nclex pn safe, effective care environment

The nurse plans to change the dressing of the client who has had arterial bypass surgery. Which technique is important for the nurse to follow?

Aseptic technique

A sexually active 20-year-old client has developed viral hepatitis. Which statement made by the client would indicate a need for teaching?

"I can never drink alcohol again."

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

"I cannot discuss any client situation with you."

The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?

"I should use disposable plates, forks, and knives."

A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which other precautions should be instituted immediately by the nurse?

Droplet precautions

The nurse is giving a client a bed bath and drops the towel on the floor. The nurse should take which action?

Wash the hands and go to the linen room to obtain another towel.

The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs of anxiety and attempts to assist the client back to the client's hospital room. The next appropriate nursing action at this time is which?

Notify the registered nurse (RN).

The nurse is preparing to change the neck ties on a tracheostomy tube. Which action should the nurse take?

Obtain a second health care team member to assist.

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which action in the care of this client?

Obtain telephone consent from the family member witnessed by two persons.

The nurse should institute which type of precaution for a client diagnosed with Clostridium difficile?

Contact

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

Incoordination Mental confusion Muscle hyperirritability

A resident in a long-term care facility refuses a medication that has been prescribed. The nurse takes appropriate action after considering which fact?

The client cannot be forced to take the medication.

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply.

Turn the client to the side during a seizure. Keep side rails and other hard objects padded.

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?

Wear a gown and gloves.

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

"Accountability can be delegated."

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?

Atropine sulfate (Isopto Atropine)

The nurse is caring for a child with a platelet disorder and should expect which prescriptions from the health care provider? Select all that apply.

Observe for bleeding. encourage the child to rest. Assist the registered nurse (RN) with blood transfusions.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply.

Place the child on a low-bacteria diet. Change dressings using sterile technique. Perform meticulous hand washing before caring for the child.

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

Place the client on one-to-one suicide precautions.

A licensed practical nurse (LPN) is providing instructions to an unlicensed assistive personnel (UAP) who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the UAP performs which action?

Places a dry sterile dressing over the open eyes

The nurse is checking a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the site. The nurse should do which first?

Remove the IV.

A licensed practical nurse has decided to purchase disciplinary defense insurance and is aware that this type of insurance would provide which type of benefits? Select all that apply.

Representation by a qualified attorney Reimbursement for travel to the state board of nursing Payment of all legal fees for defense of a nursing license

The nurse is assisting in caring for a client with a head injury who is restless and is pulling at the intravenous (IV) line. The client's health care provider does not want to sedate the client, and the family has requested that the client not be restrained. The nurse should implement which?

Stay with the client and consult with the nurse manager about the situation.

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

Tell the client that the health care provider will be contacted regarding discharge.

The nurse educator determines that a newly hired licensed practical nurse (LPN) in a local hospital demonstrates an accurate understanding of professional liability insurance when which statement is made?

"I should obtain my own malpractice insurance."

When caring for a 3-year-old child, the nurse should provide which toy for the child?

A wagon

A client with a diagnosis of cystitis has an indwelling urinary catheter and is being cared for by an unlicensed assistive personnel (UAP). The nurse observes the UAP care for the client and intervenes if the UAP performs which action?

Allows the drainage tubing to rest under the leg

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent?

An informed consent needs to be obtained from the client.

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel?

Answering the call light promptly after the enema has been given

The nurse is caring for an older Appalachian client recovering from open heart surgery. In order to provide culturally appropriate care, the nurse should be aware that which aspects of reporting pain may be impacted by the Appalachian culture? Select all that apply.

Appalachian clients may want to appear to be stoic. Appalachian clients may be afraid of addiction tendencies Appalachian clients may not want to appear to be complainers.

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription?

Apply cold compresses to the affected area.

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?

Arrange an autologous blood donation before the planned surgery.

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which would be the initial action by the nurse who observed the error?

Ask the nurse if he or she intends to report the error.

The nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is angry with the assignment because of a belief that the assignment is more difficult than the assignment delegated to other nurses on the unit. The nurse should carry out which action?

Ask the nurse manager of the neurological unit to discuss the assignment.

The nurse is caring for a client who is receiving intramuscular antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. With which crime can the client legally charge the nurse as a result of the nursing action?

Battery

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client which should be the appropriate form of isolation to use to prevent the spread of infection to others?

Blood and body fluid precautions

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel

A group of nurses are reinforcing instructions on health and safety management to survivors of a hurricane before they leave their temporary shelter and return home. Which instructions should the nurses include? Select all that apply.

Boil water for 5 to 10 minutes before drinking. Wash hands with soap and water frequently. Avoid mixing chemicals such as cleaning chemicals. Add 10 to 20 drops of chlorine bleach to a gallon of water before drinking.

The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning?

Carry the client to fresh air.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?

Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.

The nurse determines that the neutropenic client needs further teaching if which statement is made by the client?

"I will include plenty of fresh fruits in my diet."

The nurse is working in the primary care office and is conducting an interview with the parents of a child. The parents of the child state that syrup of ipecac is kept at home in case of an accidental poisoning. The nurse provides which appropriate instruction specific to the use of this medication?

"Ipecac syrup should not be given unless the poison control center indicates to do so."

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching?

"It is okay to share towels and washcloths."

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?

"The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."

A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement?

"There is no difficulty driving at dusk."

A client with tuberculosis, whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. What should the nurse tell the client?

"Three sputum cultures must be negative before returning to work."

The emergency department nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

"We will be sure not to leave hot liquids unattended."

The nurse is preparing to initiate a tube feeding for a client, and the health care provider has prescribed the use of an electronic feeding pump. The nurse brings the pump to the bedside to plug the pump cord into the wall and discovers that there is no available outlet in the wall socket. Which action should the nurse implement?

Contact the electrical maintenance department for assistance.

The nurse in a women's health clinic is reinforcing instructions to a client that is being treated for pelvic inflammatory disease (PID). Which information would be essential for the nurse to reinforce before discharge? Select all that apply.

Get plenty of rest and increase fluid intake. Refrain from sexual activity for 3 weeks Inform your sexual partner of the need for treatment, even if no symptoms are present.

A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where?

In a quiet, dim room with respiratory and cardiac support available

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will.

The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings?

Fowler's

A new nurse is employed at a local community hospital and is attending an orientation session. The nurse educator conducting the session asks the new nurse to describe an organization's mission statement. The new nurse appropriately responds with which statement?

It outlines what the organization plans to accomplish.

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.

Lanugo Amenorrhea

The nurse is caring for an older adult and knows that an ethical dilemma is most likely to occur in this population because of which issues? Select all that apply.

Limited vision Chronic illness Lack of assertiveness

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patches

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?

Monitoring for the gag reflex

The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse should avoid which action?

Obtaining the specimen from the urinary drainage bag

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the health care provider immediately. Which nursing intervention is appropriate?

Offer to assist the client to an examination room until the health care provider is notified.

A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chicken pox (varicella). The nurse should take which action to provide safety for all children on the unit?

Place the infected child and any immunocompromised children in isolation.

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome who requires an injection. The nurse should perform which action to dispose of the needle after the medication is given?

Place the needle and syringe in a puncture-resistant container.

A health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client

The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart?

Position the client supine and flat.

The nurse is orienting a new nurse to the care of a client who has an internal radiation implant. The nurse includes which instructions in discussions with the new nurse?

Pregnant women are not allowed in the client's room.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse should give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse is assisting with developing a plan of care for a client who is experiencing hematological toxicity as a result of chemotherapy. The nurse should suggest including which in the plan of care?

Restricting fresh fruits and vegetables in the diet

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.

Risk for injury Risk for infection Risk for aspiration Impaired verbal communication

The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information?

Safety

The nurse is caring for a 4-month-old infant with respiratory syncytial virus (RSV). Several clients are being admitted to the unit and assignments are being made. The nurse should question being assigned which newly admitted clients? Select all that apply.

The 1-year-old client taking corticosteroids The 6-month old with bronchopulmonary dysplasia

The nurse is caring for a 4-month-old infant with respiratory syncytial virus (RSV). Several clients are being admitted to the unit and assignments are being made. The nurse should question being assigned which newly admitted clients? Select all that apply.

The 6-month old with bronchopulmonary dysplasia The 1-year-old client taking corticosteroids

The nurse observes an outburst by a client with a history of schizophrenia, during which the client uses extreme foul language. Which appropriate documentation should the nurse make for this occurrence?

Use quotation marks, exact words, and additional objective information about affect and nonverbal behavior.

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action?

Use the edge of a sterile surgical tool to scrape out the stinger.

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?

Gloves, mask, gown, and goggles

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

I notice you are wearing a blue shirt." "Do you have any plans of harming yourself? "I will sit here with you even if you choose not to talk with me."

The nurse wants to ensure that the emergency department is prepared for a disaster and is creating an action plan for educating the staff. Which actions should the nurse plan in order to adequately prepare the staff? Select all that apply.

Identify specific nursing roles during a disaster. Test the disaster plans before a disaster occurs. Begin educating staff on roles at the time of a disaster. Encourage each nurse to create a personal emergency preparedness plan.

The nurse is aware that the ethical philosophy of deontology is composed of which "right-making characteristics"? Select all that apply.

Justice Truthfulness Fidelity to promises

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse collect data on first?

A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?

Accept the client as a person and make the client feel safe.

Following a tonsillectomy, which of the health care provider's prescriptions should the nurse question?

Allow ice cream when awake.

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

Atropine sulfate is prescribed for a client with gastrointestinal hypermotility, and the nurse reviews the client's record before administering the medication. Which finding, if noted on the client's record, indicates the need to contact the health care provider before administering the medication?

Narrow-angle glaucoma

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene?

The student suctions the client's tracheotomy tube for 15 seconds.

The nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. Which action does site marking involve?

The surgeon marking the area of the operative procedure

A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization?

"Beneficiaries are limited to those providers that are participating health care providers for any required health care services."

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?

"I need to provide a well-balanced, high-fat diet to my child."

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response to the client is appropriate?

"I will call the nursing supervisor to seek assistance regarding your request."

A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure?

"It is necessary to remove jewelry and any other metal objects."

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept?

"It represents a primary health prevention focus managed by a single case manager."

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola infantum is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse reinforce to the mother to prevent the transmission of the disease?

"The disease is transmitted by contact with nasal or oral fluids, so any items contaminated with these types of fluids, such as a drinking cup, should not be used by your other children."

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements?

"They are specific guidelines."

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?

"We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."

The nurse shares with a pregnant client that the result of her rubella screening is positive. Which is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine?

"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse should explore with the mother which suggestion to decrease the children's sense of isolation and fear?

"You should seek community after-school programs or activities for your children."

The nurse should plan to reinforce instructions to which client's about the risk for transmission of disease through blood and sexual contact? Select all that apply.

A client diagnosed with hepatitis B virus A client diagnosed with hepatitis C virus A client diagnosed with human immunodeficiency virus (HIV)

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires frequent ambulation

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

The nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for what evidence that supports this information?

A judicial decision in a court of law

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management

The nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?

A pair of scissors

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 40,000/mm3

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?

A postoperative client who develops a cough and a fever

The nurse is caring for an 18-month-old child who has been vomiting. The appropriate position to place the child during naps and sleep time is which?

A side-lying position

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. How should the nurse transfer the client from the stretcher to the bed?

A slider board and the assistance of four people

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim should the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse should question this prescription if the child had documented evidence of which condition?

A viral infection

Which car safety device should be used for a child who is 8 years old and is 4 feet tall?

Booster seat

A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities?

Break down activities into small steps.

The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately?

Call the area poison control center.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. Which action would be the appropriate initial action by the nurse?

Call the nursing supervisor.

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action?

Change the IV tubing.

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

Change the password for entering computer files at least monthly. Shred the printout of the nurse's flowchart at the end of the nurse's shift. Use own user name and password when logging into the computer system.

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client? Select all that apply.

Check temperature. Monitor white blood cell count. Remove fresh flowers or plants.

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which action?

Check the placement of the tube.

Methenamine is prescribed for a client with a gram-positive urinary tract infection. The nurse questions the prescription if which preexisting disorder is noted in the client's record?

Cirrhosis

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the health care provider (HCP) and obtain an informed consent.

Cyclobenzaprine (Flexeril) is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which disorder would indicate a need to contact the health care provider regarding the administration of this medication?

Glaucoma

The nurse is caring for a client with a health care-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which protective items will be required to perform this procedure?

Gloves, a gown, and goggles

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). After appropriately charting in the medication administration record, which action should the nurse take?

Make a notation regarding the client's refusal in the nurse's notes.

The nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad because "his feet are always cold at night." The nurse should incorporate which concept when formulating a response to the family member?

Older adults often have slower neurological response times and are therefore more at risk for burns.

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.

Pad the bed's side rails. Place an airway at the bedside. . Place oxygen equipment at the bedside. Place suction equipment at the bedside

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

Pedal pulses Capillary refill Color of the extremity Temperature of the skin

The nurse has administered a dose of diazepam (Valium) to a client. The nurse should take which most important action before leaving the client's room?

Per agency policy, put up the side rails on the bed.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of the tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task.

Which are the best ways for the nurse to avoid malpractice? Select all that apply.

Perform interventions in a timely manner. Document assessments and procedures completed. Know current nursing literature in their area of practice

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action?

Pick up the implant with long-handled forceps and place into a lead container.

The nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical (vaginal) radiation implant. Which action should the nurse suggest including in the plan of care for the client?

Place a radiation sign on the door outside of the client's room.

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the infant on the side during any seizure

A nurse lawyer provides an education session to the nursing staff regarding client rights. The nurse asks the lawyer to describe an example that may relate to invasion of client privacy. Which nursing action indicates a violation of client privacy?

Taking photographs of the client without consent

The nurse is reinforcing home care instructions to the mother of a child with bacterial conjunctivitis. Which instruction should the nurse give the mother?

That the child's towels and washcloths should not be used by other members of the household

The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used.

The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea

The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which action is performed by the UAP during communication with the client?

The UAP speaks directly into the impaired ear.

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand and obtain release from the hospital.

The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client?

Within the client's reach, on the left side

The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 cells/mm3, and the platelet count is 150,000 cells/mm3. Which nursing intervention should the nurse incorporate into the plan of care?

Maintain strict isolation precautions.

The nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which components should be included in the plan of care? Select all that apply.

Maintain the bed in a low position. Pad the side rails of the bed with blankets. Place the child in a side-lying lateral position if a seizure occurs. Protect the child's head, body, and extremities if a seizure occurs

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

The nurse performs an audit in the hospital intensive care unit of clients who have indwelling urinary catheters. Which observation, found in the audit, poses a risk for a health care-associated infection? Select all that apply.

Drainage bag port touching the floor Dependent loop in the catheter tubing Use of one measuring container between two clients with the same pathogen in the urine

The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV? Select all that apply.

Perform hand hygiene before and after contact with the client. Use biohazard bags for items saturated with blood and bodily fluids. Wear personal protective equipment when contact with blood and other bodily fluids are anticipated.

The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Places the client in an upright position

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?

Placing the bed linens on the traction ropes

The nurse is instructing a group of unlicensed assistive personnel in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the nursing assistant doing which action?

Positioning a box that is to be lifted between the knees

The nurse is preparing to comb the hair of a client who has been treated for pediculosis. The nurse should perform the actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

Soak the comb used in boiling water for 10 minutes. Divide the client's hair in sections. 2 Remove nits with a fine toothed comb. Look through the hair for nits still attached to the shaft of hair. Apply disposable gown and gloves. Remove nits with a fine toothed comb. Divide the client's hair in sections. Soak the comb used in boiling water for 10 minutes. Look through the hair for nits still attached to the shaft of hair

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Has the client open the gift with the nurse present

A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action?

Monitoring prothrombin and partial thromboplastin values

The nurse is reinforcing instructions about home safety measures to a parent. Which statement by the parent indicates a need for further teaching?

"I need to refer to medication as 'candy' only when really necessary."

A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks the nurse if this document is still effective. Which is the most appropriate nursing response?

"A living will needs to be reviewed yearly with your health care provider."

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client tells the nurse that a lawyer has prepared a living will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a witness to sign the will and requests that the nurse act as a witness. Which is the appropriate nursing response to the client?

"A nurse caring for a client cannot serve as a witness to a living will."

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client makes which statement?

"Breast-feeding after delivery is best for my baby."

A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the health care provider's office because the leukemic child has never had chickenpox. The nurse should make which response to the mother?

"Bring the child to the office for an injection called immune globulin."

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement should the nurse make to the client?

"Hands should be washed thoroughly before holding the infant."

The nurse reinforces instructions to a client diagnosed with impetigo. Which statement by the client indicates a need for further teaching?

"I can wash my laundry with other household members' items."

The nurse is caring for a child who is receiving chemotherapy for treatment of leukemia and prepares to address which expected needs of this client? Select all that apply.

Fatigue Easy bruising Possible infections

The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value?

20,000 cells/mm3

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse knows that neutropenic precautions will be implemented if the client has which white blood cell (WBC) count?

2000 cells/mm3

The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

Which is a recommended guideline for safe computerized charting?

Accidental deletions from the computerized file need to be reported to the nursing manager or supervisor.

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?

Crutches and the left leg, then advance the right leg

The nurse knows when preparing the Filipino American client for a surgical procedure it is important to assess for which culturally relevant influences? Select all that apply.

Familial hierarchy Cultural practices Reactions to surgery Pain management plans

After weeks of witnessing a man's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which criterion does the nurse use to determine if the autopsy can proceed?

Determination by the client's son

Following an airplane crash that had only a few survivors, the nurse should anticipate which survivor responses to stress? Select all that apply.

Difficulty sleeping Feeling vulnerable Feeling blame or guilt Feeling numb or in disbelie

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation?

Directly observed therapy

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

The nurse has been asked to serve on the health care facility ethics committee and knows that this committee serves which purposes? Select all that apply.

Education Case consultation Process ethical dilemmas

A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed?

Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes

A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family?

Encouraging the client to stand unassisted on the leg

The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands?

Every 30 minutes

The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which is accurate regarding immunity from this suit?

Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided.

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse use during the bathing of this client?

Gown and gloves

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

A visitor accidentally pricks a finger with a needle that was discarded in the trash. The visitor never received the hepatitis B vaccine and asks the nurse what can be given to him for protection. The nurse tells the visitor that which medication would be administered?

Hepatitis B immune globulin and hepatitis B vaccine

A client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses the client 15 minutes after administering the medication and reminds the client to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Which issues support the client's malpractice claim? Select all that apply.

Increased risk of hypotension Failure to teach the client adequately Increased need to protect the client Lack of follow-up nursing actions

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan?

Information regarding the location of shelters

The nurse is reinforcing instructions to a client with chronic vertigo. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?

Removing throw rugs and clutter in the home

The nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux tuberculin skin test. Which action by the nurse is the priority?

Report the findings.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?

Respiratory

The nurse reinforces instructions regarding respiratory precautions to the mother of a child with mumps. The mother asks the nurse about the length of time required for the respiratory precautions. The nurse should base the response on which information about mumps?

Respiratory precautions are indicated during the period of communicability.

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semireclined, rear-facing position.

Which nursing approach is important when administering an antianxiety agent to a client with acute severe anxiety?

Stay with the client until the medication becomes effective.

The registered nurse has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

Stay with the client. administer anxiolytics medications if prescribed. Ensure the client is in an environment with little stimuli.

The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

Suction machine Oxygen administration Padding for the side rails Prescribed diazepam (Valium)

A child has a basilar skull fracture. Which health care provider's prescription should the nurse question?

Suction via the nasotracheal route as needed.

The licensed practical nurse (LPN) is assisting in the admission of a child with suspected sickle cell crisis because of which signs/symptoms noted in this client? Select all that apply.

Swollen knee joint Pulse,120 beats per minute Peripheral oxygen level of 89% Pain rated as a 6 on a scale of 1 to 10

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted?

The client advances the walker with reciprocal motion.

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal would be appropriate?

The client will not develop an opportunistic infection during the remainder of pregnancy.

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions in regard to avoiding the use of herbal medications?

The mother of a 10-year-old child with a urinary tract infection

The nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to an unlicensed assistive personnel (UAP). The UAP notifies the nurse that the client's vital signs are elevated and the client is complaining of pain and dyspnea. Which is appropriate regarding the nurse's next action?

The nurse checks the client and gathers additional data before calling the health care provider.

The nurse is observing a nursing student preparing to suction a pediatric client through a tracheostomy. The nurse intervenes if the student verbalizes which intention?

To apply continuous suction when inserting the catheter

The nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. The nurse explains to the parents that this medication is used for which purpose?

To protect the newborn from contracting an eye infection from the birth process

The nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which observation noted during the assessment would present the greatest hazard to the children?

Toys with small loose parts in the playroom

The nurse is reinforcing instructions regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which points should the nurse include in the session? Select all that apply.

Tuck pant legs into socks. Wear closed shoes when hiking. Apply insect repellent containing DEET. Cover the ground with a blanket when sitting.

The nurse is performing an environmental assessment in the home of an older client. Which requires immediate attention?

Unsecured scatter rugs

The sister of a client with human immunodeficiency virus (HIV) asks the nurse to review once more what she needs to know in order to take care of her brother. Which instructions would be appropriate for the nurse to reinforce? Select all that apply.

Wash soiled clothes in hot water. Use gloves when handling body fluids. Soak cleaning rags, sponges and mops in 1:10 bleach solution for 5 minutes.

A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection?

Wear a mask when in contact with people outside of the family until medications are effective.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the client

A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?

Wears a gown when caring for the client and removes the gown immediately after leaving the client's room

The nurse employed in a mental health unit who cares for suicidal clients is reviewing the work schedule. The nurse expects to note in the schedule that additional precautions related to safety to the clients will be provided at which times?

Weekends

A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths?

"They are nursing care plans and use the steps of the nursing process."

The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The health care provider has prescribed an amount of 100 mL/hr. How much formula should the nurse plan to add to fill the feeding bag?

400 mL of formula

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?

8 inches to the front and side of the client's toes

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply.

Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary because family members have already been exposed. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies which aspect of care as a priority of care?

Actual or life-threatening concerns

The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question?

Administer medication to dilate the affected pupil.

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?

Assault

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next?

Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.

The unlicensed assistive personnel (UAP) who has been employed in a long-term care facility for 8 weeks is consistently 10 to 20 minutes late for work. The UAPs lateness has caused unrest with other staff members in the nursing unit. The UAP is due to receive a 3-month probation evaluation in 1 month. Which is the most appropriate action by the nurse in charge of the nursing unit when dealing with this situation?

Confronting the UAP to discuss the lateness and initiate problem-solving measures

The nurse is assigned to care for a newly admitted client and is reviewing the health care provider's prescriptions. The nurse notes that the health care provider has prescribed a medication dose that is twice the amount that the client reports taking before admission. Which nursing action is appropriate?

Consult with the registered nurse (RN).

The nurse is caring for a child who returned from tonsillectomy surgery 30 minutes ago and enters the room for routine monitoring to see the child repeatedly and rapidly swallowing. Using the SBAR (Situation, Background, Assessment, Recommendation) technique, which statements and/or questions should the nurse include in the conversation with the health care provider? Select all that apply.

Could you please come assess the child as soon as possible?" "I am concerned that the child is bleeding from the surgical sites." "Two minutes ago, I entered the child's room for routine monitoring and observed that she was swallowing repeatedly and rapidly." "Hello, this is Maria on the third floor. I am the nurse caring for Ella Smith, the 6-year-old child in room 342 who returned 30 minutes ago from a tonsillectomy.

A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs should best be addressed by referral to which service?

Social worker

A client is being discharged to home following spinal fusion with insertion of rods. For which home environment situation should the nurse suggest a consultation with the continuing care nurse?

The bedroom and bath are on the second floor of the home.

An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans to address which problem first?

The possibility of injury

The nurse is caring for a non-English speaking client. Best practices for client safety and quality of care incorporates which actions by the nurse? Select all that apply.

Use interpreters who are familiar with health care. Avoid the use of relatives as interpreters to prevent misinterpretation. Use dialect-specific interpreters who are the same gender if possible. Become familiar with common health care words used in the client's language.

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider that the client had terminal cancer. The emergency department health care provider examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate?

"I will contact the medical examiner regarding your request."

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

"My clothes can be laundered with other household members' clothes."

The client plans to give their lispro (Humalog) insulin injection at 0800 right before eating breakfast. The nurse knows that the client understood the education provided when the client states which time presents the greatest risk for hypoglycemia?

0930

The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used.

1 The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute 2 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 3 The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching 4 The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea

The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder should alert the nurse to contact the health care provider?

Seizure disorders

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag?

21:30

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?

Al-Anon

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

Alcoholics Anonymous

The nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which data collected by the nurse should be of highest priority?

Allergy to iodine or shellfish

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

A client on a ventilator

The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel?

A client on strict bed rest and a 24-hour urine collection

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client requiring frequent ambulation with a walker

A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first?

A client with a fever who is diaphoretic and restless

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide (Lasix), penicillin (Nafcillin) and ibuprofen (Motrin). He has received ibuprofen (Motrin) twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure.

9 total points (moderate risk)

The nurse is planning the client assignments for the day. The assignment that the nurse communicates to the unlicensed assistive personnel (UAP) includes which clients? Select all that apply.

A 9-year-old client with cystic fibrosis who requires assistance with toileting A 12-month-old client admitted 3 days ago with respiratory syncytial virus (RSV) who requires a bath A 10-month-old admitted for spasmodic laryngitis who is scheduled for discharge the following day who requires feeding

The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first?

A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action?

Activate the agency emergency response plan.

The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?

Administering medications that will dilate the pupil

A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care provider's prescriptions. Which prescription should the nurse question if written on the health care provider's prescription form?

Administration of an opioid analgesic

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply.

Age less than 32 years Practicing a religion Married over 10 years

A mother of a 6-year-old-child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which should the nurse tell the mother to immediately perform?

Call the poison control center.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the health care provider (HCP).

The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern?

Discourage the racial comments.

A client with chronic obstructive pulmonary disease (COPD) asks the nurse for assistance with preparing a living will. The client tells the nurse that she has not discussed the living will with the family and wanted to make some decisions before discussing the will with the family. Which initial step in preparing this document should the nurse inform the client to do?

Discuss the request with the health care provider.

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Documenting task completion at the end of the day

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the nursing assistant is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

Every 2 hours

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

Frequent hand washing is important. The child should avoid exposure to other illnesses Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?

Safety with activities

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action?

Increasing the level of suicide precautions

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

Institute contact precautions.

A hospitalized client is having the dosage of clonazepam (Klonopin) adjusted. The nurse should plan to implement which action?

Instituting seizure precautions

A client is placed on chloral hydrate (Somnote) for short-term treatment. Which nursing action indicates an understanding of the major side effect of this medication?

Instructing the client to call for ambulation assistance

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify?

Irrigating the nasogastric (NG) tube

The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client was performing which of these contraindicated activities?

Isometric exercises of the arms and legs

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to make sure that the health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that the client needs further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible.

The nurse is assisting in developing a plan of care for an older client to prevent a fall. Which action would be least likely to prevent a fall?

Keeping the bathroom light off at nighttime

The nurse is aware that the American's with Disabilities Act provides which rights to individuals who are disabled? Select all that apply.

Labels asymptomatic HIV as a disability Protects the privacy of individuals with HIV Prohibits discrimination in employment and public services

The licensed practical nurse knows that which items are examples of common law? Select all that apply.

Malpractice Informed consent Client's right to refuse treatment

The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles?

Mask

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

Mass casualty events do not require an increase in the number of staff that are needed." "A mass casualty event occurs only within the heath care facility and could endanger staff." "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescription?

Milk of magnesia

A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply.

Milk of magnesia Heat pad to the abdomen

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply.

Minimizing feelings Changing the subject Asking "why" questions

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease and should expect to observe which behaviors in this client? Select all that apply.

Misplacing a valuable object Difficulty coming up with the right word

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?

No charge will be made against the RN because the RN's actions are reasonable.

The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?

Notify the registered nurse.

The nurse has just been licensed and has begun to practice in an acute health care facility. The nurse knows that which nursing specialties will require more specific defined standards of care and skills? Select all that apply.

Nurse-midwives Nurse-anesthetists Intensive care unit (ICU) nurses

An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is least relevant to maintenance of balance for the older client?

Older clients cannot think quickly enough to respond to emergencies.

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply.

Perform hand hygiene after removal of PPE. Perform hand hygiene before donning any PPE. When removing PPE, always remove gloves firs Protective eyewear and face shield are indicated if there is risk of splatter.

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?

Provide safety for both the client and other clients on the unit.

The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest to use?

Providing educational programs, literature, and posters to promote awareness of healthy eating

The nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Restrict fluid intake. Administer meperidine (Demerol) 25 mg for pain.

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address the client's need for which?

Safety and security

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The health care provider visits and prescribes restraints if needed. Which action is appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

Socialize with the restrained client. Remove the restraint and perform range of motion activity. Reapply the restraint after assisting the client to the bathroom.

Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply.

Speak slowly. Use simple statements Provide the client with high-calorie beverages.

The nurse observes that an older male client is confined to his room by his daughter-in-law. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way, and my son needs me to stay here." Which is the best nursing intervention for this situation?

Suggest appropriate resources such as respite care and a senior citizens' center to the client and daughter-in-law.

The nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which is the appropriate nursing action?

Tell the client that it is necessary to notify the health care provider of the client's request.

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance?

The cane has a flared tip with concentric rings to provide stability.

The nurse is employed in a long-term care facility as a charge nurse of the night shift. The nurse determines that as a charge nurse, authority appropriately refers to which explanation?

The official power to approve an action, command an action, or to see that a decision is enforced

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which data would indicate a negative variance?

The presence of dysrhythmias in a client with a myocardial infarction

In developing a plan of care for a client hospitalized with tuberculosis (TB) the nurse should place emphasis on which intervention?

The strict adherence to following airborne precautions

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?

The surgeon marking the area of the operative procedure

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

Use nonlatex gloves. Use medications from glass ampules Do not puncture rubber stoppers with needles. Keep a latex-safe supply cart available in the client's area

The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client?

Using many exaggerated hand gestures while talking

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list?

Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs?

When no acts of aggression are observed within 1 hour after release of two extremity restraints