NCLEX Practice

A client with major depression has been admitted for medical workup before the initiation of a series of electroconvulsive therapy (ECT) treatments. While the nurse is conducting pretreatment education with the family, the client's child asks, "Isn't this treatment dangerous?" What is the most appropriate nursing response?

"Although there are some risks, your parent will have a thorough examination in advance to ensure that they are a good candidate for the treatment."

A toddler is admitted to the emergency department with a suspected seizure disorder. When informing the parents about necessary diagnostic procedures, which statement is most appropriate for the nurse?

"An important initial test is a computed tomography (CT) scan."

A client has been prescribed valproic acid for the treatment of bipolar disorder. The client tells the nurse, "I know that vitamin B can help with depressive episodes, so I am going to give that a try." What is the nurse's best response?

"Be sure to dialogue with your care provider before you start taking vitamin B supplements."

An anxious client is admitted for treatment of an exacerbation of irritable bowel disease. The client asks the nurse if biofeedback will help after reading about biofeedback online. What is the best response by the nurse?

"Biofeedback will help reduce stress."

A client comes to the emergency department reporting a headache. The client is diagnosed with hypertension and is given a prescription for an antihypertensive. In reviewing the discharge instructions, the client declines the prescription and tells the nurse "it is in God's hands now." What is the nurse's best response to the client?

"Can you tell me more about what that means?"

A nurse counsels a mother with young children after leaving her abusive husband 6 months ago. The mother says, "My 6-year-old is starting to act just like his father. I just don't know how to handle this." Which response by the nurse is most appropriate?

"Counseling for your son would be helpful."

A client with a vaginal yeast infection asks the nurse if it is a good idea to start taking acidophilus along with the prescribed vaginal cream. What assessment question would the nurse ask prior to answering the client's question?

"How often do you eat yogurt with live cultures?"

The nurse has been teaching a client about depression. Which statement indicates insight into the client's diagnosis?

"I believe that my sadness affects my work and feelings."

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my spouse look at the soles of my feet each day."

The nurse is providing care for a client who was prescribed escitalopram three weeks ago. What statement by the client should be of greatest concern to the nurse?

"I have started taking St. John's wort because I have read it can help my mood."

An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. The client was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when they make which statement?

"I need to reduce my caloric intake to 1200 calories a day."

The nurse is caring for a client who underwent an episiotomy. What statement by the client indicates teaching was successful?

"I should refrain from using tampons until advised by my healthcare provider"

The nurse is teaching a client about wearing a back brace after a spinal fusion. Which statement indicates the client understands how to wear the back brace?

"I should wear a thin cotton undershirt under the brace."

A pregnant client, who is originally from another country, is admitted to the hospital in labor. During the admission process, the spouse tells the nurse that the client will not receive any pain medication during the process. The spouse then waits in the waiting room. As the birthing process continues, the nurse asks the client if she needs pain medication. She declines the offer and reminds the nurse by saying, "My spouse told you I cannot have any pain medicine." What is the nurse's bes

"I want to advocate for you and assist with the pain during this process."

The nurse has been instructing the client about how to prepare meals that are low in fat. Which comment would indicate the client needs additional teaching?

"I will eat more liver with onions."

A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching?

"I will increase my fluid and calcium intake."

The nurse is preparing the family to see the client who just died. The family invites the nurse to pray with them. The nurse is not comfortable with this request due to a different belief system. What is the nurse's best response?

"I will stay with you while you visit."

Which statement indicates that a client with esophageal reflux disorder understands the dietary teaching?

"I won't drink any carbonated drinks."

The nurse is providing care for a client who is a Muslim. The client has recently received a diagnosis of type 1 diabetes and is receiving health education. What statement by the nurse best addresses this client's religious beliefs?

"Insulin used to be derived from pigs, but now it is produced synthetically."

The nurse is caring for a group of clients in an acute medicine setting. What statement by a client would most warrant a referral to spiritual care, with the client's permission?

"It feels like one round of bad news after another for me, like I am being punished."

A toddler is in the hospital. The parents tell the nurse they are concerned about the seriousness of the child's illness. Which response to the parents is most appropriate?

"It must be difficult for you when your child is ill and hospitalized. Tell me your concerns."

The nurse is working with a client with depression and suicidal ideation. The nurse heard the client say, "I am disappointed because thought I'd be feeling better by now since I started medication and therapy a week ago." What would be the primary nurse therapist's most therapeutic response?

"It takes time and can be frustrating to experience the physical and emotional symptoms of depression all while you learn more about yourself and try new strategies as your medication takes effect."

A birthing couple informs the nurse that they would like to have the placenta after the baby is born. What is the nurse's best response?

"Let me check about how to go about doing this."

A nurse is caring for a client who self-identifies as a practicing Catholic. The client asks if there is a "Blessed Mary Shrine" in the facility. Which is the nurse's best statement to the client regarding the question?

"Let me find out if the facility has something that may assist you."

A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. What is the nurse's best response?

"Let us try this until you can have acupuncture."

Which nursing statement is most effective when the nurse is trying to defuse a client's impending violent behavior?

"Let's talk about what happened to make you this angry."

A client is experiencing uncontrollable back pain and a physical therapist suggests a back massage. The client asks the nurse how massage will help the pain. What is the best response by the nurse?

"Massage is point stimulation used for orthopedic and neurological conditions."

A nurse should intervene when a depressed client makes which statement?

"Nobody cares about me."

A client is admitted for an exacerbation of irritable bowel syndrome who insists on being allowed to keep a head covering on at all times. What is the best response by the nurse?

"Please help me to understand this practice."

A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response?

"The baby needs to be observed more closely."

The nurse attempts to draw blood from a client with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop! Leave me alone! What are you trying to do to me? What's happening to me?" Which response by the nurse is most appropriate?

"The tests of your blood will help us figure out what's happening to you."

A Black client is admitted for newly diagnosed leukemia under isolation precautions where only immediate family members may visit. A White visitor arrives to visit the client. What is the nurse's best response to the visitor?

"There are some visiting limitations. Are you a family member?"

The nurse teaches a client with type 2 diabetes mellitus about diabetic retinopathy. Which statement if made by the client would indicate to the nurse that teaching was effective?

"Tight control of blood sugar and blood pressure can prevent damage to my eye."

The nurse teaches the parents of an infant with clubfoot requiring application of a plaster cast how to care for the cast. Which statement would indicate that the parents have understood the teaching?

"We will check the color and temperature of the toes of the casted leg frequently."

A client who has received a poor prognosis tells the nurse, "I have not been to church in decades even though I was raised Catholic. Can you arrange for a priest to come see me?" What is the nurse's best response?

"We will try to get in touch with one and ask him to come and see you."

Which questions should the nurse ask when completing a cultural assessment for a new client? Select all that apply. "What is your age?" "What are some of your health-related beliefs and practices?" "What are some of your personal values?" "What is your address?" "What are your spiritual beliefs?"

"What are some of your health-related beliefs and practices?" "What are some of your personal values?" "What are your spiritual beliefs?"

The nurse is setting goals for end-of-life care with a client who states, "I'm not a religious person, but I consider myself a spiritual person." Based on this conversation, what is the best question to ask about the client's spirituality?

"What are the beliefs that guide your daily decisions?"

A client in an acute care center lacerates the wrists. The client has a history of conflicts and acting out and asks the nurse, "I did a good job, didn't I?" Which response by the nurse is best?

"What were you feeling before you hurt yourself?"

The nurse facilitating the medication management group notices that a particular client consistently chooses a position on the perimeter of the group. In order to be culturally mindful about the origin of this behavior, what question would the nurse ask the client?

"Where will you be comfortable sitting and still remain a part of the group?"

A hospitalized adolescent diagnosed with anorexia nervosa refuses to comply with their daily before-breakfast weigh-in. The client states that they just drank a glass of water, which they feel will unfairly increase their weight. What is the nurse's best response to the client?

"You must weigh in every day at this time. Please step on the scale."

An alert and oriented client refuses chemotherapy. The client's family believes that the client should receive it. Which is the nurse's best response to the client?

"You understand that this decision is ultimately yours to make."

A client who is dying from AIDS is admitted to the inpatient psychiatric unit because they attempted suicide. Their close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time's running out." What is the nurse's best response?

"You're in a lot of pain. What are you feeling?"

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse is appropriate?

"Your cursing is interrupting the activity. Take time out in your room for 10 minutes."

The nurse performs blood pressure screening at the local community center. Which client is MOST at risk to develop hypertension? A. 30-year-old man working as an account executive with a large company whose father takes Lisinopril. B. 40-year-old woman with a 5-year history of migraine headaches. *C. 65-year-old man who drinks three 12-ounce beers daily and smokes 2 packs of cigarettes a day. D. 75-year-old woman who supplements her diet with large doses of vitamins B and C.

*C. 65-year-old man who drinks three 12-ounce beers daily and smokes 2 packs of cigarettes a day.

A nurse is caring for a pediatric client wearing diapers. The nurse must calculate the urine output for the client. The dry diaper weighs 35 g. The wet diaper weighs 250 g. How much urine output has the client had? Record your answer using a whole number.

215

The nurse is completing an intake and output record for a client who is receiving continuous bladder irrigation after transurethral resection of the prostate. How many milliliters of urine should the nurse record as output for the shift if the client received 1,800 ml of normal saline irrigating solution and the output in the urine drainage bag is 2,400 ml? Record your answer using a whole number.

600

Which client would be considered to be at the highest risk for respiratory failure?

A client with Guillain-Barré syndrome

The nurse reviews the records of four clients who are at risk for developing type 2 diabetes mellitus (DM). In which order will the nurse assess the clients? Arrange the following clients in order from greatest risk to least risk for developing type 2 DM. Use all answer choices. A. A 56-year-old Native American who is 5' 8" tall, weighs 200 lb., and has two siblings with type 2 DM. Total Cholesterol 350. B. A 42-year-old Hispanic American with a history of hypertension and a serum high-density l

A. Highest Risk - Age, Race, Obesity, Family history, Hyperlipidemia (5 Risk factors) B. 2nd Highest Risk - Age, Race, Medical Hx, Hyperlipidemia (4 Risk factors) C. 3rd Highest Risk - Race, Gestational Diabetes (2 Risk Factors) D. Lowest Risk - High triglycerides (1 Risk Factor)

Colon cancer is a major cause of mortality worldwide. All the following are known to be implicated as a probable causes of colorectal cancer EXCEPT: A. Medical history of Crohn's disease or ulcerative colitis B. High levels of dietary fat and refined sugar, and reduced fiber intake C. Aspirin or other NSAID use D. History of smoking and/or alcohol consumption

ANSWER C. Negative Polarity Question ("EXCEPT"). Use of Aspirin or other NSAID medication has been shown to be colon-protective and not a cause of colorectal cancer.

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client?

Administer acetylcysteine.

A nurse enters the room of a female client and finds her crying. The client has just been told that her breast cancer has returned. The client says, "I do not know why God is punishing me like this." How does the nurse best respond?

Allow the client to continue to verbalize her feelings.

The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort?

Apply a water-soluble lubricant to the nares.

What is the priority nursing measure for a client with von Willebrand's disease who is having epistaxis?

Apply pressure to the nose.

The nurse is concerned that a client admitted with major depressive disorder may be suicidal. What is the most important action by the nurse?

Ask a direct question such as, "Do you ever think about killing yourself?"

The client on hospice explains to the nurse, "I asked my child to pray with me because I am a very spiritual person, but my child declined and is not a believer anymore." Based on this conversation with the client, what is the best action for the nurse to initiate?

Ask if the client would like to meet with the hospital chaplain.

The nurse is caring for a 5-year-old child in pain. What is the best method to assess the child's pain?

Ask the child to point to a face drawing that indicates pain intensity.

A nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. The client gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate?

Ask the client to describe what the voices are saying while making it clear the nurse doesn't hear the voices.

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action?

Ask the client when she last changed her perineal pad.

A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? Select all that apply. The client with pyelonephritis cannot use analgesics. Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help. Short-term use of opioids has a high addiction risk. Using opioids will prolong the inpatient hospital stay.

Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help

The nurse is caring for a client who is a recent immigrant from China. Through the hospital interpreter, the client expresses an unwillingness to eat the fried fish that was on the meal tray, describing it as "too hot." What is the nurse's best action?

Ask the interpreter to ask the client about the specific meaning of the description of "hot."

An unlicensed assistive personnel (UAP) reports to the nurse that the client had a large amount of blood on the adult brief in a skilled nursing home. Place the steps the nurse will take to assess and care for the client in order. All options must be used.

Ask the unlicensed assistive personal to recover the adult brief. Examine the adult brief. Assess the client's perineal area for any further drainage. Obtain the client's vital signs. Report the findings to the healthcare provider. Report the event to the family with any change in treatment.

A client is brought to the emergency department after a house fire. What is the priority assessment by the nurse?

Assess oxygen saturation and the client's ability to speak.

The nurse is planning care for an infant with bronchiolitis. What is the nurse's priority intervention for this child?

Assess respiratory status frequently.

A client with dissociative identity disorder was admitted to the unit after a suicide attempt. Place the nursing interventions in priority order. All options must be used.

Assess suicide risk and implement a safety plan, to include a follow-up assessment. Initiate a therapeutic relationship, establish trust, and develop rapport. Explain unit policies and expectations, activity schedule, and therapeutic interventions. Teach the client specific aspects of the illness including symptoms and the treatment plan. Educate the client on medication usage, including therapeutic benefit, administration protocol, and possible side effects. Assist the client to develop a schedule allowing the client to manage this disorder in daily life.

A client has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?

Assess the blood pressure in the supine, sitting, then standing positions.

Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first?

Assess the child's vital signs and neurological status.

After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action?

Assess the groin site

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first?

Assess the pain using a pain scale and compare to the previous assessment.

The nurse is teaching the client to prevent back injury. What should the nurse instruct the client to do?

Avoid prolonged sitting and standing.

The patient presents with a history of severe pain epigastric pain immediately after eating a high-fat meal and is diagnosed with cholecystitis after medical evaluation. Which of the following patients has the highest risk for Cholecystitis: A. 22-year-old Melanie, whose mother had gallbladder disease. B. 55-year-old Harold has fair skin, Crohn's disease, and Cholesterol of 320. C. 45-year-old Susan, mother of 2 sons, has T2 diabetes D. 52-year-old Janice who is 5'7" tall and weighs 125 lbs. A. Female, Family History (2 Risk Factors) B. Fair skin, Obesity, Hyperlipidemia (3 Risk Factors) C. Age, Female, Fertile, Diabetes (4 Risk Factors) D. Female (1 Risk Factor)

B. Fair skin, Obesity, Hyperlipidemia (3 Risk Factors)

he nurse is presenting a seminar at a community health fair about stroke recognition and prevention. In providing examples of patients, the nurse will place these order of highest to lowest risk for having a stroke/brain attack: A. 36-year-old female, blood pressure 121/63, whose mother-in-law had a stroke B. 58-year-old Asian American male with medial history of atrial fibrillation C. Hispanic American female, blood pressure 142/93, who runs 2 miles three times a week. D. Diabetic woman who tak

B. Highest Risk - Age, Gender, Medical Hx of AFib (3 Risk factors) C. 2nd Highest Risk - Race, Blood Pressure (2 Risk factors) D. 3rd Highest Risk - Diabetes (HDL and Triglycerides are normal) - (1 Risk factor) A. Lowest Risk - No risk factors for a stroke

The nurse is performing a medical history and physical assessment for a client. Which assessment findings lead the nurse to conclude that the client is at risk for development of osteoporosis? Select three that apply A. An obese woman from Ontario, Canada B. Survived breast cancer after 6 weeks of chemotherapy C. Drinks at least four cans of diet cola every day D. Walks her dog a mile and a half 4 times a week E. Smoked two packs of cigarettes a day for 40 years A. No risk factors for osteoporos

B. Survived breast cancer after 6 weeks of chemotherapy C. Drinks at least four cans of diet cola every day E. Smoked two packs of cigarettes a day for 40 years Rationale: A. No risk factors for osteoporosis B. Chemotherapy depletes bone structure C. Phosphorus opposes calcium and weakens bones D. No risk factors for osteoporosis E. Smoking is inflammatory and a major risk factor for osteoporosis.

The nurse is preparing to feed an infant diagnosed with pyloric stenosis prior to surgical repair. What is the nurse's most important intervention?

Burp the infant frequently.

The nursing student learns that deep vein thrombosis (DVT) can lead to serious complications such as pulmonary embolism but is having trouble remembering the risk factors for DVT. Help out this student by arranging the following individuals in order from greatest risk to least risk for developing DVT. Use all answer choices. A. Asian American woman, 35 weeks gestation, flies from New York to Hawaii for vacation. B. 65-year-old male with prior medical history of atrial fibrillation who is complia

C - Highest Risk - Sitting for long periods, Prior history DVT, Smoking (3 Risk factors) A - 2nd Highest Risk - Pregnant, long plane flight (2 Risk Factors) D - 3rd Highest Risk - Birth control pills (1 Risk factor) B - Lowest Risk - No risk factors for DVT

A newly hired nurse has been studying about Alzheimer's Dementia in preparation for completing a shift in the Memory Care Unit of the facility. The nurse learns about risk factors for Alzheimer's and places the following clients in order from highest to lowest risk for developing this type of dementia: A. 82-year-old male takes ginkoba and niacin. Refuses to eat red meat. B. 66-year-old obese male takes coumadin for prior stroke. Father died of COPD. C. 59-year-old-female has APOE4 variant.

C. Highest Risk - 59-year-old-female, has APOE4 variant. A1C 9, Cholesterol 340. Sister has Alzheimer's Dementia. (5 Risk Factors: Age - high risk at age 50 due to APOE4 variant and family history; Genetic predisposition; Diabetes) B. 2nd Highest Risk - 66-year-old obese male, takes coumadin for prior stroke. Father died of COPD. (3 Risk Factors: Age over 65; Obese; Hx of stroke.) D. 3rd Highest Risk - 48-year-old female, history of traumatic brain injury, smokes 2 packs of cigarettes per day.(2 Risk Factors: Hx of TBI, Smoking) A. Lowest Risk - 82-year-old male, takes ginkoba and niacin. Refuses to eat red meat. (1 Risk Factor: Age > 65)

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?

Carefully position and handle the omphalocele.

The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed?

Check the fetal heart rate for bradycardia.

A school-age child with a dog bite is brought to the emergency department by the parents. What is the nurse's priority action?

Clean and irrigate the bite wounds.

An elderly Jewish client received a lunch tray that consists of a cheeseburger, French fries, and an apple. The client tells the nurse to remove the tray. What is the nurse's understanding of why the client wants the tray removed?

Clients of the Jewish faith do not allow the mixture of dairy and meat.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.

The nurse is providing care for a client who immigrated three months ago. The nurse observes that the client is reluctant to make eye contact when responding to the nurse's questions. What is the nurse's best response?

Consider the norms around nonverbal communication in the client's culture.

Gastroesophageal Reflux Disease (GERD) is a common GI track disorder that affects many populations. Which of the following patients has the greatest risk of developing GERD? A. 32-year-old weight-lifting competitor, who drinks alcohol heavily on the weekends. B. 19-year-old who throws-up after every meal because she thinks she is obese. C. 23-year-old pregnant woman with one child who has a hiatal hernia. D. 61-year-old fireman, who weighs 290 pound smokes 2 packs of cigarettes a day. A. Weightl

D. Hiatal sphincter weakens with age. Overweight. Smoking is a major risk factor causing GERD (3 risk factors).

What is an expected assessment finding when caring for a client with a percutaneous feeding tube?

Dark pink stoma without drainage

The health care team has noticed an increase in intravenous (IV) infiltrations on the pediatric floor. As part of a "Plan, Do, Study, Act" quality improvement plan, the team should perform the actions in which order? All options must be used.

Decide to monitor IV gauges. Perform chart audits. Analyze the data. Write a new IV insertion policy.

A client who is at the end of life tells the nurse about experiencing "spiritual distress." What should the nurse do first?

Determine what spiritual distress means to the client.

A hospital client has told the nurse that their religion involves the burning of incense and has asked permission to do so on the unit. The nurse is aware that this practice would violate the hospital's fire regulations. What is the nurse's best action?

Dialogue with the client about alternative rituals or the possibility of performing the ritual outdoors.

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?

Elevate the affected part.

The infant with hemophilia A experiences bleeding at the elbow and is seen in the emergency department. Which nursing intervention would be most appropriate to minimize bleeding in the affected area?

Elevate the elbow above the level of the heart.

A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend?

Elevate the feet several times a day.

A nurse is caring for a client of the Buddhist faith who is dying. The client's family is at the bedside. Which intervention would the nurse implement to support the client's death with dignity?

Ensure that the room is calm, dimly lit, and quiet.

A typically developing preschool child is experiencing pain after an appendectomy. Which data collection tool is the most appropriate for the nurse use to assess the pain?

FACES Pain Rating Scale

The obstetrical nurse is caring for a client who is three hours postpartum. The client tells the nurse that nearly a dozen family members will be soon arriving to visit her and her infant. The client assures the nurse that this is the norm in her culture. What is the nurse's best action?

Facilitate the visit, unless it is ruled out medically or logistically.

A client tells the nurse on admission that they are uneasy about having to leave their children with a relative while being in the hospital for surgery. What should the nurse do?

Gather more information about the client's feelings about the childcare arrangements.

A client learns that she is pregnant, and asks the nurse for the names of abortion clinics. The nurse does not believe abortion is moral alternative. What is the most appropriate response by the nurse?

Give the client the available preprinted list of clinics.

The nurse is providing preoperative instructions to a client who is deaf. Which strategy is most effective in assuring that the client understands the information?

Give the client written material to read, and follow up with time for questions.

A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention?

Give the parent instructions on how to call poison control.

An adolescent client is admitted for surgical treatment of genital lesions. The client appears withdrawn. What action will the nurse use with the client's care?

Have an assistant when providing care.

A client who is 5 cm dilated reports that she has the urge to push. Which is the appropriate response by the nurse?

Have client blow out breath to keep from pushing.

The nurse is caring for a 3-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention?

Have the dietician meet with the child and family to provide foods the child will eat.

Which nursing intervention would be most effective in helping a 2-year-old child stay quiet after a bronchoscopy?

Have the parents stay at the bedside.

An alert and oriented client comes to the emergency department after hitting his head in a motor vehicle accident. What should the nurse do first?

Immobilize the client's head and neck

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention?

Inform the client that the discharge is colostrum, and a normal finding.

While performing an assessment of a 75-year-old client in the emergency department, a nurse notes several areas of ecchymosis in various stages of healing on the client's body. What is the nurse's priority action?

Inquire how these bruises occurred.

A client is admitted to the psychiatric emergency department with difficulty sleeping, poor judgment, and incoherent speech. The client reports being a special messenger from the Messiah who needs to be "sacrificed to save the world." Which action should the nurse take first?

Institute suicide precautions.

The nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do?

Instruct the client to elevate the left leg when sitting in the chair.

A child has ingested poisonous hydrocarbons. What is the most important nursing intervention?

Keep the child calm and relaxed.

The nurse asks the parent of a terminally ill infant if the parent would like the child to be baptized. The parent becomes upset and asks to speak to the nurse-manager. What is the nurse-manager's best response?

Let the parent express the parent's own spiritual beliefs and wishes.

A client has a respiratory rate of 4 breaths/min. What are this nurse's priority assessments?

Level of consciousness and a pulse oximetry value

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse?

Maintain a patent airway.

A client is being discharged following an open reduction and internal fixation of the left ankle and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches?

Maintain two to three finger widths between the axillary fold and underarm piece grip.

The community psychiatric nurse conducts a weekly education group for older adult clients. The nurse suspects that one of the clients with cognitive impairment is experiencing elder abuse based on bruising, but the client mentions experiencing falls at home. What is the nurse's priority action?

Make an immediate appointment to visit the home to assess the situation.

A nurse has been voicing concerns to colleagues about unfair client assignments being assigned by the charge nurse with some nurses consistently having less complex client assignments than others. What action should the charge nurse take upon learning this information?

Meet with the nurse privately and provide an opportunity to express concerns.

An adolescent client is admitted for treatment of anorexia nervosa with a body mass index (BMI) of 13. What is the nurse's priority in planning the care?

Monitor the client's urine output and vital signs.

What is the nurse's priority action in caring for a client who has just had a liver biopsy?

Monitor vital signs.

The nurse is preparing the client with heart failure to go home. Which instruction should the nurse give to the client?

Monitor weight daily.

The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses that the client's respiration rate is 30 breaths/min and respirations are rapid and shallow; there is the presence of a faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was adminis

Notify the health care provider (HCP).

Which nursing assessment is recommended to confirm placement of the nasogastric (NG) tube into the stomach of a client?

Obtain a chest X-ray and measure the pH of stomach contents.

The nurse is caring for a client who has begun to lose hair from chemotherapy treatment. The client appears withdrawn and answers questions in one-word statements, which is a change from previous behavior. What is the nurse's priority response?

Perform a depression screening assessment with the client.

The nurse is preparing to perform a cultural assessment of a new client. How should the nurse best perform this assessment?

Perform a systematic assessment using a recognized cultural assessment instrument.

A nurse is standing next to a person eating fried shrimp at a parade. Suddenly, the person clutches the throat and is unable to speak, cough, or breathe. The nurse asks if the person is choking, and the person nods yes. What action should the nurse take next?

Perform the Heimlich maneuver.

A 4-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery?

Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.

A nurse is caring for a 7-month-old infant who has just had surgical repair of a cleft palate. Which instruction would be the highest priority to the parents prior to discharge?

Place child in prone position.

Which steps should a nurse follow to insert a straight urinary catheter?

Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.

A client is admitted to the labor and delivery unit at 30 weeks' gestation. She has a history of cesarean birth, and reports severe abdominal pain that started less than one hour ago. When the nurse palpates tetanic contractions, the client again reports severe pain. After the client vomits, she states that the pain is better and then loses consciousness. The fetal heart rate is 100. What is the nurse's priority intervention?

Prepare the client for immediate surgery

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. What is the most important action by the nurse?

Preparing to administer hypertonic saline or mannitol per provider order

Which nursing intervention is a priority for a child with hemophilia, who has fallen, and has an acutely bruised leg?

Pressure on the site and administration of the required clotting factor

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse?

Provide privacy and emotional support.

The nurse and occupational therapist are planning an outdoor volleyball game and picnic for eight mental health clients. What action should the nurse take for the two clients taking nortriptyline for depression?

Provide protective clothing and apply sunscreen before going out.

A deceased client is a member of a culture where the family is expected to bathe the body after death. What should the nurse do to support the client and family at this time?

Provide the needed supplies to the family.

A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle accident. What would be the nurse's priority assessment?

Pulse oximetry readings

The Orthodox Jewish family of a client admitted for cochlear implantation expresses outrage at their child being served a pork dish after they identified their religion to the nursing staff. What is the nurse's best response?

Recognize their request and respectfully take corrective action.

A client with obsessive-compulsive disorder washes their hands multiple times daily and is late for meals and milieu activities. What is most appropriate for the nurse to do initially?

Remind the client about meal and activity times so that the ritual can be completed on time.

The nurse is reviewing the lab report for a client in hospice care with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next?

Report the elevated calcium level immediately.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

Report the incident to risk management.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?

Report the suspicion to the health care provider.

A nurse is caring for a client with a percutaneous feeding tube. The client has a prescription for 325 mg enteric coated aspirin to be given via the feeding tube once daily. How should the nurse give this medication?

Request an alternate formulation

The nurse is monitoring a very drowsy client in the immediate postprocedure phase of moderate sedation. The client will open the eyes to repeated verbal stimulation but does not respond verbally. The nurse has an order to give an antiemetic that is known to cause sedation. What assessment tool should the nurse utilize for this client?

Richmond Agitation-Sedation Scale (RASS)

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? All options must be used.

Splint the incisional site. Inhale through the nose. Exhale through pursed lips. Cough deeply from the lungs.

The nurse interviews clients during a cancer-screening event at a local older adult center. Which female clients are at risk for the development of breast cancer? (Select three that apply.) A. An older adult client who received radiation treatment for non-Hodgkin lymphoma. B. A middle-aged client who reports an increase in waist size and abdominal fat during the last two years. C. An adult client who drinks 1 to 2 alcoholic beverages per week. D. An adult client with a history of ovarian cancer

Step 1: Topic? risk factors breast cancer. Steps 2-4: are not relevant to 'select all that apply'' questions. Move to Step 5. Step 5: Read each answer and determine if it is a risk factor for breast cancer. Rephrase each answer as "yes/no," "correct/incorrect," or "true/false" to answer the question. A. Correct, risk factor (Prior radiation treatment cause epigenetic changes that trigger cancer cells to activate in the body. People who are cured from one type of cancer often develop cancer in another part of their body later in life. B. Correct, risk factor (Metabolic Syndrome. Central obesity excretes estrogen which contributes to the growth of reproductive system cancers.) C. Incorrect, not a risk factor. Eliminate. (Note - drinks 1-2 beverages PER WEEK - not per day) D. Correct, risk factor (Individuals with the BRCA gene mutations are at higher risk for BOTH ovarian and breast cancer) E. Incorrect, not a risk factor. Eliminate. (Must be a 1st degree relative

A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate I.V. for 3 hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing, blood pressure of 150/100 mm Hg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min, and urine output of 20 ml/hr. Which action would be most appropriate?

Stop the magnesium sulfate infusion.

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium daily.

The nurse is caring for a client diagnosed with postoperative atelectasis. What intervention performed by the nurse best addresses the underlying pathophysiology that leads to atelectasis?

Teach deep breathing, coughing, and incentive spirometry exercises.

A client's partner tells the nurse that he will remain in the waiting room while the client is in labor. The client's sister has been chosen to be her birth companion. Which of the following responses from the nurse would be most appropriate?

Tell the partner that he will receive updates of the client's progress and be called as soon as the baby is born.

A diabetic patient is reviewing the hospital menu to order lunch. The client asks the nurse for suggestions for "cold" foods to order. What is the nurse's understanding of why the client asking about suggestions for "cold" foods?

The client is balancing the disease with cold foods.

After the family leaves, a Muslim client admitted for gastroenteritis explains that prayers must be performed five times a day even while in the hospital. The client later asks which direction is west. What should the nurse recognize in this client? Select all that apply. The client loves nature and watching sunsets each evening. The client plans to wave goodbye as the family drives away. The client is demonstrating an active faith practice. The client is advocating to be able to meet religious

The client is demonstrating an active faith practice. The client is advocating to be able to meet religious needs. The client is successfully communicating spiritual needs.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions.

The nurse is educating a client after a tonsillectomy on performing throat irrigations to decrease pain. Which instruction is correct for the client?

The client will need to use cool water to best relieve discomfort.

The nurse is providing care for a client who is a recent immigrant. What principle should the nurse apply to the client's care?

The client's preferences around touch and personal space may differ from the nurse's.

A client who is being treated for cancer has expressed interest in exploring complementary and alternative therapies. What is the nurse's best action?

The nurse should maintain open communication about complementary and alternative treatments, and unless there is a known safety risk, the client's interest should be facilitated. The nurse should make it clear that the client does not have to choose between conventional treatment and alternatives. If there is a safety risk, the care team should educate the client about the risk and should not arrange the treatment for the client.

A school nurse is called to assess a preadolescent, a newly immigrated Vietnamese person attending a new school. A teacher tells the nurse that the student sits in the back of the class and won't speak when spoken to, although the parents confirmed the student speaks English. Which assessment finding is most likely?

The student is experiencing cultural shock.

A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. What should the nurse tell the client that the test results indicate?

There is evidence of fetal well-being.

The nurse has recently accepted a position in a community with an ethnically and culturally diverse population. What action should the nurse first perform in order to enhance cultural competence?

Thoughtfully reflect on the characteristics of their own culture.

The nurse is developing a plan of care for a hospitalized client who is at risk for suicide. What is the most important intervention for the nurse to include?

Use a caring approach to maintain close observation of the client

A client is admitted to a mental health unit. While assessing the client, the nurse finds the client exhibiting signs of hyperexcitability, increasing agitation, and distractibility. Based on this assessment, which nursing intervention has priority?

Use a quiet room for the client away from others.

A client is to have radiation therapy after a modified radical mastectomy. What instruction should the nurse give the client about caring for the skin at the site of the radiation therapy?

Wash the area with water.

A nurse is developing a teaching plan for a client who has recently been diagnosed with open angle glaucoma. The healthcare provider ordered pilocarpine 0.25% ophthalmic drops, two drops to eyes each eye four times a day. How should the nurse instruct the client to instill the eye drops? Select the correct order. All options must be used.

Wash your hands. Take top off the medication bottle and place on a clean cloth. Using a tissue or cotton gently pull the skin below the eye downward. Put two drops into the conjunctival sac of the right eye. Close the eye. Using your finger and a tissue place gentle pressure on the nasolacrimal duct for 30 to 60 seconds.

The nurse is providing discharge instructions about preventing infection to a client who had a modified radical mastectomy and will be pruning flowers when they return to work. To prevent infection, what should the nurse instruct the client to do?

Wear protective gloves when gardening.

A nurse is coordinating outpatient care for a 38-year-old client who is homeless and has a history of chronic schizophrenia. Which one intervention would be best for the nurse to suggest for this client?

a life and social skills group

A client develops chronic pancreatitis. The nurse should suggest which diet?

a low-fat, bland diet distributed over five to six small meals daily

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

a small amount of yellow drainage at the left pin insertion site

The nurse is developing a plan of care for a client who has joint stiffness because of rheumatoid arthritis. Which measure will be the most effective in relieving stiffness?

a warm shower before performing activities of daily living

An older adult client with pneumonia is admitted with prescriptions for intravenous antibiotics, supplemental oxygen as needed, and antipyretics. The nurse should immediately notify the health care provider for which assessment finding?

acute onset delirium

A client in the hospital for gout reports an excruciating migraine but declines analgesic medications when offered. Later the nurse observes a visitor performing what appears to be a type of physical manipulation of the client's head and neck. The client reports that the visitor is a therapist. The best action for the nurse to take is to:

advise the client how the client might receive adjunct services.

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104°F (40°C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3 (16 × 109/L). What is the priority for nursing intervention?

airway obstruction

A 7-year-old client has been diagnosed with bacterial meningitis. Who should receive chemoprophylaxis?

all household contacts and close contacts

A client with a history of posttraumatic stress is panting and breathing heavily while shouting out some strange words. The nurse reviews the nursing assessment and understands that the client is practicing a form of relaxation called power breathing. The best action for the nurse to take is to:

allow privacy, but check on the client frequently.

After teaching the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching?

application of powder to the skin under the cast

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

arterial blood gas (ABG) findings

A client with multiple serious chronic illnesses says to the nurse, "I would like to strengthen my faith, but I am struggling." What action(s) by the nurse would assist the client in strengthening faith? Select all that apply. asking the client about original spiritual beliefs identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs reading aloud Bible passages that relate to the client's needs offering to pray with the client to

asking the client about original spiritual beliefs identifying current or past spiritual supports exploring factors that are creating conflict with client's beliefs

The nurse is developing a teaching plan with a client with myasthenia gravis. The nurse should include information about the risk for which health problem?

aspiration

A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m. (0700), before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to

assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin.

A nurse is teaching an older adult who has had a left modified radical mastectomy with axillary node dissection about lymphedema. What should the nurse tell the client about when lymphedema occurs?

at any time after surgery

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it is slightly concave. Additional assessment should proceed in which order?

auscultation, percussion, and palpation

The nurse is caring for a client struggling with alcohol dependence. It is most important for the nurse to:

avoid blaming or preaching to the client.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

avoiding using deodorant soap on the irradiated areas

The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet the client's needs?

baked chicken, an apple, and a slice of white bread

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign?

blood pressure

For a client with a circumferential chest burn, what is the most important factor for the nurse to assess?

breathing pattern

The nurse is assessing for oxygenation in a client with dark skin. Where will oxygenation be most evident on this client?

buccal mucosa

A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource?

contacting the Poison Control Center by phone

A 30-year-old multiparous client in active labor is admitted to the labor and delivery unit. She has received no prenatal care for this pregnancy. Which data would the nurse obtain first?

date of last menstrual period (LMP)

A client is admitted for detoxification following a cocaine overdose. The client reports frequent cocaine use but claims the ability to control use. Which coping mechanism is the client using?

denial

A nurse is conducting a spiritual assessment on a client admitted for surgery and developing a plan of care based on this assessment. To help ensure that the nurse is most successful in meeting the client's spiritual needs and promote a comfortable working relationship with the client, which aspect would be most important initially for the nurse?

developing an awareness of one's own beliefs about the connection between spirituality and health

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child?

diluting the chemicals

A client who has experienced the loss of their spouse through divorce, the loss of their job and apartment, and the development of drug dependency is experiencing situational low self-esteem. Which outcome is most appropriate initially?

discuss their feelings related to their losses.

There has been a large disaster, and nurses from various units have been assigned to help with the large influx of clients. To which client would it be most appropriate to assign an obstetric-postpartum nurse?

female in pelvic traction who is three months pregnant

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which assessment findings are consistent with this syndrome?

fever, decreased level of consciousness (LOC), and impaired liver function

A client reports nausea unrelieved by a recent antiemetic dose. The client asks for another treatment for the nausea. What is an alternative therapy to treat nausea?

ginger

A client discusses with the nurse the possibility of using alternative therapies for management of hypertension and diabetes. Which is an expected alternative therapy used by the client?

ginseng

An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the client to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources?

ham and eggs

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

head of the bed elevated 45 degrees

The nurse is conducting a wellness program for adults about cancer. The nurse should teach clients about which potential risk factor for the development of colon cancer?

history of inflammatory bowel disease

A multigravida client has given birth to a large-for-gestational-age infant with an Apgar score of 8 and 9. What is the priority nursing assessment for the infant?

hypoglycemia

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

hypokalemia

While assessing a male neonate whose parent desires that the infant be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication?

hypospadias

The nurse works in an institution that expects nurses to initiate referrals to social or spiritual resources. What might trigger a nurse to initiate such a referral? Select all that apply. impending death family conferences a client expressing a cultural concern a client requesting occupational therapy a client requesting time alone

impending death family conferences a client expressing a cultural concern

When assessing a family suspected of abusing its 4-year-old child, which behavior is the most important criterion that would suggest abuse?

incompatibility between the history (mechanism) and the injury

The health care provider (HCP) prescribes scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, what would the nurse include as the purpose?

increase in the fetal heart rate and variability

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?

lean meats and low-fat milk

What is the priority nursing assessment of a client with an eating disorder?

level of danger to self

A client in a long-term nursing care facility who decides to be placed on hospice care expresses to the nurse, "I have outlived my family and friends; I have lost hope and there is no need for me to continue on." What underlying client concerns would the nurse first address with this client?

loneliness and feelings of isolation

A client has just returned from surgery for a gastrectomy. The nurse should position the client in which position?

low Fowler's

The nurse is teaching the client with vitamin B12 deficiency about ways to increase the dietary intake of vitamin B12. Which foods would provide the best supply of vitamin B12?

meats and dairy products

An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder?

metabolic alkalosis

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect?

neuroleptic malignant syndrome

A mother who gave birth some three hours ago asked the nurse why her baby is so difficult to keep awake. The nurse informs the mother that this behavior indicates

normal progression into the sleep cycle.

A toddler is admitted to the facility for treatment of a severe respiratory infection. The child's recent history includes fatty stools and failure to gain weight steadily. The physician diagnoses cystic fibrosis. By the time of the child's discharge, the child's parents must be able to perform which task independently?

performing postural drainage

The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply. potatoes apples bagels corn pizza

potatoes apples corn

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean birth. The client tells the nurse that they have been taking gingko biloba to help manage blood sugar. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication?

prolonged bleeding

A nurse is caring for a child with pheochromocytoma. What is the most important intervention by the nurse?

promoting an environment free from emotional distress

A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction?

providing the client with information about what to expect postoperatively

A client is voluntarily admitted to a substance use disorder unit. The client admits to drinking at least 1 qt (1 L) of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings will the nurse document as evidence of alcohol withdrawal?

pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness

A nurse is developing a plan of care for a postpartum client of Arab American descent. The nurse integrates knowledge of which cultural belief as important for this client?

reluctance to bathe due to belief that air gets into the mother and causes illness

The nurse is caring for a client in labor. The nurse notes variable decelerations on the fetal monitor strip. What is the nurse's priority intervention?

repositioning the client to the other side

During gentamicin therapy, the nurse should monitor a client's

serum creatinine level.

Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis?

signs of increased intracranial pressure (ICP)

The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessment(s)? Select all that apply. suicide or self-harm ideation incentives that motivate the client recent use of substances of abuse allergic reactions or adverse drug reactions dietary preferences

suicide or self-harm ideation recent use of substances of abuse allergic reactions or adverse drug reactions

A 6-year-old male client is having an examination in the community clinic. Click to highlight the findings that will require the nurse to follow up. Client is a 6-year-old male brought to the clinic by a parent to be evaluated for behavior changes. The parent reports the child constantly taps their feet and runs throughout the house. The client's teachers at school are concerned because the client constantly talks and interrupts others. The client also keeps losing their coats and sweaters. Sc

taps their feet and runs throughout the house constantly talks interrupts others losing their coats and sweaters. School activities are not completed. loses interest easily angered

For the past 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician orders topical nystatin to be applied to the perineum four times daily. The nurse should focus her assessment on:

the inside of the infant's mouth.

The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The parent does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his parent, the nurse should consider that:

these circumstances may allow the child to translate.

A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?

to reduce or prevent edema of the legs and feet

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client:

uses the sternocleidomastoid muscles.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The client is instructed to return to the office laboratory weekly for 6 months to have blood drawn. Which laboratory results would be of concern to the nurse after the third test?

white blood count (WBC) of 3000