the following findings of the dress moderate & when assessing for acute compartment syndrome?

Edema

A nurse is assessing for allergies before administering Propofol to a client placed on the mechanical ventilator. Which of the following allergies is a contraindication to the medication?

Eggs

A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care?

Elevate the client's affected extremity when in bed

A nurse manager is planning an audit to measure the quality of care on the unit. Which of the following is the most appropriate source for the nurse to consult?

Evidence-based practice data

A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

hepatits C

A nurse in a provider's office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client's history is a contraindication to use in combination oral contraceptives?

impaired liver function

A nurse is caring for a client who has lactose intolerance and has eliminated dairy products from his diet. The nurse should instruct the client to increase consumption of which of the following foods?

spinach

A nurse is caring for a child who has infectious mononucleosis.. Which of the following findings are associated with this diagnosis? Select all that apply

splenomegaly Malaise Sore throat

A nurse is planning care for a client following gastric bypass surgery. The nurse should include which of the following dietary instructions when preparing the client for discharge?

start each meal with a protein source.

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve

top left side :)

A nurse discovers that the wrong dosage of medication was given to client. When determining what action to take your should recognize that which of the following ethical principles should be applied?

veracity

A nurse is teaching a client about nutritional intake. The nurse should include which of the following in the teaching?

"Carbohydrates should be at least 45% of your caloric intake."

A nurse is educating a client about caloric intake and weight reduction. Which of the following client statements indicates an understanding of the teaching?

"If I eat 500 fewer calories per day, I should lose 1 pound per week."

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

1 cm of water present in the water seal chamber

A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

1800

Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

A 50- year old client who has slurred speech, is disoriented, and reports a headache

A nurse on a medical-surgical unit is receiving report on four clients. Which of the following clients should the nurse assess first?

A client who is receiving a blood transfusion and reports low-back pain

A nurse is planning care for four clients. Which of the following clients is the highest priority?

A client who is wearing an arm cast and reports numb fingers

A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?

A client who reports tingling in the fingers following a thyroidectorny

A nurse if caring for a group of clients in a medical surgical unit. Which of the following situations requires completion of an incident report?

A client whose IV pump has malfunctioned

A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?

Abdominal rigidity

A nurse is assessing an older adult client who had a stroke. Which of the following findings should the nurse recognize as an indication of dysphagia?

Abnormal movements of the mouth

A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP?

Administrative oral fluids to client was dysphasia

Which of the following client is appropriate for the nurse to refer to speech therapy for swallowing evaluation?

An older adults who has difficulty taking in fluids

A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the following prescription is given by the provider should the nurse clarify?

Apply heat to affect extremity for 45 minutes on the 45 is off.

A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse?

Apply sterile gloves.

A client who does not speak English arrives at the emergency department accompanied by a child. Which of the following actions should the nurse take?

Ascertain what language the client speaks and get an interpreter.

A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion?

Atrial fibrillation

A nurse is caring for client was GERD. Which of the following assessment findings the nurse expect to find?

Atypical chest pain

A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take?

Check for an allergy to eggs

A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first?

Client placed in restraints to the aggressive behavior

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an AP?

Client who had a cerebrovascular accident two days ago and needs help toileting

Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the nurse report to provider first?

Client who has gatroenteritis & is lethargic & confused

A nurse is planning to delegate client assignments to the assistive personnel. which of the following task is appropriate for the nurse to delegate?

Collecting urine sample

A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

Come outside with me for a walk."

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement, "When the cat's away, the mice will play". The client response was, "The mice come out when the cat is not around". The nurse should document this finding which of the following in the client's chart?

Concrete thinking

The nurses reviewing clients admission laboratory results. Which of the findings required further evaluation?

Creatinine 1.8

A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?

DO you have any active lesions?

Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first?

Determine pain level

A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which of the following medications should the nurse administer?

Diphenhydramine

A client was having suicidal thoughts tells the nurse "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses for the nurses appropriate?

Do you have a plan to end your life?

A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?

Drink hot water with lemon juice each morning when you wake up

A nurse is caring for a newborn who is under phototherapy lights. Which of the following is an appropriate nursing action?

Ensure eye shield is covering the eyes.

Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?

Fever

A nurse is caring for a 7 month-old infant who is being treated for severe dehydration. Which of the following assessment findings indicates treatment has been effective?

Flat anterior fontanel

Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate?

Give the client enalapril 2.5 mg PO twice daily

A nurse is obtaining the medical history of a client who has a new prescription for isosorbide monotitrate. Which of the following should the nurse identify as a contraindication to medication?

Glaucoma

A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of the following laboratory tests is an indicator of long-term disease management?

Glycosylated hemoglobin - Ha1c

A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect?

Head Compression

A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take?

Heat the skin one minute prior to placing the program

A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

Heightened perceptual field

A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, "I don't know how much longer I can take this, but I'm afraid he'll really hurt me if I leave. "Which of the following is an appropriate nursing intervention?"

Help the client to recognize the signs of escalation of abuse behavior

A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should recognize that these findings are potential manifestations of which of the following?

Heroin intoxication

Nurse managers preparing an educational program on infection control measures. Which of the following should the nurse include when discussing contact precautions?

Herpes simplex

Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?

Hydromorphone

A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor?

Hypnosis promotes increased control of her pain perception during contractions

A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone you dislike)

I think that people just you're just lazy and should earn money honestly

A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan?

I understand I may experience difficulty sleeping on this medication

A nurse is providing teaching for a client has a new prescription for methadone. Which of the phone following client statements indicates need for further teaching?

I understand the methadone may cause me to have difficulty sleeping

A nurse is providing discharge instructions for a client who has a new prescription for furosemide. Which of the following client statements indicates a need for further teaching?

I will limit my intake of fish."

The nurses providing discharge instructions about engorgement for client has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction by the nurse?

I will manually express breastmilk

A nurse is caring for a client in a mental health facility. The clients daughter is crying and tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following is an appropriate response?

I'd like to know more about what's bothering you."

The nurses planning care for newly admitted adolescent who has bacterial meningitis. Which the following instructions is appropriate for the nurse to include in the plan of care?

Initiate droplet precautions for the client

Is caring for clients was a new prescription for enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?

Inject the medication the lateral abdominal wall

A nurse is planning care for a client who has Alzheimers disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

Leave one side rail up on the clients bed.

A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac disease. Which of the following positions should the nurse place the client to best promote optimal cardiac output?

Left lateral

A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

Lipsmacking

The nurses assessing client with post traumatic stress disorder. Which of the following findings to the nurse expect to find?

Loss of interest in usual activities

A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC?

Lyme disease

A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients often agitated and frequently wanders the halls. Which of the following intervention should the nurse include in the plan of care?

Maintain Nutritional requirements by offering finger foods

A nurse is planning care for a child who has increased intracranial pressure with a decreased level of consciousness. Which of the following intervention should the nurse including the plan of care?

Maintain the head at a midline position.

A client with the left leg cast is using crutches for ambulation. The nurse recognizes client needs further instruction of the client

Maintains 3 to 4 finger width between the crutch pad and axilla

A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

Massage the fundus.

A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?

Meat and dairy products are eaten separately.

nurse is taking a medication history from client was type II diabetes mellitus is scheduled for an arteriogram. Which of the following medications to the nurses instruct the client to discontinue 48 hrs prior to the procedure?

Metformin

A nurse is caring for a client who has preeclampsia and is experiencing postpartum hemorrhage. The nurse should identify that which of the following medications is contraindicated?

Methylergonovine.

A nurse is delegating tasks to an assistive personnel. Which of the following instructions demonstrates appropriate communication of the task?

Obtain a blood pressure reading from the client in room 116 after lunch and report a systolic level less than 90."

The nurses is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care?

Obtain a cardiac rehabilitation consult

A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?

Oliguria

A nurse is reviewing the results of an ABG performed on a client with chronic emphysema. Which of the following results suggests the need for further treatment?

PaCO2 level of 55 mm Hg

A nurse is assessing a client who has pericarditis. Which of the following findings is priority

Paradoxical pulse

A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel?

Perform chest compressions during cardiac resuscitation.

Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to

Perform weight bearing exercises

Home health nurse is carefully planned for Alzheimer's disease. To the following action should the nurse include in the plan of care

Place a daily calendar in the kitchen

A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention?

Provide standby assist with the client from bed

A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

Pulse 54/min

A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox?

Rash in the mouth

A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which of the following is a contraindication for administration?

Recent blood transfusion

A nurse is planning care for a client to prevent complications for immobility. Which of the following actions should the nurse include in the plan of care?

Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.

A nurse is teaching post-operative care with the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

Remove elbow splints periodically to perform range of motion.

A nurse is planning care for an adolescent who has chronic renal failure. Which of the following actions should the nurse include in the plan of care?

Restrict protein intake to the RDA.

A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which the following food selections indicates that client understands teaching?

Rice with black beans

A nurse is review in the prescription for doxazosin with a client. Which of the following should be included in the teaching?

Rise slowly when sitting up from bed.

A nurse is assessing client brought to the hospital psychiatric emergency services by a law enforcement officer. The client has disorganized, incoherent speech with loose associations and religious content. You should recognize the signs and symptoms as being consistent with which of the following?

Schizophrenia

The nurse is assessing an adolescent client for sickle cell anemia. Which of the following is a priority finding by the nurse?

Shortness of breath

*A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the following actions in response take?

Sit at or below the clients eye level during feedings.

A nurse is monitoring the client during an IV urography procedure. Which of the following client reports is the priority finding?

Swollen lips

A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment?

Tell me how often do you drink alcohol

A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client. They are using the clients name and discussing details of his diagnosis. Which of following actions should the nurse take first?

Tell the AP to discontinue their conversation

A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which the following indicates that the client is in the latent phase of labor?

The cervix is dilated 2 cm

*A nurse is providing preoperative teaching to a client who will use PCA morphine sulfate following surgery. Which of the following information should the nurse include?

The client can administer a dose of medication every 6 to 8 min.

A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately?

The client experiences coughing and wheezing after eating.

A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority?

The client has surgical hypoparathyroidism and positive Trousseau's sign

Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

The nurses assessing a client plus blood glucose level of 250 mg/dl. Which of the following clinical manifestations are associated with this finding?

Thirst

The nurses providing teaching to a client who has mild persistent asthma has been prescribed montelukast. Which of the following statements to the nursing put in teaching?

This medication helps decrease swelling and mucus production

A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

Transport a school-age child to x-ray.

A nurse in the telemetry unit is receiving the laboratory findings for adult male client who's been treated for myocardial function. The following is an expected finding for the client?

Troponin 1 (TNI) 8 ng/ml

The nurses caring for a client whose taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication?

Uric acid level

Nurses caring for a client whose 1 day postop following a Hypophysectomy for the removal of the pituitary tumor. Which of the following findings requires further assessment by nurse?

Urinary output greater than fluid intake

A nurses caring for client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

Urine output of 20 mL per hour

A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

Urine specific gravity 1.001

A nurse is caring for a client who has human immunodeficiency virus (HIV) with neutropenia. Which of the following precautions should the nurse take while caring for this client

Use a dedicated stethoscope for the client.

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

Use a designated stethoscope when caring for the toddler.

A nurse is teaching a female client how to reduce the risk of urinary tract infections (UTIs). Which of the following should the nurse include as a risk factor for developing a UTI?

Using perfumed toilet paper

*A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene?

Viewing the newborn's actions to be uncooperative

A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should nurse report to provider?

WBC3,000/mm3

A nurse is planning care for client sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Wear a dosimeter film badge while in the client's room

A nurse is providing teaching to a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following should the nurse include in the teaching?

Wear clothing over the area of radiation treatment.

A nurse caring for a client who is receiving total parental nutrition. Which of the following assessment findings required immediate intervention by the nurse?

Weight increase of two kg/day

A nurse is caring for client who is taking levothyroxin. Which of the following findings should indicate that the medication is effective?

Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)

A nurse is caring for a male adolescent client who has heart failure. Based on the client's chart finds. Which of the following actions should the nurse plan to take?

Withhold digoxin (0.8-2.0)

A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should nurse take?

Withhold heparin IV infusion

A charge nurse is evaluating the time management skills for new licensed nurse. The charge nurse should intervene when a newly licensed nurse does which of the following?

Works on several tasks simultaneously

A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash after a school event. The mother states, I never should have let him take the car. Its all my fault!" Which of the following responses by the nurse is appropriate?

You appear to be feeling overwhelmed"

A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate?

You should receive Rh immune globulin within 72 hours of delivery."

client is receiving IV moderate (Conscious) sedation with midazolam. The client has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?

administer flumazenil

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is

asymmetric, with variegated coloring

A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces contaminated with blood. Which of the following agents said the nurse include in the teaching?

chlorine bleach

A nurse is caring for a client who is preparing his advance directives. Which is the following statements by the client indicates an understanding of advanced directives? select all that apply

d) I have the right to refuse treatment e) My health care proxy can make medical decisions for me

A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should nurse monitor?

d) Weight

A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?

diaphoresis

A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first?

dry the newborn

A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as in an indication for hemodialysis?

glomerular filtration rate of 14 mL/ minute

A nurse is assisting the provider with a paracentesis for a client who has ascites. Following collection of the specimen, which of the following actions should the nurse take next

label the specimen

A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding?

oatmeal

A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention?

paresthesia of the distal extremity

A community health nurse is teaching a group of adults about the importance of health screenings. The nurse should include African American males almost twice as likely as caucasian males to experience which of the following?

stroke

A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which of the following is the safest site for the nurse to use?

ventrogluteal

Nurse is giving discharge instructions to client has new ileostomy. The nurse should recognize that the teaching has been effective when the client states.

My stoma will drain liquid fluid continuously

A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash. Which of the following interventions are appropriate? Select all that apply

a. Apply direct pressure to bleeding wounds c. Cover wounds with a sterile dressing e. Determine date of last tetanus toxoid vaccination.

A provider has written a do not resuscitate order for a client who is comatose and does not have advance directives. A member of the clients family says to the nurse, "I wonder when the doctor will tell us what's going on" Which of the following actions should the nurse take first

Ask the family what the provider has discussed with them.

The nurse is completing an assessment for newborn who is 2 hrs old. Which of the following findings are indicative of cold stress?

Jitteriness of the hands

A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility policy prohibits smoking inside. Which of the following actions should the nurse take?

Inform the client of the risks involved if she leaves.

A nurses caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client. "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?

a) Assault