Passpoint - The Nursing Process

A licensed practical nurse (LPN) receives a report on several assigned clients at the beginning of the evening shift. The nurse would plan to collect data on which client first? a client with a central line infusion at 60 mL/hour with 400 mL remaining in the IV bag an older adult client with bacterial pneumonia experiencing periods of confusion a client scheduled for a cardiac catheterization in the morning who is visiting with family a client with a chest tube inserted for a pneumothorax who is resting comfortably

an older adult client with bacterial pneumonia experiencing periods of confusion

A 1-year-old child is diagnosed with a congenital cardiac defect after cardiac catheterization. The parents have expressed concern about activities at home. Which response by the nurse would be best when reinforcing education with these parents? "You'll have to establish strict discipline so that the child learns what activities are limited." "Allow the child to play and be active as long as the child doesn't get fatigued." "The child will only be able to play alone." "Discipline and limit-setting need to be relaxed to reduce stress and crying."

"Allow the child to play and be active as long as the child doesn't get fatigued."

A nurse is reinforcing education for a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client? "Consume alcoholic beverages in moderation when taking the drug." "Avoid foods such as scallops, anchovies, and yeast breads." "You can take aspirin to relieve the pain in your feet as needed." "Take the medication between meals to promote absorption."

"Avoid foods such as scallops, anchovies, and yeast breads."

A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask a nurse if anything can be done to prevent the other children in the family from developing rheumatic fever. What is the best response by the nurse? "Be sure the other children are fully immunized against hepatitis B." "The other children should not be exposed to your child with rheumatic fever for at least two weeks." "The children have already been exposed, so they will all probably develop rheumatic fever." "Be sure that if any of the children have strep throat or scarlet fever they are properly treated with antibiotics."

"Be sure that if any of the children have strep throat or scarlet fever they are properly treated with antibiotics."

A nurse is providing care for a pregnant 16-year-old client who says that she is concerned she may gain too much weight and wants to start dieting. What is the best response by the nurse? "The prenatal vitamins should ensure that the baby gets all the necessary nutrients." "You shouldn't begin dieting during pregnancy because you're eating for two." "Let's talk about how you are feeling a bit more." "Dieting could deprive your baby of nutrients leading to developmental and growth problems."

"Dieting could deprive your baby of nutrients leading to developmental and growth problems."

A client presents to the medical clinic for evaluation of a rash and throat tightness. The client reports that the symptoms developed 24 hours after eating peanuts. Which question should the nurse ask the client? "Does using an albuterol inhaler help you to ease the tightness in your throat?" "Are you prescribed prednisone to manage your allergies and airway swelling?" "Do you have injectable epinephrine available to carry with you at all times?" "Have you ever used diphenhydramine to reduce the swelling in your throat?"

"Do you have injectable epinephrine available to carry with you at all times?"

A nurse is reviewing prenatal care with a client. Which statement by the client best expresses an adequate understanding of the nutritional needs during pregnancy? "Even though I need to eat more, I should make sure I don't fill up with junk food." "After gaining a few pounds each month, I'll really get big and put on 20 pounds or so." "I guess I'll get big and gain 20 to 30 pounds and look pregnant." "Since I have to eat for two, I should eat whatever I want whenever I feel hungry."

"Even though I need to eat more, I should make sure I don't fill up with junk food."

15-year-old comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that the parents might be notified of the test results. Which response by the nurse is most appropriate? "HIV testing is confidential; after we get the test results, we will discuss your options with you only." "Your parents must sign the consent form before we can test you." "HIV testing is very serious; we must notify your parents of the results." "Discussing testing with your parents can be frightening, but I can stay with you while you tell them."

"HIV testing is confidential; after we get the test results, we will discuss your options with you only."

The employer of a client on a psychiatric unit calls the nursing station inquiring about the client's progress. The nurse is unsure whether the client has given consent for information to be shared with callers on the phone. Which response by the nurse would be best? "I'll give you the name and telephone number of the client's health care provider." "I'll have the client call you." "I'm not permitted to discuss the client's progress." "I can't confirm whether your employee is a client here."

"I can't confirm whether your employee is a client here."

A child is transferred to the medical-surgical floor from the intensive care unit (ICU) after sustaining a closed head injury that left the client comatose. The child's mother is identified as the only guardian. During the evening shift, a man identifying himself as the child's father asks the nurse for information about the child's condition. How should the nurse respond? "Let's go to the conference room, where we can discuss your child's condition privately." "What have you been told about your child's condition?" "I can't give out information about a client without consent from the client or the client's legal guardian." "The child was just transferred to our floor. The ICU staff can best answer your questions."

"I can't give out information about a client without consent from the client or the client's legal guardian."

The nurse reinforces the client's teaching on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional instruction has been effective? "I chose a baked potato with broiled chicken for dinner." "I chose chicken bouillon soup for lunch every day." "I chose a tossed salad with sardines and oil and vinegar dressing for lunch." "I can still eat a ham-and-cheese sandwich with potato chips for lunch."

"I chose a baked potato with broiled chicken for dinner."

A nurse is reinforcing education for a client with pernicious anemia requiring vitamin B12 replacement therapy. Which statement indicates that the client understands the treatment program? "I'll take one vitamin B12 tablet every morning for 2 weeks." "I'll take a vitamin B12 tablet once each month for life." "I'll need an injection of vitamin B12 every month for life." "I'll only need daily injections of vitamin B12 until my blood count improves."

"I'll need an injection of vitamin B12 every month for life."

A nurse who is caring for a client who underwent a hemorrhoidectomy begins preparing a sitz bath for the client to use after the rectal packing has been removed. The client is reluctant to take the sitz bath and says to the nurse, "What good is it anyway?" Which response by the nurse would be most appropriate? "Sitting in a sitz bath is more comfortable than sitting in a chair." "It helps reduce swelling in the rectal area, which helps relieve the discomfort." "It will help soften your stool so that it won't be painful when you pass it." "It helps prevent bleeding, which may occur after the packing is removed."

"It helps reduce swelling in the rectal area, which helps relieve the discomfort."

The nurse is reviewing a client's plan of care. The following statement appears on the client's plan of care: "Client will ambulate in the hall without assistance within 4 days." What does the nurse recognize this statement as an example of? Subjective data A nursing intervention A client outcome A nursing diagnosis

A client outcome

A client who underwent surgery 1 day ago is concerned about worsening incisional pain and isn't scheduled to receive pain medication for 2 hours. Which action by the nurse is most appropriate? Encourage diversional activities to divert the client's attention away from the pain. Administer another dose of pain medication and notify the physician. Assist the client with ambulation to reduce pressure on the incision. Assess the incision and then notify the charge nurse of the client's worsening pain.

Assess the incision and then notify the charge nurse of the client's worsening pain.

A client is diagnosed with a brain tumor. As the nurse is assisting the client from the bed to the chair, a generalized seizure occurs. Which action should the nurse perform first? Assist the client to the floor, and place the client in a side-lying position. Initiate the code team response and begin cardiopulmonary resuscitation (CPR). Put a padded tongue blade into the client's mouth and restrain the extremities. Record the type of seizure and the time that it occurred.

Assist the client to the floor, and place the client in a side-lying position.

A nurse is planning care for a client after a tracheotomy. One of the client's goals is to overcome verbal communication impairment. Which nursing intervention should the nurse include when assisting with development of the care plan? Encourage the client to communicate by allowing time to write words. Speak for the client to reduce occurrence of frustration. Avoid using a tracheostomy plug because it blocks the airway. Make an effort to read the client's lips to foster communication.

Encourage the client to communicate by allowing time to write words.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Fear Urinary retention Excess fluid volume Toileting self-care deficit

Excess fluid volume

While assessing a home care client, the nurse notices a family member smoking near the client's oxygen. Which action by the nurse is best? Asking the family member to go outside to smoke Doing nothing because it's the client's home Explaining to the family member that oxygen is flammable and smoking must be avoided Posting a "No Smoking" sign on the oxygen delivery system

Explaining to the family member that oxygen is flammable and smoking must be avoided

A client in her second trimester tells the nurse that she feels very anxious because she is not sure of what will happen when she goes into labor to give birth. Which intervention by the nurse would be most appropriate for this client? Arrange for a more experienced pregnant woman to assist her. Provide her and her partner with written information about the birthing process. Help her enroll in birth preparation classes at the facility where she plans to give birth. Tell her that she will learn to cope as her pregnancy progresses.

Help her enroll in birth preparation classes at the facility where she plans to give birth.

A licensed practical nurse (LPN) who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short-staffed. The nurse has never worked in a CCU. Which action by the nurse would be most appropriate? Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU. Speak to the nursing supervisor about the request for the nurse to go to the CCU. Call the hospital risk manager to report the request as a violation. Refuse to go to the CCU due to lack of experience.

Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU.

A nurse suspects that another nurse is chemically impaired. The nurse smells alcohol on the other nurse's breath and notes occasional slurred speech. What is the best course of action for the first nurse to take? Cover for the nurse because the profession depends on loyalty from colleagues. Inform the nurse about having one more chance but if the behavior occurs while on duty again, the nurse will be reported. Immediately notify the supervising nurse on duty of the suspicions. Notify law enforcement, asking them to arrest the nurse because the clients' lives are in danger.

Immediately notify the supervising nurse on duty of the suspicions.

After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client? Inability to speak clearly Arm and leg weakness Difficulty swallowing Absence of the gag reflex

Inability to speak clearly

A client is experiencing mild diarrhea through the colostomy. Which instruction is correct? Eat prunes. Drink apple juice. Increase lettuce intake. Increase intake of bananas.

Increase intake of bananas.

A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time? Impaired gas exchange related to increased blood flow Excess fluid volume related to peripheral vascular disease Risk for injury related to edema Ineffective peripheral tissue perfusion related to venous congestion

Ineffective peripheral tissue perfusion related to venous congestion

A female client has a fractured left hip. Her left leg is in Buck's traction while the client is being prepared for a hip pinning. What should the nurse plan to do when inserting an indwelling catheter? Choose a No. 12 French catheter. Instruct the client to deep breathe during catheterization. Add tape to the catheter tray for taping the indwelling catheter to the client's abdomen. Instruct the client to turn on her right side with both legs flexed.

Instruct the client to deep breathe during catheterization.

A female client has a fractured left hip. Her left leg is in Buck's traction while the client is being prepared for a hip pinning. What should the nurse plan to do when inserting an indwelling catheter? Choose a No. 12 French catheter. Instruct the client to turn on her right side with both legs flexed. Instruct the client to deep breathe during catheterization. Add tape to the catheter tray for taping the indwelling catheter to the client's abdomen.

Instruct the client to deep breathe during catheterization.

A nurse is caring for a client who's taking the anticoagulant warfarin (Coumadin). Which instruction regarding warfarin therapy should the nurse give to the client? Use a straight razor when shaving. Limit foods high in vitamin K. Report incidents of diarrhea. Take aspirin for pain relief.

Limit foods high in vitamin K.

A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best? Notify the charge nurse and nursing supervisor of the incident. Ask the nurse why she's accessing the medical record and ask her to leave the client care area. No action is necessary. Notify security and the client's physician of the incident.

Notify the charge nurse and nursing supervisor of the incident.

A client who underwent surgical repair of a herniated lumbar disk has a physician's order to ambulate during the immediate postoperative period. The client states that he has numbness, weakness, and pain in his leg. How should the nurse intervene? Notify the physician of the client's concerns. Notify the physician and prepare the client for a return to the operating room. Maintain bed rest. Administer pain medication and assist the client to a standing position.

Notify the physician of the client's concerns.

A client undergoing a brain computed tomography (CT) scan because of continual migraine headaches is placed in the CT scanner and suddenly reports having palpitations, shortness of breath and shaking. What is the client most liekly experiencing? Allergic reaction Hypoglycemic episode Panic attack Myocardial infarction (MI)

Panic attack

A client admitted with a high fever mentions that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best? Performing mouth care Explaining to the client that he can't have anything by mouth until after testing. Increasing the infusion rate of the client's I.V. fluids. Offering the client ice chips

Performing mouth care

While driving home from work, a nurse realizes that she failed to communicate to the oncoming nurse that a client asked for more information about advance directives. Which action would be appropriate for the nurse to take? Perform an Internet search on advance directives and provide the client with the information in the morning. Return to work immediately and inform the nurse who is caring for the client. Phone the nurse caring for the client and inform her of the client's request. Provide the client with information when she returns to work in the morning.

Phone the nurse caring for the client and inform her of the client's request.

A nurse demonstrates how to clean dentures to an unlicensed assistive personnel (UAP). Which action should the nurse make sure to teach the UAP? Scrub the dentures with a cleaning agent and cold water. Put a washcloth in the sink to prevent damage the dentures. Rinse the dentures under hot running water. Clean the dentures over the sink with the drain closed.

Put a washcloth in the sink to prevent damage the dentures.

A client returns to the client care area after undergoing abdominal surgery. As the nurse inspects the client's dressing, she notes that it's completely saturated with bright-red blood. Which action should the nurse take? Reinforce the dressing and contact the physician. Reinforce the dressing and continue to monitor the client. Immediately obtain the client's vital signs and then change the dressing. Remove the saturated dressing and re-dress the surgical site with sterile dressings.

Reinforce the dressing and contact the physician.

A nurse is providing care to a child on the pediatric unit. While visiting the child, two family members begin arguing in a child's room and start to hit each other. The child becomes visibly upset and begins to cry. Which action would the nurse implement as the priority? Call security to come and intervene. Ask one of the family members to leave the room. Try to reason with both family members. Remove the child from the room.

Remove the child from the room.

A client who had a stroke is admitted to the hospital. Four hours later, a nurse obtains these vital signs: blood pressure, 170/80 mm Hg; apical pulse, 58 beats/minute with a regular rhythm; respiratory rate, 14 breaths/minute; axillary temperature, 101° F (38.3° C). Which initial nursing action is most appropriate? Report the vital signs to the registered nurse (RN). Monitor vital signs more frequently. Check the client for an overdistended bladder. Monitor the client for signs of overhydration.

Report the vital signs to the registered nurse (RN).

A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, what should the nurse plan to speak with the client's family about? Brushing the client's teeth with a firm toothbrush Encouraging the client to eat his favorite Mexican foods Pproviding hot fluids, such as tea and broth, between meals Rinsing the client's mouth with diluted hydrogen peroxide every 2 hours

Rinsing the client's mouth with diluted hydrogen peroxide every 2 hours

A nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What are the appropriate actions for the nurse to take? Select all that apply. Speak to the charge nurse about the assignment. Ignore the assignment and leave the unit. Document all concerns in writing about the assignment. Trade assignments with another nurse. Refuse to carry out the assignments.

Speak to the charge nurse about the assignment. Document all concerns in writing about the assignment.

A nurse is reinforcing education with parents on how to reduce the spread of impetigo. What should the nurse encourage the parents to do? Teach children to cover mouths and noses when they sneeze. Arrange for their children to be immunized against impetigo. Teach children the importance of proper hand washing. Isolate a child with impetigo from other members of the family.

Teach children the importance of proper hand washing.

A primary health care provider has instructed a client to check the radial pulse each morning before taking digoxin. After the nurse reinforces education with the client on how to take a radial pulse, which client behavior indicates an accurate understanding of the technique? The client states that the radial pulse should be taken immediately after breakfast. The client counts the radial pulse for 10 seconds and multiplies by 6. The client places a stethoscope over the apex of the heart. The client uses the middle three fingertips to palpate the radial artery.

The client uses the middle three fingertips to palpate the radial artery.

An older adult client admitted to the hospital with an exacerbation of heart failure is confused, has inadvertently pulled out the IV catheter, and is attempting to get out of bed. The health care provider orders the use of physical restraints. Which nursing action reflects safe nursing care? Remove the restraints once per shift to check skin integrity and circulation. Cover the restraints with a blanket so that the client cannot see them. Apply the restraints so that a finger can be inserted underneath them. Tie the restraints to the bed frame using a quick-release knot.

Tie the restraints to the bed frame using a quick-release knot.

Which information should the nurse include when reinforcing instructions for a client about using vaginal medications? Use a water-soluble lubricant when inserting a suppository. Use a tampon after insertion to increase medication absorption. The suppositories should be kept at room temperature. Release and pull up on the applicator before removal.

Use a water-soluble lubricant when inserting a suppository.

A woman in her eighth month of pregnancy is having dinner with her husband at their favorite restaurant. The woman suddenly begins choking on a piece of chicken. The client's husband yells out, "Please somebody help us!" A licensed practical nurse is sitting at the next table and offers to help. Which action would the nurse most likely perform? a chest thrust reposition the client on her side begin cardiopulmonary resuscitation (CPR) an abdominal thrust

a chest thrust

A newly hired licensed practical nurse (LPN) is establishing priorities for morning client evaluations with the assistance of a preceptor. Which client should the nurses evaluate first? a newly admitted client with acute abdominal pain a client who underwent surgery 3 days ago who requires a dressing change a client receiving continuous tube feedings who needs the tube feeding residual checked a sleeping client who received pain medication 1 hour ago

a newly admitted client with acute abdominal pain

A nurse is assigned to care for a client in the immediate postoperative recovery phase. Which data collection takes priority during the initial assessment? vital signs, presence of reflexes, and intake and output airway, respiratory rate and depth, other vital signs, and skin color dressings, drains, and intake and output level of consciousness and presence of reflexes

airway, respiratory rate and depth, other vital signs, and skin color

A nurse is providing care for a client who underwent a mitral valve replacement. Which finding indicates to the nurse that the client is making progress toward a priority goal of treatment by the time of discharge? tolerating short periods of sitting up in the chair after surgery able to change the surgical site dressing without assistance ambulating from the room door to the end of the hall and back assisting with bathing the face, neck, arms, trunk, and genitals

ambulating from the room door to the end of the hall and back

A client with pulmonary edema is receiving furosemide. To determine the effectiveness of this diuretic, what data should the nurse obtain? breath sounds bowel sounds heart sounds neurovascular status

breath sounds

A client with altered mental status fell out of bed while hospitalized, and now the family wants to sue the facility. Which elements must be proven by the family's attorney in this case to result in a guilty verdict of professional negligence? breach of duty, damages, and causation duty, breach of duty, damages, and causation duty, breach of duty, and damages duty, damages, and causation

duty, breach of duty, damages, and causation

A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask a nurse if anything could have been done to prevent this disorder. Which intervention would have been most effective in preventing rheumatic fever? immunization with the hepatitis B vaccine isolation of individuals with rheumatic fever use of prophylactic antibiotics for invasive procedures early detection and treatment of streptococcal infections

early detection and treatment of streptococcal infections

A licensed practical nurse (LPN) is working on a wing of a medical-surgical unit that is also staffed with a registered nurse and a certified nursing assistant (CNA). When providing care, which task would be most appropriate for the LPN to delegate to the CNA? increasing the oxygen flowmeter to 4 L/minute obtaining vital signs of a client who just returned from a colonoscopy feeding a client for the first time after he experienced a stroke encouraging a client to drink fluids

encouraging a client to drink fluids

A client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process? evaluation data collection implementation analysis

evaluation

A client presents to the clinic because she thinks she may be pregnant. The licensed practical nurse is reviewing the client's medical record. Which finding would the nurse identify as a positive sign? fetal heart tones auscultated amenorrhea enlarging uterus quickening

fetal heart tones auscultated

An older adult client has been admitted to the medical-surgical unit after surgery. While the nurse is off the floor, the client falls out of bed, resulting in a fracture of the right leg. The nurse finding the client states that the "side rails were left down and the bed was in the high position." Which charge is most appropriate for the nurse's actions? comparative negligence battery collective liability negligence

negligence

The nurse obtains laboratory results on assigned clients during morning report. Which results needs to be immediately reported to the health care provider? glucose level 98 mg/dL hemoglobin 13.6 mg/dL potassium level 6.2 mg/dL creatinine level 0.6 mg/dL

potassium level 6.2 mg/dL

A nurse is caring for a 10-year-old child with rheumatic fever. When obtaining the child's health history from the parent, the nurse should ask if the child recently had which illness? chickenpox mononucleosis influenza strep throat

strep throat

Professional regulations and laws that govern nursing practice are in place for what reason? to ensure that practicing nurses are of good moral standing to limit the number of nurses in practice to ensure that enough new nurses are always available to protect the safety of the public

to protect the safety of the public

Professional regulations and laws that govern nursing practice are in place for what reason? to protect the safety of the public to ensure that practicing nurses are of good moral standing to limit the number of nurses in practice to ensure that enough new nurses are always available

to protect the safety of the public

A 5-month-old infant is brought to the pediatric clinic by the parent. The child has had recurrent middle-ear infections since 3 months of age. Which information is most important for the nurse to collect at today's visit? the child's temperature the child's weight gain since the last visit whether the child received all the prescribed antibiotic at the time of the last infection the child's eating habits

whether the child received all the prescribed antibiotic at the time of the last infection

A 5-month-old infant is brought to the pediatric clinic by the parent. The child has had recurrent middle-ear infections since 3 months of age. Which information is most important for the nurse to collect at today's visit? the child's eating habits the child's weight gain since the last visit whether the child received all the prescribed antibiotic at the time of the last infection the child's temperature

whether the child received all the prescribed antibiotic at the time of the last infection

Which statement reflects appropriate documentation in the medical record of a hospitalized client? "Client seems to be mad at the physician." "Client's skin is moist and cool." "Client had a good day." "Small pressure ulcer noted on left leg."

"Client's skin is moist and cool."

A client with a history of duodenal ulcers states to the nurse, "I take antacids once in a while to relieve the pain." Which statement by the client should be reported immediately? "I've had a lot more pressure at work lately." "My bowel movements have been sticky and black." "I have this bad taste in my mouth after taking my antacid and feel like I have to vomit." "I have this gnawing pain in my belly a few hours after I eat that causes nausea."

"My bowel movements have been sticky and black."

The nurse assesses capillary refill in a client admitted with pneumonia and dehydration. Which capillary refill duration is considered abnormal and should be reported? 1 second 4 seconds 3 seconds 2 seconds

4 seconds

A client at 36 weeks gestation is admitted with thrombophlebitis. The client is on strict bed rest, vital signs every 4 hours, fetal heart tones every 4 hours, and an intravenous heparin drip. The client is concerned about the effect the drug might have on her baby. She states, "If it makes my blood thinner, then won't it make my baby's blood change?" Which response by the nurse would be most appropriate? "Your health care provider can answer this question. Wait until tomorrow and ask the care provider then." "Heparin doesn't cross the placenta, so it can't get into the baby's blood system." "The heparin molecule is too large to get to the baby, so no damage will occur." "This drug can't possibly change your baby's blood."

"Heparin doesn't cross the placenta, so it can't get into the baby's blood system."

A 20-year-old female client is asking questions about breast cancer. Which information should the nurse provide to this client? "It is important that you become familiar with your breasts so that you can detect any changes." "You should start wearing a bra without underwire that provides good support for your breasts." "Women should have their first screening mammogram before they are 40 years old." "Every month before the start of your menstrual cycle, you should examine your breasts."

"It is important that you become familiar with your breasts so that you can detect any changes."

A client in active labor is having difficulty remaining focused. Her husband, sister, and mother are in the room with her. The fetal monitor shows slowing of the fetal heart rate (FHR) that begins after the peak of each contraction. What is the priority nursing action? Let the client get up and walk around the room for several minutes every once and a while. Turn on the television to give the client something on which to gain her focus. Leave the client and the family alone to allow the woman to concentrate on events. Have the client lie on her left side while asking a family member to be with the client one at a time.

Have the client lie on her left side while asking a family member to be with the client one at a time.

A nurse is caring for a client with acute pancreatitis who is exhibiting deficient fluid volume. What is the most appropriate nursing intervention for a client with this disease? Administer an antiemetic as prescribed. Maintain IV fluids at 125 mL/hour. Provide a full liquid diet. Elevate the extremities while in bed.

Maintain IV fluids at 125 mL/hour.

A nurse is caring for a client who just had surgery. What is the nurse's highest priority for this client? Monitor for hemorrhage. Maintain a patent airway. Manage the client's pain. Evaluate vital signs every 15 minutes.

Maintain a patent airway.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition? Record fluid intake and output. Encourage oral consumption of at least 2,000 calories per day. Note that the client reports less nausea and vomiting. Monitor the client's weight every day.

Monitor the client's weight every day.

While caring for a client who's immobile, the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." When creating the nursing care plan, which diagnosis would the nurse select to accurately reflect this information? Constipation related to immobility Impaired skin integrity related to immobility Risk for impaired skin integrity related to immobility Disturbed body image related to immobility

Risk for impaired skin integrity related to immobility

A client with a neurogenic bladder is beginning bladder training. Which nursing action is most important? Set up specific times for the client to empty the bladder. Provide adequate roughage. Encourage the use of an indwelling urinary catheter. Force fluids.

Set up specific times for the client to empty the bladder.

A nurse is admitting a client with tuberculosis who is coughing. To minimize the transmission of tuberculosis, which nursing measure is most appropriate? Restrict visitors until the client has taken antituberculin medications for 2 weeks. Wear a N95 disposable respirator when entering the client's room. Wear gloves and an N95 disposable respirator when entering the client's room. Place the client in a positive-pressure room with windows that are open.

Wear a N95 disposable respirator when entering the client's room.

A nurse is reinforcing education for a client with allergies about anaphylaxis. What should the nurse be sure to include in this discussion? Dry-mop all hardwood floors. Wear a medical identification bracelet. Avoid areas with high pollen counts. Stay away from animals.

Wear a medical identification bracelet.

A client who speaks and understands minimal English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? Asking an interpreter to relay the instructions to the client Demonstrating the procedure and having the client perform a return demonstration Asking frequently whether the client understands the instructions Writing out the instructions and having a family member read them to the client

Demonstrating the procedure and having the client perform a return demonstration

Which intervention does the nurse educator include in his or her preparation as an example of primary prevention? Using occupational therapy to help a client cope with arthritis Obtaining a Papanicolaou (PAP) test to screen for cervical cancer Administering digoxin to a client with heart failure Administering a measles, mumps, and rubella immunization to an infant

Administering a measles, mumps, and rubella immunization to an infant

A nurse is caring for a postoperative client. Which nursing intervention should the nurse perform to prevent thrombophlebitis? Apply a sequential compression device. Encourage the client to cough and breathe deeply. Encourage the client to turn frequently. Gently massage the lower legs with lotion.

Apply a sequential compression device.

A client reports a lot of gas in the colostomy bag. Which instruction is best to give this client? Put a tiny hole in the top of the bag. Burp the bag. Eat fewer beans. Replace the bag.

Burp the bag.

A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client? Ineffective cardiopulmonary tissue perfusion related to hyperventilation Deficient fluid volume related to nausea and vomiting Excess fluid volume related to intracellular fluid shift Imbalanced nutrition: Less than body requirements related to decreased intake

Deficient fluid volume related to nausea and vomiting

The nurse reinforces instructions about how to feed a client with a self-care deficit for the client's family members. Which instruction should the nurse stress to the family? Keep the client on a soft foods or a full liquid diet. Have the health care provider prescribe a gastrostomy tube for feeding the client. Determine which foods the client tolerates best and offer those foods. Ask the health care provider to prescribe parenteral nutrition (PN) for the client.

Determine which foods the client tolerates best and offer those foods.

A nurse is caring for a client who has a brain tumor and increased intracranial pressure (ICP). Which nursing intervention should be included in the client's care? Position the client's head toward the side of the tumor. Encourage coughing and deep breathing. Provide rest periods between nursing interventions. Provide sensory stimulation to improve neural activity.

Provide rest periods between nursing interventions.

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce? "Make sure to get sunlight exposure daily." "Do not limit your activity between flare-ups." "Monitor your temperature for signs of infection." "Stop the steroid when your symptoms subside."

"Monitor your temperature for signs of infection."

A nurse is administering captopril to a client with heart failure. Which evaluation finding should prompt the nurse to withhold the next dose and notify the healthcare provider? hyperkalemia hypertension third heart sound (S3) dyspnea

hyperkalemia

A primigravida client is being treated for her second case of simple vaginitis during pregnancy. Which instruction is most important for the nurse to reinforce with the client? "Avoid contaminating the area after elimination." "Change your laundry detergent." "Douche daily with a mild soap solution." "Douche regularly to increase the pH of your vagina."

"Avoid contaminating the area after elimination."

A nurse is instructing a client about taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands the treatment plan? "I should take corticosteroids on an empty stomach." "If I don't have an asthma attack for 1 week, I can stop taking corticosteroids." "Taking corticosteroids will help build up my immune system." "My other health care providers should be informed that I'm taking a corticosteroid."

"My other health care providers should be informed that I'm taking a corticosteroid."

A nurse is reviewing the care plan of a client who has been receiving an intravenous solution. What appropriate expected outcome for this client should the nurse expect to find on the care plan? "There is a risk for infection related to I.V. insertion." "Edema and warmth are noted at I.V. insertion site." "The client remains free of signs and symptoms of phlebitis." "Monitor fluid intake and output every 4 hours."

"The client remains free of signs and symptoms of phlebitis."

A female client is scheduled to undergo abdominal surgery for possible ruptured tubal pregnancy. A nurse is witnessing the client's signature on a consent form. Which client statement would the nurse interpret as the best indicator of the client's informed consent? "I know I'll be fine because the health care provider has done this procedure a lot." "I know I'll probably have pain after the surgery." "The health care provider may have to remove my fallopian tube if it has burst." "I should have no problems getting pregnant again since I'll still have my ovaries."

"The health care provider may have to remove my fallopian tube if it has burst."

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives? Decide on a treatment plan if the client cannot. Respect individuals' moral rights. Inform the client or legal guardian of the right to execute an advance directive. Advise clients not to execute an advance directive because it limits treatment options.

Inform the client or legal guardian of the right to execute an advance directive.

Family members of a client report to the nurse that they are exhausted and it is difficult taking care of a dependent family member. Which approach by the nurse is in the client's best interest? Call a family conference and ask social services for assistance. Tell the family the client should go to a nursing care facility. Ask the client what he or she would like to do. Tell the family members to discuss it among themselves.

Call a family conference and ask social services for assistance.

A nurse is about to give a full-term neonate their first bath. What intervention should the nurse perform first? Obtain medicated soap. Check the neonate's temperature. Fill a tub with warm water. Scrub the neonate's skin to remove the vernix caseosa.

Check the neonate's temperature.

The parents of a pediatric client are waiting in the surgical family lounge while their son undergoes emergency surgery. A physician enters the family lounge and tells another family that surgery for their family member was unsuccessful. What should the nurse do to best serve these families? Escort the parents who are waiting to hear about their son to another area. Escort the family who received the discouraging news to a private area. Ask the physician to inquire about the progress of the pediatric client's surgery. Do nothing.

Escort the family who received the discouraging news to a private area.

The nurse is revising a client's plan of care. Revision of the care plan takes place in which step of the nursing process? Planning Evaluation Data collection Implementation

Evaluation

A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client? Identifying one way to increase social interaction Reporting increased adaptation to changes in health status Identifying at least one factor contributing to altered sexuality patterns Returning a demonstration of measures that can increase independence

Identifying one way to increase social interaction

A nurse is caring for a client who recently underwent a total hip replacement. The client is progressing well and expects to be discharged the following day. When returning to bed after ambulating, the client reports severe pain in the surgical wound. Which action should the nurse take? Assume the client anxious about being discharged, and administer pain medication. Reassure the client that pain is a direct result of increased activity. Suspect a wound infection, and monitor the client's temperature and vital signs. Inspect the surgical site and affected extremity.

Inspect the surgical site and affected extremity.

A client undergoing a brain computed tomography (CT) scan because of continual migraine headaches is placed in the CT scanner and suddenly reports having palpitations, shortness of breath and shaking. What is the client most liekly experiencing? Allergic reaction Myocardial infarction (MI) Panic attack Hypoglycemic episode

Panic attack

What should the nurse do with linens that have been soiled by a client with hepatitis? Place them in a plastic bag that has a contamination symbol. Place them in a hazardous waste receptacle. Place them on the floor until the laundry department can pick them up. Place them in the dirty linen receptacle.

Place them in a plastic bag that has a contamination symbol.

What nursing intervention should be provided for a client who is experiencing a seizure? Place client in prone position. Restrain the client's arms only. Turn the client to one side. Insert a bite block in the mouth.

Turn the client to one side.

A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. Which information should be provided to the school? These students are too young to screen; instead, older students should be screened. Scoliosis screening requires sophisticated equipment and cannot be done in school. This is an appropriate request and arrangements will be made as soon as possible. These students are too old to screen and will no longer benefit from screening for scoliosis.

This is an appropriate request and arrangements will be made as soon as possible.

The nurse receives a medication order from a health care provider over the telephone. Which nursing intervention is a priority when receiving a telephone order? Verify the order by repeating it back to the health care provider over the phone. Request that a second health care provider repeat the order to the nurse over the telephone. Insist that the health care provider sign the medication order within 1 hour. Inform the health care provider that the Nurse Practice Act prohibits taking medication orders over the telephone.

Verify the order by repeating it back to the health care provider over the phone.