PN Comprehensive
nurse caring for toddler. Which of following objects should nurse select from playroom for this child during hospitalization?
10 piece wooden puzzle
community health nurse contributing to plan of care for for high-risk newborns who were discharged yesterday. Which following newborns should nurse recommend to care for first?
A 4 day old newborn who has elevated Bilirubin level & requires photo therapy
A nurse on the pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?
A Client in DKA and a blood glucose of 375
A nurse in an urgent care center is collecting data from a group of clients who all have in odor Of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse?
A client who is difficult to arouse and is unable to respond to questions
nurse in a long-term care facility is caring for group of clients. One of clients as walking in hallway & bumping into walls & does not respond to his name. Which of following actions should nurse take first?
A company to his room
nurse On pediatric unit is assisting with plan care for preschooler who will have surgical procedure in morning. Child has been crying despite his parents presence at his bedside. Nurse should recommend engaging child in therapeutic play for care plan because it offers which following benefits?
Allows child to manipulate toy medical equipment
nurse delegates newly Licensed nurse to provide one on one observation for a client who requires suicide precautions. Which of following actions by newly licensed nurse indicates need for further reinforcement of teaching?
Ambulates client's roommate while client sleeps
nurse in an urgent care center reviewing laboratory results for several clients who have benefit stations of influenza. Which of following clients should nurse report to provider in mediately?
An infant who is wbc count is 24,000
A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma?
And irregularly shaped brown lesion with light blue areas on the neck
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?
Apply continuous pressure to the lower part of the child's nose
A nurse is caring for a client who has a platelet count Of 50,000. After discontinuing the clients peripheral IV site, which of the following actions should the nurse take?
Apply pressure to the catheter removal site for 10 minutes
nurse in an acute care clinic is talking with client reports that her osteoarthritis pain in her knees increasing each day. Client wants to discuss nonpharmacological approaches that will relieve her pain. Which of following interventions should nurse suggest?
Apply warm compresses to sore joints
nurse facilitating a group discussion with preschool teachers about child abuse. Which of following data should nurse use as common example of suggestive finding?
Arm cast for spiral fracture of forearm
A nurse is assisting with developing a plan of care for a client who has GERD. The nurses should suggest monitoring the client for which of the following complications?
Aspiration
A nurse is observing a client who has schizophrenia and is in the day room when another client asks him if two items of clothing match. He replies a match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on. The nurse should identify these statements as which of the following speech alterations?
Associative looseness
nurse is assisting with admission of client who has a urinary tract infection & history of Myelomeningocele. After admission history is complete, which of following actions should nurse recommend?
Attach a latex allergy alert identification band
nurse caring for client who spent past several minutes mumbling about being doomed to die & now pacing in an increasingly agitated & angry manner. Which of following actions nurses priority?
Attempt to reduce environmental stimuli
A nurse is caring for a client who has a deep partial and full thickness burns and requires a topical anti-microbial drug. The nurse should reinforce with the client that the goal of this medication therapy is to reduce which of the following outcomes?
Bacterial growth
A nurse is reinforcing discharge teaching with a client who had a TIA. The nurse should instruct the client to monitor which of the following parameters at home?
Blood pressure
A nurse in a prenatal clinic is collecting data from several clients. which of the following client reports should the nurse identify as an expected physiologic adaptation to pregnancy?
Breast tenderness
nurse on mental health unit is caring for client who has depression. Which of following actions should nurse take to foster therapeutic environment for this client?
Build trust with client by sitting quietly with him.
nurse beginning her shift & reviewing medication administration records for her clients. She notes dosage of medication above safe range & sees that nurse administered that dosage during previous shift. Which of following actions should nurse take?
Call provider to clarify dosage
A nurse is collecting data from a toddler who has aids. The nurse should identify which of the following findings as an indication infection?
Candidiasis
A nurse response to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first?
Check airway patency
nurse reinforcing teaching with client who has hypothyroidism & taking levothyroxine. Nurse should instruct client to report which of following manifestations to provider?
Chest pain
nurse reinforcing teaching with an assistive personnel about dietary restrictions for client who is taking phenelzine to treat depression. APs selection of which of following foods for clients lunch indicates an understanding of instructions?
Chicken salad
nurse caring for client during Her first prenatal visit & notes that she is lactose intolerant. Which of following foods should nurse include on list of calcium sources for this client?
Collard greens
The healthcare facilities leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurse take first?
Collect the staff input about planning and implementing the change
nurse preparing to administer medications to client who is unconscious. Nurse should bring medication administration record to clients bedside & perform which of following verification procedures?
Compare medical record number & name on medication administration record with clients identification band
A nurse is caring for a client who has a new diagnosis of acute systemic lupus erythematosus And is to begin medication therapy. Which of the following types of medications should the nurse expect to administer?
Corticosteroids
nurse reviewing medical record of client who has requesting prescription for sildenafil citrate. Which of following data in clients record should nurse identify contradiction for use of this medication?
Current use of nitro to treat heart failure
nurse assisting with admission of client to medical unit & ask him if he has advanced directives. Client states I have document with me name of someone who can make healthcare decisions for me I am not able to. Should identify that client referring to which of following documents?
DPA
nurse collecting data from client who has aids & taking zidovudine. Which of following findings priority for nurse to report to provider?
Decreased hemoglobin
nurse reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris & myocardial infarction. Which following manifestations should nurse identify as indications Of myocardial infarction?
Diaphoresis, dizziness, anxiety, impending doom, nausea, & vomiting
A nurse is caring for a client who is taking acarbose to treat type two diabetes. Which of the following should the nurse monitor for adverse effects?
Diarrhea
A nurse is reinforcing teaching with the parents of an infant who has a cleft palette. The parents asked the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months to prevent which of the following outcomes?
Difficulty with language acquisition
nurse reinforcing discharge teaching with client who has new prescription for metoprolol. Which of following instructions should nurse include?
Do not stop taking his medication abruptly, count your radial pulse daily, change positions slowly
A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from a parent? The following questions should the nurse ask?
Does anyone smoke around four in the same house as your child?
nurse is caring for a client who has MRSA infection. A dietary assistant asks nurse what precautions are necessary for entering clients room with lunch tray. Which of following instructions should nurse give dietary assistant?
Don gloves when entering room & use hand sanitizer when exiting
nurse contributing to plan of care for client who had stroke & to receive feeding via a gastrostomy tube. Which of following actions should nurse recommend to take prior to initiating each feeding?
Elevate head of bed
nurse collecting data fromclient who is taking varenicline for smoking cessation . Which of following findings is nurses priority?
Erratic Behavior
A nurse is reviewing the laboratory data of a client who reports manifestations that suggests systemic lupus erthematosus. The nurse should expect an increase in which of the following parameters for a client who has SLE?
Erythrocyte sedimentation rate
A nurse is discussing the fire safety with newly hired nurses. Which of the following identify as the priority if a fire occurs in the health care facility?
Evacuate clients from the unit
A nurse is caring for an older adult client who has an in the canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as a source for this sound?
Excessive wax In the ear canal
A new resident provider asks the nurse for an access code to review a clients online record. The resident is not scheduled to attend the Facility's orientation computer class until next week. Which of the following actions should the nurse take?
Explained that it is against policy to share access codes and refer the resident to his supervisor
nurse talking with a group of clients at a senior center about risk factors for osteoporosis. Which of following statements should the nurse include?
Extended periods of immobility increase your risk for osteoporosis
nurse participating in community health fair is providing information to a client who has a BP of 150/90 during blood pressure screening. Which of following actions should nurse take?
Give client a written record of his blood pressure to bring to his provider
nurse caring for client who has dehydration. Which of the following laboratory values should nurse expect for this client?
Hematocrit 55%
A nurse is reinforcing teaching with a client about how to use an albuterol MDI. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?
Hold the mouthpiece 1 to 2 inches in front of your mouth, tilt your head back slightly and open your mouth wide, depress the canister while taking a slow deep breath, and hold your breath for 10 seconds
A nurse is assisting with the care of a client who has Addison's disease and comes to the emergency department reporting nausea, vomiting, diarrhea, and of abdominal pain. To prevent addisonian crisis, the nurse should expect that the provider will prescribe which of the following medications?
HydroCortisone
nurse reviewing laboratory report for client who has CDK. nurse finds following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, & phosphate 4.8. Which of following findings priority for nurse to report to provider?
Hyperkalemia
A nurse in a substance use disorder program is interacting with the client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission?
I have read that problems with substance can have a variety of predisposing factors
nurse in providers office is talking with an older adult client reports having trouble sleeping. Which of following statements should nurse identify as possible causes for patients sleeping difficulties?
I often have a cup of coffee with my dessert before going to bed
A female client who has we currency Cystitis asked the nurse about preventing future episodes. Which of the following statements should the nurse provide for the reinforcement of teaching?
I prefer tub baths to showering
nurse reinforcing teaching with client who has spinal cord injury & will need to perform intermittent urinary self catheterization at home after discharge. Which of following statements indicates that client understands procedure?
I will perform intermittent self catheterization every 2 to 3 hrs
A nurse is reinforcing teaching with the parent of a child who has type one diabetes how to manage the child's disorder during illness, such as cold. Which of the following statements by the parent indicates an understanding of the teaching?
I'll check his blood glucose more often
nurse caring for client who's taking warfarin. Which of following laboratory values should nurse recognize as an effective response to medication?
INR 3.0
A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further instruction is required?
If the patient seems confused, I will raise all four side rails so that he doesn't hurt himself
During client care staff meeting, charge nurse discusses potential problems with data security that affect confidential client information. Which of following environments should charge nurse identify as an acceptable area for discussing client information?
In unit medication room
A nurse is reinforcing teaching with a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include?
Increase her caloric intake with meals
A nurse is assisting with the admission of a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurses priority?
Initiate airborne precautions
charge nurse coordinating evacuation of clients from facility following a bomb threat. Which of following actions should nurse take when implementing evacuation process?
Instruct clients who are able to ambulate to leave
A nurse is caring for a client who takes more friend to treat chronic a fib and has early manifestations of Alzheimer's disease. The clients partner asked the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make?
It is likely that ginkgo biloba will interfere with the effectiveness of his other medications
nurse reinforcing teaching with family of child who has autism spectrum disorder. Which of following statements indicates that family understands instructions?
It will help our child if we structure our daily routine
A nurse at a long-term care facility hears an AP talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions?
It's almost time for your appointment. Let me do your hair for you and brush your teeth
A nurse is reinforcing teaching with the school-age child has just had a fiberglass cast application follow a lower extremity fracture. Which of the following instructions should the nurse reinforced with the child and his parents about care during the first 48 hours?
Keep the cast above the level of your heart
nurse on antepartum unit caring for client who is at 28 wks of gestation & reports dizziness when lying on her back. Into which of following positions should nurse assist client?
Lateral
provider tells a client who reports practicing Hinduism that at 12 wks gestation she needs more protein in her diet & suggest eating more meat. After provider leaves examination room, client tells nurse that eating animal products will cause her to miscarry. Which of following responses should nurse make?
Let's discuss other foods that are also high in protein that you could substitute for meat
Nurse is collecting data from a 66-year-old client during a routine physical examination at her first clinic visit and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies I am not sure but it's been at least five years since I've had any immunizations. Which of the following responses should the nurse make?
Let's go ahead with giving you this immunization
nurse caring for client who has terminal illness. Family wants to care for client at home. Which of following statements indicates that nurse understands family centered care?
Let's set up meeting with the doctor to discuss your options for home care
nurse in rehabilitation facility is observing an AP help client transfer from bed to wheelchair. Which of following actions indicate to nurse that AP understands how to perform this task?
Lock brakes on bed & wheelchair before moving client.
nurse is collecting data from a client who has tuberculosis & prescription for EthAmbutol. Nurse should inform client that he is likely to develop which of following alterations as an adverse effect of this medication?
Loss of red\green color discrimination
A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make?
Maintain the head of the bed at 30°
nurse caring for an infant who is experiencing dehydration. Which of following data related to hydration status is nurses priority to collect?
Measure clients weight daily
nurse caring for client who has chronic phantom limb pain following & above the knee amputation. Which of following medication prescriptions should nurse verify with provider?
Meperidine
nurse going to medical surgical unit caring for client who developed deep, rapid respirations. Arterial blood gas Analysis: pH 7.25, PaCO2 morning 40, HCO3 18. Which of following should nurse identify & report to provider?
Metabolic acidosis
A nurse is talking with the parent of a four month old infant about growth and development. Which of the following statements indicates that the parent needs further instruction?
My baby loves to play with pillows in her crib
nurse assisting with plan of care for client who is post operative following hip arthroplasty. In clients medical record, nurse notes history of COPD. Which of following oxygen delivery method should nurse recommend to use this client?
Nasal cannula
nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. Which of following findings should nurse report to provider as an indication of impending airway obstruction?
Nasal flaring
nurse reinforcing discharge teaching to client who does not speak same language as nurse. Clients neighbor, who speaks to clients native language & nurses, arrives to drive client home. Which of following actions should the nurse take?
Obtain services of an interpreter
nurse is preparing to care for a client who is in balanced skeletal traction to stabilize her femur fracture. Which of following actions should nurse recommend for clients plan of care?
Offer client a diet high in fluid and fiber
A nurse is reinforcing teaching with the parent of a client who has severe reactive airway disease about Glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it Orally. Which of the following information should the nurse provide to the parent?
Oral glucocorticoids are more likely to slow linear growth in children
nurse is assisting with care of client who had precipitous delivery. nurse should identify collection which of following data as a priority during the fourth stage of labor?
Palpating clients fundus
A nurse is caring for a client who has a pseudomembranous colitis do to CDIff. Which of the following interventions is the nurses priority?
Performing hand hygiene before and after contact with the client
A nurse is reinforcing teaching with a client who has a new prescription for a Doxycycline. The nurse should reinforce to the client the need to monitor for which of the following adverse effects of this medication?
Photosensitivity
nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. Which of following actions should nurse take to improve clients level of orientation?
Post a large calendar on bulletin board
nurse assigned to care for several clients who are post operative. Nurse should identify client taking which of following medications at risk for delayed wound healing?
Prednisone to treat persistent arthritis exacerbations
A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication?
Pulse ox of 85%
A nurse is reinforcing teaching with the Parent of a child who has a new prescription of iamotrigine For a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?
Rash
A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?
Reading the newspaper
A nurse is planning to delegate the post operative care of a client following an appendectomy. Which of the following actions should the nurse assigned to an assistive personnel?
Record urinary output after emptying the indwelling urinary catheter
nurse reinforcing discharge teaching with client who has had transient ischemic attack. Which of following instructions should nurse include?
Reduce dietary sodium
A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following findings should indicate to the nurse that the AAA is expanding?
Report of sudden severe back pain
A newly licensed nurse in an urgent care center is caring for a client who has bruises that the nurse suspects are due to child abuse. Which of the following actions should the nurse take?
Report the suspected abuse to local authorities
A nurse is collecting data from a client who has an acute visual disturbance and describes it as a curtain pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?
Retinal detachment
A nurse is reinforcing teaching about self a ministration of NPH insulin with a client who has type two diabetes. Which of the following instructions should the nurse include?
Rotate injection sites within the same area
A charge nurse in a long-term care facility notes that several staff members are linked in completing an annual mandatory educational session about extremity restraint safely. Which of the following actions should the nurse plan take?
Send an email to each nonadherent employee that includes a link to upcoming educational sessions
charge nurse in skilled nursing facility notes several recent conflicts among staff on different shifts. Which of following strategies should charge nurse plan to use to resolve these conflicts?
Set up series of meetings for all staff members to discuss issues
A nurse is reinforcing teaching with the client who is going to have an EEG in the morning. Which of the following information should the nurse provide to the client?
Shampoo your hair before the procedure, and don't put any styling products on it afterward
nurse reinforcing teaching about body mechanics with assistive personnel. Which of following instructions should nurse include?
Sit with your back supported, keep your knees at hip level, & use an ergonomically designed computer keyboard
nurse on a mental health unit is caring for client who has antisocial personality disorder & becoming increasingly loud & belligerent. Which of following approaches should nurse use to manage clients behavior?
Speak to client with clear calm caring statements
nurse collecting data from school age child who has celiac disease. Which of following findings should nurse expect?
Steatorrhea (Oily Stool known as: fatty stool)
A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?
Stop reinforcing the teaching and check with the surgeon about informed consent
A nurse is reinforcing teaching with a client who has a new prescription for sertraline. Client asked nurse if we should continue to take St. John's wort for depression. Which of following instructions should nurse to give client?
Stop taking herbal supplement while taking medication
A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction?
Stop the infusion
nurse on pediatric mental health unit caring for school age child. Which of following questions or statements should nurse make to foster rapport & engage him in conversation?
Tell me about your favorite videogame
A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make ?
Tell me what concerns you most about being hospitalized
nurse is collecting data from client who's receiving clozapine to treat schizophrenia. The nurse should identify that an increase in which of following parameters is an early indication of agranulocytosis?
Temperature
A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hours ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make?
The client has had an exposure to tuberculosis
nurse caring for an adolescent client who gave birth to stillborn preterm fetus. Client is crying & says to nurse why did this happen to me? Which of following responses should nurse make?
This must be so difficult for you
nurse assisting to prepare for the transfer of client from post anesthesia care unit following a sub total thyroidectomy. Which of following equipment should nurse have available at patient's bedside?
Tracheostomy tray
A nurse is reinforcing teaching with a client about treatment options for profound sensorineural hearing loss. The client should include which of the following information about the function of cochlear implants?
Transmits impulses directly to the auditory nerve endings
nurse reinforcing teaching with parent of toddler whos undergoing insertion of tympanostomy tubes. Which of following statements should nurse include?
Tubes should stay in place until they fall out on their own
A nurse is talking with a parent of a preschooler. The parent reports that her child grows upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent?
Use a stable relaxing routine such as a bath and bedtime story before bed
nurse is preparing to administer 10 units of insulin glargine & 4 units of NPH insulin subcutaneously to a client. Which of following actions should nurse take?
Use separate syringes for administering insulin glargine & NPH insulin
nurse at family planning clinic preparing to give presentation to clients about to use diaphragm. Which of the following information should nurse plan to include in session?
Use spermicidal jelly whenever you use your diaphragm
nurse is assisting with planning recreational activities for young adult client who has an acute exacerbation of schizophrenia. Which of following activities should nurse recommend for client?
Walking with staff member
Ours in an acute mental health facility caring for client who has schizophrenia. Client asks nurse can I vote in upcoming presidential election? Which of following responses should nurse make?
We can work together to find out how you can get a mail in ballot
A nurse is reinforcing teaching with a client who has type two diabetes. The client states I eat pasta every day. I can't imagine giving it up. Which of the following responses should the nurse make?
You don't have to give up pasta; just adjust the amount you eat
nurse reinforcing teaching with client who is scheduled for LASIK surgery which of following information should nurse include?
Your procedure will only take 10 to 15 minutes per eye
nurse is reinforcing teaching with client who has come to family planning clinic requesting an IUD. Which of following information should nurse reinforced with client?
Your risk for ectopic pregnancy increases with an IUD
hospice nurse visiting with family member of a client. family member states that client has insomnia almost nightly. Which of following practices should nurse identify as contributing to clients insomnia?
client watches television in her bed during day
client at routine prenatal care visit asks nurse if it's common to develop vaginal yeast infections during pregnancy. Which of following responses should nurse make?
hormonal changes of pregnancy change acidity of vagina, making yeast infections more common
nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for health fair for adults in community. Which of following topics should nurse recommend to include
importance of colonoscopy screening starting at age 50 yrs old
Results of enzyme linked immunosorbent assay testing for an 18 month old infant who has pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, nurse should consider which of following factors?
infants mother is likely HIV positive
