nclex

The nurse has reinforced teaching with a client who is receiving prescribed vardenafil. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1."I will take the medication one hour before I engage in sexual activity." 2."I may experience a headache and facial flushing." 3."I can continue to take prescribed isosorbide mononitrate." 4."I should notify my primary health care provider if I have pain in my jaw." 5."I can take an additional dose of the medication if I do not experience the desired effects within three hours."

1,

The nurse has attended a staff development conference about advance directives. Which of the following information should the nurse understand pertains to advance directives? Select all that apply. 1.living will 2.organ donation 3.implied consent 4.do not resuscitate (DNR) prescriptions 5.power of attorney for health care

1,2,3,4

The nurse is collecting data from a client who had a kidney transplant 5 days ago. Which of the following findings would require immediate intervention? 1.blood pressure, 154/96 mm Hg 2.blood urea nitrogen (BUN), 20 mg/dL (7.1 mmol/L) 3.urine output of 120 mL in the past 4 hours 4.incisional pain rated 5 on a scale of 0 (no pain) to 10 (severe pain)

3

The nurse in an outpatient care facility has received the following telephone messages from clients who were previously seen at the facility. The nurse should first telephone the client who is reporting 1.no memory of the postprocedure instructions following an esophagogastroduodenoscopy (EGD) 2.a sore throat and cough following a bronchoscopy 3.shortness of breath following a bronchoscopy 4.abdominal cramping following a colonoscopy

3.shortness of breath following a bronchoscopy

The nurse is caring for a client who is experiencing new onset profuse epistaxis. Which of the following actions should the nurse take? Select all that apply. 1.Check the client's vital signs. 2.Apply a warm compress to the client's nose. 3.Assist the client to apply pressure to the nares. 4.Encourage the client to spit out blood instead of swallowing it. 5.Place the client in an upright position with the head tilted forward. 6.Encourage the client to blow the nose periodically until the epistaxis resolves.

3,4,5

The nurse is contributing to a staff development conference about clients who are pregnant and rubella non-immune. Which of the following information should the nurse suggest including? Select all that apply. 1."Fetal effects from the mother's exposure to rubella tend to be mild." 2."Exposure to rubella during pregnancy is only harmful in the first trimester." 3."Clients that are not immune to rubella should be vaccinated postpartum. 4."Antibiotics administered after exposure eliminate the risks of rubella for the fetus." 5."Pregnancy should be prevented for 4 weeks after receiving the rubella vaccine."

3,5

The nurse has reinforced teaching with a client who is receiving prescribed alendronate. Which of the following statements by the client would indicate a correct understanding of the teaching? 1."I should take the medication with orange juice." 2."I can take the medication at any time of day." 3."I will avoid taking over-the-counter (OTC) vitamin D supplements." 4."I must sit upright for 30 minutes after taking the medication."

4. "I must sit upright for 30 minutes after taking the medication."

The nurse is collecting data from a client with sickle cell anemia. Which of the following statements by the client would be essential to follow up? 1."I usually drink 4 L of water or juice daily." 2."I am scheduled to receive the influenza vaccine." 3."I may need to receive a prescribed anti-infective if I develop a fever." 4."I have been applying cold packs daily to help relieve the pain in my knees."

4."I have been applying cold packs daily to help relieve the pain in my knees."

The nurse is reinforcing teaching with a client who has iron-deficiency anemia. Which of the following information should the nurse reinforce? Select all that apply. 1."Continue to take your prescribed iron supplement after your symptoms resolve." 2."Consult with a genetic counselor to establish inheritance patterns." 3."Alternate periods of activity and rest throughout the day." 4."Increase your dietary intake of foods such as legumes."" 5."Take the prescribed iron supplement with a glass of milk if you experience gastric upset."

5."Take the prescribed iron supplement with a glass of milk if you experience gastric upset."

The nurse is collecting data from a client with an acute myocardial infarction (MI). Which of the following findings would be consistent with an acute MI ? Select all that apply. 1.nausea and vomiting 2.diaphoresis 3.dyspnea 4.nailbed splinter hemorrhages 5.petechiae

5.petechiae

what to do when the patient has pertussis?

Wear a surgical mask when assisting the client to eat or giving medications

The nurse is preparing to insert a nasogastric (NG) tube for a client. Select, in the correct order, the steps the nurse should take. All options must be used.

steps

The nurse is caring for a 12-year-old client who has a prescription for lorazepam 0.05 mg/kg, p.o., stat. The client weighs 103 lb (47 kg). The nurse has 2 mg/mL of solution available. How many milliliters should the nurse administer to the client? Record your answer using one decimal place.

0.05mg/kgXx/47X2mg/ml=

The nurse is caring for a client who has a prescription for darbepoetin 0.45 mcg/kg, subcutaneously. The client weighs 190 lb (86 kg). The nurse has 100 mcg/mL of solution available. How many mL should the nurse administer with each dose? Record your answer using one decimal place.

0.45mcg/kg X x/86X ml/100 mcg = 0.38 or 0.4

The nurse is contributing to a staff development conference about electronic medical records. Which of the following information should the nurse suggest including? Select all that apply. 1."An advantage of using electronic medical records is improved legibility in documentation." 2."The nurse should log off the computer system before leaving a computer terminal." 3."An issue surrounding computerized documentation is access to secure information." 4."A nurse with experience documenting in 1 electronic medical record system can use another system without training." 5."The nurse should refrain from sharing security passwords for the electronic medical record system." 6."A disadvantage of the use of electronic medical records is that departments are unable to interact within the system."

1,2,3,5

The nurse is contributing to a staff education conference about advance directives. Which of the following information should the nurse recommend including? Select all that apply. 1."Advance directives support a client's ethical right to autonomy." 2."A client may designate another person to make health care decisions for the client." 3."Health care facilities must ask clients if they have completed an advance directive." 4."Advance directives indicate a client's treatment wishes for acute diagnoses." 5."A living will must be witnessed by a client's attorney."

1,2,4

The nurse is reinforcing teaching with a client who is at risk for coronary artery disease (CAD). Which of the following information should the nurse reinforce? Select all that apply. 1."Exercising once a week will decrease the risk for CAD." 2."You should maintain a body mass index (BMI) of less than 25." 3."You may continue to consume alcoholic beverages as you desire." 4."You should avoid exposure to environmental tobacco smoke." 5."A diet high in fruits, vegetables and unsaturated fats will decrease your risk for CAD."

1,2,5

The nurse is preparing to administer prescribed regular insulin to a client. Which of the following routes should the nurse understand can be used to administer regular insulin? Select all that apply. 1.subcutaneous 2.oral 3.intravenous 4.intramuscular 5.intradermal

1,3

The nurse is collecting data from a client who has hypovolemic shock. Which of the following findings would be consistent with hypovolemic shock? Select all that apply. 1.confusion 2.hypertension 3.decreased urine output 4.elevated respiratory rate 5.jugular vein distention (JVD)

1,3,4

The nurse has reinforced teaching with a female client who sustained a spinal cord injury at T5 three weeks ago. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply. 1."I need to maintain a fluid intake of at least 2 L daily." 2."I will be able to ambulate with crutches once I have completed physical therapy." 3."I will need to perform range-of-motion (ROM) exercises several times each day." 4."I should see a fertility specialist if I want to conceive a child because I may be infertile." 5."I should notify my primary health care provider if I experience a pounding headache."

1,3,5

The nurse is assisting with the plan care for a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply. 1.Avoid the use of restraints. 2.Avoid reminiscing about happy times in the client's life. 3.Use distraction when the client becomes anxious or agitated. 4.Provide the client with a wide selection of food choices at mealtimes. 5.Speak slowly and use short, simple sentences when providing the client with information. 6.Provide family members with information about community support services for respite care.

1,3,5,6

The nurse on the maternity unit is talking with a staff member from another unit. The staff member asks the nurse about a mutual friend who had a baby at the health care facility. Which of the following would be an appropriate response for the nurse to make? Select all that apply. 1."You should give her a call on the telephone to see how she is doing." 2."I saw her this morning, and she is going to be discharged home today." 3."Take a look in the computer system to find out which room she is in so you can visit." 4."I understand the delivery went well and her spouse is with her." 5."I cannot give you any information about her condition."

1,5

The nurse is preparing to administer prescribed regular insulin and NPH insulin to an assigned client. Select, in the correct order, the steps the nurse should take. All options must be used. 1. Aspirate a volume of air equal to the prescribed dose of NPH insulin and inject the air into the vial 2. Withdraw the prescribed amount of regular insulin into the syringe 3. With draw the prescribed amount of NPH insulin into the syringe 4. Administer the injection to the client 5. Aspirate a volume of air equal to the prescribed dose of regular insulin and inject the air into the vial

1,5,2,3,4

The nurse is caring for assigned clients. The nurse should recognize that the client at highest risk for developing peritonitis is a client who had 1.an appendectomy for a ruptured appendix 12 hours ago 2.a nasogastric (NG) tube inserted 6 hours ago for gastrointestinal (GI) bleeding 3.an abdominal cholecystectomy 16 hours ago and has 300 mL of greenish-brown drainage in the biliary drainage tube 4.a subtotal gastrectomy 8 hours ago and is reporting pain rated 7 on a scale of 0 (no pain) to 10 (severe pain)

1. an appendectomy for a ruptured appendix 12 hours ago

The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide UAP with the best directions for the assignment? 1."Clients who are able to ambulate should be assisted to ambulate after meals." 2."Notify me if any client develops an abnormal temperature." 3."Check the meal trays distributed to clients with diabetes mellitus (type 1)." 4."Obtain vital signs first for the client with hypertension and report the results to me."

1."Clients who are able to ambulate should be assisted to ambulate after meals."

The nurse has attended a staff development conference about elder abuse. Which of the following statements by the nurse would indicate a correct understanding of the teaching? 1."Clients who are physically disabled and living in a long-term care facility are the typical victims of elder abuse." 2."The nurse should explain to the victim of elder abuse that data collected about the abuse will be kept confidential." 3."Older adults who are abused will readily explain their situation to a health care provider if asked directly." 4."A health care worker or family member who threatens to withhold food, water or medical care is committing a form of abuse."

1."Clients who are physically disabled and living in a long-term care facility are the typical victims of elder abuse."

The nurse is talking with a client who has borderline personality disorder. Which of the following statements would the nurse expect the client to make? 1."I often feel bored and empty." 2."I hear voices others are unable to hear." 3."I need to go to my room to wash my hands again." 4."I am worried the food on this meal tray has been poisoned."

1."I often feel bored and empty."

The nurse has assisted with the orientation of new staff members to the care of postpartum clients. Which of the following statements by a staff member would indicate a correct understanding of the orientation? 1."I should encourage a client to wear gloves when the client applies a prescribed medicated cream to the hemorrhoids." 2."I should wear gloves to assist a client who is breast-feeding her newborn." 3."I must wear a mask when checking a client's lochia." 4."I will offer a client gloves to wear during formula feedings if the client's newborn develops a fine white rash over the nose and chin."

1."I should encourage a client to wear gloves when the client applies a prescribed medicated cream to the hemorrhoids."

The nurse is contributing to a staff education program about caring for a client with active pulmonary tuberculosis (TB). Which of the following information should the nurse suggest including? 1."It is mandatory to report a client's positive TB test results to the public health department." 2."It is necessary to isolate a hospitalized client for 24 hours after initiating antitubercular therapy." 3."Antitubercular therapy is continued until the client provides sputum cultures that test negative for TB." 4."Droplet precautions must be implemented as soon as the hospitalized client is suspected of active TB."

1."It is mandatory to report a client's positive TB test results to the public health department."

The nurse is reinforcing teaching about sleep and rest at home for a client who had a vaginal delivery 24 hours ago. Which of the following information should the nurse reinforce? 1."Take a nap when your baby is sleeping." 2."Perform all of your household chores in the morning, when you have more energy." 3."Wake up and go to sleep at the same time every day." 4."On the weekend, plan and prepare all meals for the week to prevent fatigue."

1."Take a nap when your baby is sleeping."

The nurse is caring for a client who had an abdominal paracentesis 1 hour ago. Which of the following statements by the client would be a priority to follow up? 1."The urine in my drainage bag looks pink." 2."I will avoid sleeping on my left side for two days." 3."I feel dizzy when I change positions in bed too quickly." 4."It is easier for me to breathe when I am sitting up in bed."

1."The urine in my drainage bag looks pink."

The nurse is caring for a client with pediculosis. Which of the following infection control precautions should the nurse implement? 1.Place a thermometer in the client's room to be used with that client only. 2.Wear a surgical mask when assisting the client to bathe. 3.Keep the door to the client's room closed. 4.Remove the gloves after leaving the client's room.

1.Place a thermometer in the client's room to be used with that client only.

The nurse is caring for a client who has mycoplasma pneumonia. Which of the following infection control precautions should the nurse implement? 1.Wear a surgical mask when checking the client's breath sounds. 2.Place the client in a private room with monitored negative air pressure. 3.Place a stethoscope in the client's room to be used with that client only. 4.Remind visitors to put on a protective gown before entering the client's room.

1.Wear a surgical mask when checking the client's breath sounds

The nurse in an outpatient facility has collected the following data regarding the clients' concerns. The nurse should place in a private room first the client with 1.a productive cough with night sweats 2.diabetes mellitus (type 1) with tingling in both feet 3.red eyes with moderate tearing 4.emphysema with clubbing of the fingernails

1.a productive cough with night sweats

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate for the nurse to assign to UAP? 1.applying a condom catheter to the male client with a hip fracture who is incontinent 2.applying a pressure dressing to the right hand of the client who has a stab wound 3.inserting a nasogastric (NG) tube for the client with anorexia nervosa (AN) 4.obtaining vital signs from the client who is experiencing delirium tremens (DTs)

1.applying a condom catheter to the male client with a hip fracture who is incontinent

When collecting data on a 4-month-old client with gastroenteritis, the nurse observes an irregular area of dark blue pigmentation on the client's sacral area. The nurse should first 1.determine whether this finding is normal for an infant of the client's racial background 2.ask the client's parent whether the child has shown any tendency toward bleeding 3.report the finding to the charge nurse as evidence of possible child abuse 4.apply gentle pressure to the area to check for tenderness

1.determine whether this finding is normal for an infant of the client's racial background

The nurse is caring for a client who sustained a closed-head injury. Which of the following findings would require immediate intervention? 1.ecchymotic area over the left temple 2.Glasgow Coma Scale (GCS) score of 13 3.blood pressure of 136/76 mm Hg 4.headache that worsens with coughing

1.ecchymotic area over the left temple

The nurse is collecting data from a client with right-sided heart failure. Which of the following findings would be consistent with right-sided heart failure? Select all that apply. 1.edema 2.dyspnea 3.dry cough 4.weight gain 5.jugular vein distention (JVD)

1.edema 2.dyspnea

The nurse is reinforcing teaching with the parents of a 10-year-old client with a seizure disorder about ketogenic diet therapy. The nurse should reinforce that a ketogenic diet includes foods that are 1.high in fat, contain adequate protein and are low in carbohydrates 2.low in fat, high in sodium and high in protein 3.high in fat, low in protein and contain caffeine 4.low in fat, low in sodium and are lactose-free

1.high in fat, contain adequate protein and are low in carbohydrates

The nurse is contributing to the plan of care for a client with gestational hypertension who is at 32 weeks gestation. Which of the following should the nurse recommend be included in the plan of care? 1.monitoring the client's urinary output 2.instructing the client to report any increase in fetal activity 3.instructing the client to use relaxation techniques to relieve a headache 4.minimizing the client's dietary intake of high-calcium foods

1.monitoring the client's urinary output

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate for the nurse to assign to UAP? 1.obtaining vital signs from the client with major depression 2.providing medication teaching to the client with schizophrenia 3.monitoring medication side effects of the client with bipolar I disorder 4.telephoning the primary health care provider to report the intake and output information from the client with anorexia nervosa (AN)

1.obtaining vital signs from the client with major depression

The nurse is checking a client with disseminated herpes zoster (shingles) who is in a private room. The nurse should understand the client may be developing sensory isolation if the client reports the onset of 1.photophobia 2.headaches 3.anxiety 4.tremors

1.photophobia

The nurse is caring for a client with moderate Alzheimer's disease (AD). The nurse should immediately intervene if a staff member is observed 1.providing the client with a sandwich to eat while wandering in the hallway 2.offering the client several ounces of fluid at regular intervals 3.securing the client to a shower chair before the shower begins 4.letting the client choose what sweater to wear

1.providing the client with a sandwich to eat while wandering in the hallway

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate for the nurse to assign to a UAP? 1.removing a condom catheter for the male client who has a fractured pelvis 2.providing discharge teaching to the client with chronic obstructive pulmonary disease (COPD) 3.evaluating the pain level for the client who had an abdominal hysterectomy several hours ago 4.determining the effectiveness of an antianxiety medication for the client with moderate Alzheimer's disease (AD)

1.removing a condom catheter for the male client who has a fractured pelvis

The nurse is caring for a client who had a thoracentesis 1 hour ago. Which of the following findings would require immediate follow-up? 1.respirations of 24 2.tenderness at the puncture site 3.temperature of 99.6° F (37.6° C) 4.small amount of bleeding at the puncture site

1.respirations of 24

The charge nurse in a long-term care facility has been advised that the following clients will be admitted during the shift. The charge nurse should assign the only available private room to the client with 1.scabies 2.salmonellosis 3.hepatitis B (HBV) 4.cytomegalovirus (CMV)

1.scabies

The nurse is caring for a 6-year-old client who is receiving prescribed skeletal traction. Which of the following would be a priority for the nurse to monitor? 1.the distance between the client's knees 2.the pull of the traction on the client's pins 3.the degree of flexion of the client's ankles 4.the position of the client's cervical spine on the bed

2 the pull of the traction on the client's pins

The nurse is contributing to a staff education conference about informed consent. Which of the following information should the nurse suggest including? Select all that apply. 1."The nurse witnessing the consent is responsible for explaining the procedure to the client." 2."Consent is implied for care required to treat the client's condition in a life-threatening emergency situation." 3."The nurse's signature on a consent form is documentation that the client had no questions about the procedure." 4."When the nurse signs the consent form, the nurse is confirming that the client appears competent to give consent." 5."When the client refuses to give consent for a procedure, the nurse should document the refusal in the medical record."

2,3,4

The nurse is caring for a client who has active pulmonary tuberculosis (TB). Which of the following infection control precautions should the nurse implement? Select all that apply. 1.Put on sterile gloves to administer prescribed medications to the client. 2.Perform hand hygiene prior to checking the client's vital signs. 3.Wear a particulate respirator mask when assisting the client to bathe. 4.Wear a protective gown if clothing may become soiled. 5.Close the door after entering the client's room.

2,3,5

The nurse is contributing to a staff development conference about client confidentiality. Which of the following information should the nurse suggest including? Select all that apply. 1."The client's medical record is the client's property and the client may have access to the record at any time." 2."Unneeded computer-generated worksheets must be shredded at the end of the shift to ensure client confidentiality." 3."Personal computer passwords may not be shared with anyone, including other members of the client's health care team." 4."Medical information about the client may be shared with a police officer who brought the client into the emergency department (ED)." 5."Keep your voice low when speaking with the client because direct interactions with clients must be kept as private as possible."

2,3,5

The nurse is contributing to the plan of care for a client who sustained full-thickness (third-degree) burns on 30% of the body 3 days ago. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply. 1.Discourage movement of the affected body parts. 2.Offer the client prescribed opioid analgesics prior to providing wound care. 3.Wear a hair covering and a surgical mask when the burn wounds are exposed. 4.Use ice and other cold therapy as an adjunct to pharmaceutical pain relief. 5.Stress the importance of strict intake and output recording for the client with the unlicensed assistive personnel (UAP).

2,3,5

The nurse in a rehabilitation facility is admitting a client who had a stroke. The client has an advance directive. Which of the following actions should the nurse take? Select all that apply. 1.Obtain a do not resuscitate (DNR) prescription for the client. 2.Make the health care team aware of the advance directive. 3.Notify the client's family that emergency care will not be given.. 4.Witness the client's signature on the advance directive, and have it notarized. 5.Document in the medical record that the client has an advance directive.

2,5

The nurse has reinforced teaching with a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements by the client would indicate a correct understanding of the teaching? 1."I will experience a tonic-clonic seizure for approximately 15 minutes during the ECT procedure." 2."ECT is commonly used to treat depression when several antidepressants have not been effective." 3."ECT is effective because it decreases the level of neurotransmitters in the central nervous system." 4."Common side effects of ECT are diarrhea, a low-grade fever and short-term memory loss."

2. "ECT is commonly used to treat depression when several antidepressants have not been effective."

The nurse has participated in a staff development conference about caring for clients with various religious beliefs who are terminally ill. Which of the following statements by the nurse would indicate a correct understanding of the teaching? 1."A family member will turn a client who practices Buddhism east to face Mecca prior to death." 2."After death, a member of a burial society will wash the body of a client who practices Orthodox Judaism." 3."After death, a family member will cover the mirrors in the room of a client who practices the Greek Orthodox religion." 4."A priest will tie a thread around the wrist of a client who practices Roman Catholicism to signify a blessing prior to death."

2."After death, a member of a burial society will wash the body of a client who practices Orthodox Judaism."

The nurse is contributing to a staff development conference about informed consent for surgery. Which of the following information should the nurse suggest including? 1."The nurse must be present when the surgeon explains the surgical procedure to the client." 2."All minors require a parent's or guardian's consent for a surgical procedure." 3."Clients cannot withdraw consent once consent has been obtained." 4."The nurse may sign the consent form as a witness to the client's signature."

2."All minors require a parent's or guardian's consent for a surgical procedure."

The nurse is reinforcing teaching with a client with chronic lymphocytic leukemia who is at risk for developing thrombocytopenia. Which of the following information should the nurse reinforce? 1."You should use a disposable razor rather than an electric razor when shaving." 2."Frequent deep-breathing exercises should be performed, but avoid coughing and blowing your nose." 3."Frequent oral hygiene should be performed, including flossing your teeth and using alcohol-based mouthwashes." 4."You may take over-the-counter (OTC) ibuprofen for any discomforts, but avoid using OTC acetaminophen."

2."Frequent deep-breathing exercises should be performed, but avoid coughing and blowing your nose."

The nurse has reinforced teaching with a client who has an ileal conduit. Which of the following statements by the client would indicate a correct understanding of the teaching? 1."I will need to awaken several times at night to empty the pouch." 2."I can expect to have mucus in my urine." 3."The stoma should be a dark purple color." 4."I will need to limit my fluid intake."

2."I can expect to have mucus in my urine."

The nurse is caring for a client who has just been told their cancer has metastasized. The nurse enters the room and observes the client crying. Which of the following responses would be appropriate for the nurse to make first? 1."You seem upset. May I sit with you for awhile?" 2."I can telephone a family member to come and stay with you." 3."Do you have a spiritual advisor that you would like me to notify?" 4."I will give you some time alone and will come back soon."

2."I can telephone a family member to come and stay with you."

The nurse is preparing to insert an indwelling urethral catheter for an assigned client. Which of the following statements by the client would be a priority to follow up? 1."I have had a catheter before and felt pressure when the catheter was placed." 2."I developed a rash on my neck when I ate shrimp several months ago." 3."I just urinated so I won't need a catheter placed." 4."I haven't been drinking many fluids lately."

2."I developed a rash on my neck when I ate shrimp several months ago."

The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which of the following statements by the client would be essential to follow up? 1."I prefer to receive my medication subcutaneously rather than intramuscularly." 2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1 year ago." 3."I held pressure on the puncture site for 5 minutes after the nurse drew blood from my arm." 4."I have avoided blowing my nose today because I have had 2 episodes of epistaxis."

2."I have been taking 1 aspirin every day since I had a myocardial infarction (MI) 1 year ago."

The nurse is talking with the parent of a 3-month-old client. The parent expresses concern that the infant is unable to roll over. Which of the following would be an appropriate response for the nurse to make? 1."We should inform your child's primary health care provider about this delay." 2."Most infants are able to roll over between the ages of 4 to 6 months." 3."Does your infant smile in response to your smile?" 4."Is your infant able to pick up objects?"

2."Most infants are able to roll over between the ages of 4 to 6 months."

The nurse is contributing to a staff development conference about confidentiality. Which of the following information should the nurse suggest including? 1."Clients must wait until after discharge to view their medical records." 2."Nurses on a hospital unit may review the medical records for all clients on that unit." 3."Certain information in the client's medical record may not be considered confidential." 4."Clients must disclose all personal information in order to receive care."

2."Nurses on a hospital unit may review the medical records for all clients on that unit."

The charge nurse in a long-term care facility has made client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the charge nurse would provide the best information to a UAP about the assignment? 1."The client needs assistance to get out of bed." 2."The client needs to have food cut into bite-sized pieces." 3."The client needs range-of-motion (ROM) exercises every 4 hours." 4."The client needs frequent perineal care."

2."The client needs to have food cut into bite-sized pieces."

The charge nurse in a long-term care facility has made client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the charge nurse would provide the best ​directions to a UAP about the assignment? 1."The client with a urinary tract infection (UTI) should drink two pitchers of water this shift." 2."The client with mild dementia needs assistance with bathing." 3."The client who had a stroke needs to ambulate in the hallway." 4."The client with peripheral neuropathy should receive good skin care."

2."The client with mild dementia needs assistance with bathing."

The charge nurse in a long-term care facility has completed client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the charge nurse would provide the best directions to a UAP regarding the assignment? 1."Record your assigned clients' vital signs before you take a mid-morning break." 2."Weigh your assigned clients before breakfast with the scale used 1 day ago." 3."Help the clients who eat their meals in the dining room with breakfast." 4."Measure your assigned clients' intake and output regularly."

2."Weigh your assigned clients before breakfast with the scale used 1 day ago."

The nurse is reinforcing teaching with a client who is scheduled for a thoracentesis. Which of the following information should the nurse reinforce? 1."You should lie on the affected side for 4 hours after the procedure." 2."You will be placed in a sitting position with your arms resting on a bedside table during the procedure." 3."You will be given a dose of a prescribed sedative/hypnotic before the procedure." 4."You should not have anything to eat or drink for 24 hours before the procedure."

2."You will be placed in a sitting position with your arms resting on a bedside table during the procedure."

The charge nurse in a long-term care facility has just completed client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the charge nurse would provide the best direction to a UAP about the assignment? 1."The client with heart failure should be weighed and have vital signs checked before breakfast is served." 2."You will need to assist the client with mild Alzheimer's disease (AD) with activities of daily living (ADL)." 3."You need to follow proper infection control precautions when assisting the client with active pulmonary tuberculosis (TB)." 4."The client with paraplegia should have the monthly safety check completed on the wheelchair."

2."You will need to assist the client with mild Alzheimer's disease (AD) with activities of daily living (ADL)."

The nurse is reinforcing teaching with the parents of a 9-year-old child who is receiving prescribed methylphenidate. Which of the following information should the nurse reinforce? 1."Give your child methylphenidate no more than 3 hours before bedtime." 2."Your child will need to visit the primary health care provider periodically." 3."Check your child's pulse daily before administering methylphenidate." 4."Increase your child's intake of foods that are high in iron and potassium."

2."Your child will need to visit the primary health care provider periodically."

The nurse has reinforced dietary teaching with a client who has esophageal varices. Which of the following food choices by the client would indicate a correct understanding of the teaching? 1.1 cup vanilla yogurt 2.8 oz of chicken broth 3.4 oz of pretzels 4.1 fresh apple

2.8 oz of chicken broth

The nurse is contributing to the plan of care for a client who has a nasogastric (NG) tube for feeding. Which of the following interventions should the nurse recommend including in the client's plan of care? 1.Raise the head of the client's bed 15 degrees. 2.Apply sterile gloves to irrigate the client's NG tube. 3.Use pH paper to measure the pH of the client's aspirate. 4.Encourage the client to cough while removing the NG tube.

2.Apply sterile gloves to irrigate the client's NG tube.

The nurse is caring for a client who has a prescription for a sputum specimen for culture and sensitivity (C & S). Which of the following actions should the nurse take? 1.Request a prescription for a bronchodilator to be administered before the specimen is obtained. 2.Place the specimen in the refrigerator until it can be transported to the laboratory. 3. Tell the client to rinse the mouth with water before the specimen is obtained. 4.Obtain the sputum specimen before the client goes to bed at night.

2.Place the specimen in the refrigerator until it can be transported to the laboratory.

The nurse is contributing to the plan of care for a client with chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse suggest including in the client's plan of care? 1.Place the client in low-Fowler's position for meals. 2.Provide the client with a high-carbohydrate diet and high-carbohydrate snacks. 3.Restrict the client's fluid intake to 500 mL daily. 4.Provide the client with small, frequent meals, and schedule a rest period before and after meals.

2.Provide the client with a high-carbohydrate diet and high-carbohydrate snacks.

The nurse is contributing to the plan of care for a client who had a stroke 3 days ago and has right-sided hemiplegia and dysphagia. Which of the following nutritional outcomes would be most appropriate for the nurse to recommend including in the client's plan of care? 1.The client will eat 90% of each meal. 2.The client will eat without episodes of coughing. 3.The client will drink 4 oz of juice or water with each meal. 4.The client will drink liquids without drooling.

2.The client will eat without episodes of coughing.

The charge nurse in a long-term care facility has been advised that the following assigned clients will be admitted during the shift. The charge nurse should assign the only available private room to the client with 1.Pneumocystis pneumonia (PCP) 2.a positive varicella zoster titer 3.hepatitis C (HCV) 4.a positive cytomegalovirus (CMV) titer

2.a positive varicella zoster titer

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate to assign to UAP? Select all that apply. 1.bathing the client who has an altered mental status 2.assisting the client who uses a walker to ambulate 3.checking the vital signs of the client who has a peripheral venous access device (VAD) 4.adjusting the prescribed oxygen flow rate for the client based on oxygen saturation levels 5.measuring the oral intake and urine output for the client who has an indwelling urethral catheter

2.assisting the client who uses a walker to ambulate

The nurse is collecting data from a client with a preliminary diagnosis of abdominal aortic aneurysm. Which of the following findings would be consistent with an abdominal aortic aneurysm? 1.urinary retention 2.back pain 3.neck vein distention 4.dysphagia

2.back pain

The nurse is caring for a client with a panic disorder. Which of the following findings would the nurse expect to observe? 1.dry skin 2.chest pain 3.decreased pulse 4.delusional thinking

2.chest pain

The nurse is contributing to the plan of care for a client with multiple sclerosis (MS). Which of the following should the nurse recommend be included? 1.encouraging the client to perform aerobic exercise several times daily 2.limiting the amount of time that the client spends in a hot environment 3.offering the client between-meal snacks that are high in vitamin C 4.keeping the client's legs elevated when sitting upright in a chair

2.limiting the amount of time that the client spends in a hot environment

The nurse is reinforcing discharge instructions with a client taking prescribed isosorbide dinitrate. The nurse should reinforce that the client should avoid 1.exposure to sunlight 2.sudden position changes 3.vigorous exercise 4.taking antacids

2.sudden position changes

The nurse in a rehabilitation facility is caring for a client who had a right knee arthroplasty 8 days ago and has been diagnosed with pneumonia. The client is being transferred to an acute care facility. It would be essential for the nurse to communicate in the transfer report that 1.the discharge to home is anticipated for the client after 1 more week of physical therapy 2.the client lives in a ranch home that requires climbing 2 stairs to get into the house 3.the most recent focused data collection reveals bilateral crackles (rales) auscultated in the client's lungs 4.the client's spouse will be visiting the client at the hospital later today after leaving work

2.the client lives in a ranch home that requires climbing 2 stairs to get into the house

The nurse is contributing to a staff education conference about atenolol. Which of the following information should the nurse recommend including in the conference? 1."Atenolol blocks the vasoconstrictor and aldosterone-producing effects of angiotensin II." 2."Atenolol blocks the conversion of angiotensin I to angiotensin II." 3."Atenolol blocks the stimulation of beta1 adrenergic receptors." 4."Atenolol blocks the post-synaptic alpha1 adrenergic receptors."

3."Atenolol blocks the stimulation of beta1 adrenergic receptors."

The nurse is caring for a client who has been diagnosed with a hookworm infestation. The client's parent asks, "How can I prevent my other children from getting hookworm?" Which of the following would be an appropriate response for the nurse to make? 1."Cook all meats thoroughly." 2."Have your pets treated for worms." 3."Encourage your children to wear shoes when outside." 4."Wash all clothing in hot water."

3."Encourage your children to wear shoes when outside."

The nurse is collecting data from an 85-year-old male client. Which of the following statements would be essential to follow up? 1."I find that it takes longer to do tasks such as balancing my checkbook." 2."I feel some stomach discomfort after eating a large meal." 3."I have awakened from sleep because of shortness of breath." 4."I have a problem starting a strong stream of urine."

3."I have awakened from sleep because of shortness of breath."

The nurse has reinforced discharge teaching with the parent of a newborn. Which of the following statements by the parent would require follow-up? 1."I will leave my baby's diaper off when possible if the diaper area starts to become red." 2."I will secure my baby in a rear-facing infant seat in the front seat of the car since there is an airbag there." 3."I should give my baby a pacifier at bedtime to reduce the risk for sudden infant death syndrome (SIDS)." 4."I should squeeze the bulb syringe before inserting it into my baby's mouth when I suction excess secretions."

3."I should give my baby a pacifier at bedtime to reduce the risk for sudden infant death syndrome (SIDS)."

The nurse is talking with the spouse of a client who has malignant melanoma and is terminally ill. Which of the following statements by the spouse would be essential to follow up? 1."I give my spouse the prescribed pain medication regularly even though the medication causes my spouse to become drowsy." 2."I feel as though there is so much happening now and I have been relying on my adult children to help care for my spouse." 3."I sometimes feel bad because I often have 1 or 2 glasses of wine to help me relax and sleep at night." 4."I try to keep my spouse's window open when the weather is nice because my spouse enjoys listening to the birds."

3."I sometimes feel bad because I often have 1 or 2 glasses of wine to help me relax and sleep at night."

The nurse is assisting with the admission of a client who is scheduled for a colon resection. Which of the following statements made by the client would be most important for the nurse to clarify? 1."I take acetaminophen for occasional headaches." 2."I had successful cataract surgery two years ago." 3."I usually have a few glasses of wine in the evening." 4."I have urinary incontinence when I sneeze."

3."I usually have a few glasses of wine in the evening."

The nurse has reinforced teaching with a client who had a colostomy created 5 days ago. Which of the following statements by the client would indicate a correct understanding of the teaching? 1."I will begin an aerobic exercise program because I will not be able to go swimming." 2."I should avoid emptying the pouch more than two times a day so that I do not loosen the seal around the appliance." 3."I will notify my primary health care provider if I develop a fever or redness and drainage from the incision." 4."I can expect to experience a burning sensation around the stoma until the incision is completely healed."

3."I will notify my primary health care provider if I develop a fever or redness and drainage from the incision."

The nurse has reinforced teaching with clients about preventing skin cancer. Which of the following statements by a client would indicate a correct understanding of the teaching? 1."I can wear a wide-brimmed hat rather than sunscreen if I am outdoors for a short period of time." 2."I will gradually increase the amount of time I am exposed to the sun to prevent sunburn." 3."I will wear sunscreen with a sun protection factor of at least 15 when spending time in the sun." 4."I do not need to wear sunscreen on cloudy days because clouds provide natural protection."

3."I will wear sunscreen with a sun protection factor of at least 15 when spending time in the sun."

A client is admitted with severe pain in the left lower extremity. The client is scheduled for a complete blood count (CBC), urinalysis, chest x-ray, and x-ray of the lower extremities. The client asks the nurse, "Why do I have to have all these tests? The pain is in my leg." Which of the following responses by the nurse will best help the client deal with feelings of anxiety? 1."The tests will not take long to complete." 2."These tests are part of the admission procedure." 3."It must be difficult not understanding what is happening to you." 4."Perhaps that is something you need to discuss with your physician."

3."It must be difficult not understanding what is happening to you."

The nurse is contributing to a staff education conference about the stages of grief in clients with terminal illness. Which of the following information should the nurse suggest including? 1."The nurse should confront the client in the denial phase and emphasize that the client's diagnosis will indeed result in death." 2."The nurse should leave the client alone as much as possible if feelings are misdirected toward the nurse during the anger phase." 3."The client may openly express feelings of sadness during the depression phase or withdraw from friends and family members." 4."The client avoids making plans during the acceptance phase."

3."The client may openly express feelings of sadness during the depression phase or withdraw from friends and family members."

The nurse has reinforced teaching with a female client who will receive prescribed oxytocin for induction of labor. Which of the following statements by the client would indicate a correct understanding of the teaching? 1."The breathing exercises that I learned will not help manage labor pain." 2."I will have my blood pressure checked every 60 minutes." 3."The oxytocin infusion can result in uterine hyperstimulation and fetal harm." 4."I can expect to have a headache and vomiting because of the oxytocin infusion."

3."The oxytocin infusion can result in uterine hyperstimulation and fetal harm."

The nurse is talking with the spouse of a client with left-sided hemiplegia. The spouse tells the nurse, "I scheduled this appointment because I noticed a sore had developed on my spouse's hip. I feel so guilty because I caused this to happen. I do not know what to do." Which of the following would be an appropriate ​initial ​response for the nurse to make? 1."Have you been offering your spouse fluids at regular time intervals?" 2."How often do you change your spouse's position?" 3."The type of care that you have undertaken is not easy." 4."We will make sure that you have help if this requires special dressings."

3."The type of care that you have undertaken is not easy."

The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide UAP with the best directions about an assignment? 1."The client is weak on the right side, so please assist the client with dressing and bathing." 2."Please check the client's capillary blood glucose level, and tell me the results by 0700." 3."We need to document vital signs for the client every 4 hours today." 4."Please encourage the client to change positions frequently."

3."We need to document vital signs for the client every 4 hours today."

The nurse is measuring a client for crutches. Which of the following actions should the nurse take? 1.Measure the client's height and subtract 8 in (20 cm) to obtain the correct crutch length. 2.Ask the client to stand upright and position the shoulder rest of the crutch 6 in (15 cm) below the axilla. 3.Adjust the crutches so the client's elbows are at a 30-degree angle while the client's hands are resting on the hand grips. 4.Measure from the anterior fold of the axillae to the toes of the client's feet and add 1 in (2.5 cm) while the client is in a supine position.

3.Adjust the crutches so the client's elbows are at a 30-degree angle while the client's hands are resting on the hand grips.

The nurse is caring for a client born 6 hours ago and observes the finding depicted below. Which of the following actions should the nurse take in response to this finding? 1.Notify the primary health care provider of the findings. 2.Continue to perform routine newborn care. 3.Administer oxygen therapy prescribed p.r.n. 4.Prepare the client for phototherapy.

3.Administer oxygen therapy prescribed p.r.n.

The nurse is assisting to admit a client with active pulmonary tuberculosis (TB). Which of the following actions should the nurse take prior to the client's arrival? 1.Assign the client to room with a client who has pertussis if a private room is not available. 2.Have a particulate respirator mask available for client transport. 3.Have particulate respirator masks available for staff who care for the client. 4.Post a sign outside the room restricting pregnant women from entering the room.

3.Have particulate respirator masks available for staff who care for the client.

The nurse is reinforcing teaching with a client who is receiving prescribed insulin glargine. Which of the following information should the nurse reinforce? 1.After administering the insulin glargine the same syringe can be used to administer regular insulin. 2.Extra vials of insulin glargine that have not been opened can be stored in the freezer. 3.Insulin glargine does not have a peak action time. 4.Insulin glargine should be administered 3 times each day 15 minutes before meals.

3.Insulin glargine does not have a peak action time.

The nurse is collecting data from a client with Guillain-Barré. The client is experiencing paralysis and paresthesias of the lower extremities and has a respiratory rate of 18. Which of the following actions should the nurse take? 1.Massage the client's legs every 2 hours. 2.Pad the side rails of the client's bed. 3.Monitor the client's respiratory rate frequently. 4.Keep the head of the client's bed elevated at 30 degrees.

3.Monitor the client's respiratory rate frequently.

A nurse who is pregnant is assigned to care for a 3-month-old client with respiratory syncytial virus (RSV) pneumonia. The client is receiving ribavirin therapy. Which of the following actions would be most appropriate for the nurse to take? 1.Maintain strict isolation precautions while caring for the client. 2.Discuss the assignment with the client's physician. 3.Request a change of assignment from the charge nurse. 4.Switch the client assignment with a coworker.

3.Request a change of assignment from the charge nurse.

The nurse is contributing to the plan of care for a client who sustained a spinal cord injury at T1 five days ago. Which of the following interventions should the nurse recommend including in the client's plan of care? 1.Limit the client's fluid intake to one liter daily. 2.Encourage the client to increase the intake of foods high in carbohydrates. 3.Request a prescription for a stool softener to be administered to the client daily. 4.Perform lower extremity passive range-of-motion (ROM) exercises for the client once daily.

3.Request a prescription for a stool softener to be administered to the client daily.

The nurse is collecting data on a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would be a priority to report to the charge nurse? 1.The client reports getting tired easily. 2.The client reports having increased sputum production in the morning. 3.The client's breathing is shallow. 4.The client's sputum is yellow.

3.The client's breathing is shallow.

The nurse is caring for a client who has a prescription to remove a nasogastric (NG) tube. Which of the following actions should the nurse take? 1.Withdraw the tube steadily while the client takes shallow breaths. 2.Have the client hyperextend the neck before withdrawing the tube. 3.Withdraw the tube quickly while the client holds a deep breath. 4.Have the client flex the neck before withdrawing the tube.

3.Withdraw the tube quickly while the client holds a deep breath.

The nurse is caring for a client. Which of the following prescriptions should the nurse clarify? Click the exhibit button for additional client information. 1.2 g sodium diet 2.implement bed rest 3.furosemide 20 mg, p.o., once daily 4.enalapril 5 mg, p.o., twice daily

3.furosemide 20 mg, p.o., once daily

The nurse is caring for a client who has right-sided hemiplegia and is ambulating using a walker. It would indicate a correct understanding of how to use the walker if the client is observed 1.taking a step forward with the left leg and then advancing the right leg and the walker 2.moving the walker forward 12 in (30 cm) then swinging both legs forward together 3.moving the walker and the right leg forward 6 in (15 cm) and then moving the left leg forward 4.placing the rear legs of the walker and the right leg forward and then moving the left leg forward

3.moving the walker and the right leg forward 6 in (15 cm) and then moving the left leg forward

The nurse is reinforcing teaching with the parents of a child who is scheduled for surgical repair of hypospadias. The nurse should reinforce that intended outcomes of the procedure include 1.relief from pain 2.relief from bladder obstruction 3.the ability to void while standing 4.the ability to achieve an erection

3.the ability to void while standing

The nurse is caring for a client who is receiving long-term glucocorticoid therapy. The nurse should encourage the client to select a diet that is high in 1.calcium 2.magnesium 3.thiamine (vitamin B1) 4.vitamin K

3.thiamine (vitamin B1)

The nurse has received the following information about assigned clients. The nurse should first check the client 1.who has right-sided heart failure and is reporting frequent urination 2.with active pulmonary tuberculosis (TB) who is reporting expectorating blood-tinged mucus 3.who has a fractured femur and received a dose of pain medication intramuscularly 1 hour ago and is reporting that the pain has not been relieved 4.with benign prostatic hyperplasia (BPH) who is reporting having no bowel movement for the past 3 days and is requesting a dose of a prescribed laxative

3.who has a fractured femur and received a dose of pain medication intramuscularly 1 hour ago and is reporting that the pain has not been relieved

The nurse is preparing to assist a client who has recently developed a visual impairment to ambulate. To ensure the client's safety, it would be appropriate for the nurse to 1.hold the client's hand while walking next to the client 2.place one hand on the client's shoulder and walk in front of the client 3.apply a gait belt around the client's waist and walk at the client's side 4. instruct the client to hold onto the nurse's upper arm while the nurse walks slightly ahead of the client

4. instruct the client to hold onto the nurse's upper arm while the nurse walks slightly ahead of the client

The nurse is talking with a client who has schizophrenia. The client states, "I just returned from Mars." Which of the following responses would be appropriate for the nurse to make? 1."I need to tell you that you cannot talk about silly things here." 2."Why do you think you made that trip?" 3."How does it feel to be back?" 4."I am here to listen to your concerns."

4."I am here to listen to your concerns."

The nurse is caring for a client with pneumococcal pneumonia. Which of the following statements by the client would require follow-up? 1."I have four cats." 2."I stopped smoking four years ago." 3."I usually swim twice a week." 4."I live with my 89-year-old mother."

4."I live with my 89-year-old mother."

The nurse has reinforced teaching with the parent of a child about prevention of Lyme disease. Which of the following statements by the parent would indicate a correct understanding of the teaching? 1."I will make sure my child is bathed after being outside." 2."I will keep my child away from other children who have Lyme disease." 3."I will ensure that potato salads and macaroni salads are kept at 39.9° F (4.4° C)." 4."I will make sure that my child wears long sleeves and long pants when playing in wooded areas."

4."I will make sure that my child wears long sleeves and long pants when playing in wooded areas."

The nurse is caring for an adolescent recently diagnosed with diabetes mellitus (type 1). The client states, "You don't understand what it is like to have to give yourself injections every day!" Which of the following responses would be appropriate for the nurse to make? 1."I have cared for many clients who are the same age as you and they have adjusted." 2."There are many athletes who have the same diagnosis and are very healthy." 3."I can teach one of your parents how to give the injections." 4."It must be difficult to self-administer an injection every day."

4."It must be difficult to self-administer an injection every day."

The nurse is contributing to a staff education conference about fall prevention. Which of the following information should the nurse recommend including in the conference? 1."Raise the side rails for a client with memory impairment." 2."Encourage a client with impaired balance to avoid ambulation." 3."Instruct a client with orthostatic hypotension to ambulate slowly." 4."Place a commode at the bedside of a client with urinary frequency."

4."Place a commode at the bedside of a client with urinary frequency."

The charge nurse in a long-term care facility has made client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the charge nurse would provide the best directions to a UAP about the assignment? 1."Your clients will need assistance to ambulate once in the morning and once in the afternoon." 2."Obtain vital signs for clients every 4 hours and report any abnormal measurements." 3."Assist clients who are on special diets to eat their meals." 4."Turn clients who are on bed rest onto the left side for 2 hours and then onto the right side for 2 hours until lunch is served."

4."Turn clients who are on bed rest onto the left side for 2 hours and then onto the right side for 2 hours until lunch is served."

The nurse is caring for a 17-year-old client with Guillain-Barré syndrome who is beginning to have return of sensation and motor function. The client states, "I'm going to miss my senior dance. It's not fair." Which of the following responses would be appropriate for the nurse to make? 1."You will be able to have your friends visit and tell you about the dance." 2."You should be happy that you are getting some movement back." 3."You will graduate from high school soon and there will be dances at the college you plan to attend." 4."You are sad because you will miss something you have looked forward to for a long time."

4."You are sad because you will miss something you have looked forward to for a long time."

The nurse is assisting to admit a client who has Streptococcal pharyngitis. Which of the following actions should the nurse take? 1.Wear a surgical mask when checking the client's vital signs. 2.Ensure the assigned room has monitored negative air pressure. 3.Obtain particulate respirator masks for staff members to use when providing client care. 4.Request the dietary department provide disposable dishes and utensils for the client's meals.

4.Request the dietary department provide disposable dishes and utensils for the client's meals.

The nurse is caring for a client who has just returned from the radiology department after having an upper gastrointestinal (UGI) series. Which of the following actions should the nurse take first? 1.Administer the prescribed enema. 2.Give the prescribed multiple vitamin that was withheld prior to the procedure. 3.Determine whether follow-up x-rays are to be taken. 4.Verify the preliminary test results.

4.Verify the preliminary test results.

The nurse is preparing a client for emergency surgery to repair a depressed skull fracture. Which of the following actions would be essential ​for the nurse to take? 1.determining the time that the client last ate 2.showing the client a picture of the postoperative wound drainage system 3.telling the client what will occur in the postanesthesia care unit (PACU) 4.checking the client's corneal reflex

4.checking the client's corneal reflex

The nurse in a pediatric outpatient care facility has received telephone messages from parents of clients who were previously seen at the facility. The nurse should first telephone the parent of a client who has 1.acute otitis media and reports insomnia after taking prescribed amoxicillin 6 hours ago 2.a fracture of the left tibia and has placed a crayon in the cast 3.a colostomy and reports skin irritation around the stoma 4.epilepsy and has pink, frothy sputum

4.epilepsy and has pink, frothy sputum

The nurse has received the following information about assigned clients. The nurse should first check the client who 1.has gastroenteritis, is reporting nausea and vomited 100 mL of green liquid 2.has a long leg cast and is sitting in a chair with the casted leg elevated on a stool 3.had an appendectomy 1 day ago and has a 0.8 in (2 cm) area of serosanguineous drainage on the incision dressing 4.had a thyroidectomy 2 days ago and has muscle spasms in the wrist when the blood pressure is taken

4.had a thyroidectomy 2 days ago and has muscle spasms in the wrist when the blood pressure is taken

The nurse is caring for a client with dysthymic disorder. Which of the following behaviors would the nurse expect to observe? 1.grandiose actions 2.reports of auditory hallucinations 3.expansive, pressured speech 4.inability to experience joy or pleasure in life

4.inability to experience joy or pleasure in life

The nurse is observing a newly hired nurse administer a client's transdermal patch. The nurse should intervene if the newly hired nurse is observed 1.instructing the client to avoid massaging the patch 2.cleansing the client's skin with soap and water after removing the old patch 3.initialing the patch and writing the date and time the patch was applied on the patch 4.omitting documentation about the location on the client's body where the patch was applied

4.omitting documentation about the location on the client's body where the patch was applied

The nurse is observing a coworker suctioning a client with a tracheostomy. The nurse should intervene if the coworker 1.applies suction as the catheter is being withdrawn 2.wears a face shield throughout the procedure 3.applies suction for 10 seconds at each pass of the catheter 4.wears clean, nonsterile gloves throughout the procedure

4.wears clean, nonsterile gloves throughout the procedure

The nurse is caring for a client who is scheduled to have an arterial blood gas (ABG) sample obtained. Which of the following tests should the nurse anticipate will be performed prior to the procedure? 1.Coombs' test 2.Schilling test 3.Ham test 4.Allen test

Allen Test