Knowledge and Clinical Judgment
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill?
Chlorine (bleach)
A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider?
Dimpling of the tissue in the upper outer quadrant.
A nurse is assisting with the preparation of an education program regarding advance directive for newly hired staff. Which of the following information should be included about living wills?
Living wills detail treatment wishes of the client in the event of terminal illness.
A nurse is assisting with preparation f a teaching program abut healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program?
Prepare a health meal to serve at the end of class
A nurse is caring for a client who is receiving intermittent enteral tube feeding and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings?
Reduce the rate of the feedings.
A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter?
Supine
A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicated a need for further teaching to prevent life injuries?
Twisting at the waist and shoulders.
A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing and adverse effect of the medication?
Urinary Retention
A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions?
away from the body
A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status?
deep reddish-colored tongue
A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching?
q.d.
A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxain (Cipro) 250 mg PO two times daily. The amount available is 100 mg/tablet. How many tablets should the nurse administer with each dose?
2.5 tablets
Which collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take?
Cover the area with a transparent wound barrier.
A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (prednisone). Which of the following indicated the client is experiencing an adverse effect of the medication?
Hyperglycemia
A nurse is collecting data on a recently admitted client. What of the following techniques should the nurse us to measure tissue perfusion?
Obtaining the client's level of oxygen saturation.
A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin?
Pallor
The nurse is providing discharge education to the parents of a preschooler who has prescribed acetaminophen (Tylenol) 300 mg every 4 hr as needed. The acetaminophen liquid suspension that has been prescribed provides 120 mg/5 mL. How many teaspoons should the nurse teach the parents to administer per dose?
2.5 tsp
A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicated a breach of confidentiality and requires intervention by the nurse preceptor?
Discussing changes in a client's plan of care with his friend who is a nurse in another unit.
A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teachings?
I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities.
A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, "I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate?
Tell me more about your concerns.
