(2 of 3 )

A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,

"My stoma will drain liquid fluid continuously."

A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience muscle weakness."

A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

"Please stop this discussion."

A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make?

"Bring the child to the funeral service before visitors arrive."

A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?

"Do you have a plan to end your life?"

A community health nurse is teaching a group of restaurant workers about hepatitis A. Which of the following statements should the nurse make?

"Hepatitis A can be spread by fecal-oral contact."

A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?

Allow the infant to suck on a pacifier during feedings.

A community health nurse is planning to make home visits to several clients who all live within a few miles radius of the office - Who to see first?

An infant who has failure-to-thrive and was discharged from a facility yesterday to a foster home on daily weights

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?

Blood pressure 94/68 mm Hg

A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings Indicates fluid overload?

Bounding pulses

A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome?

Change in mental status

A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

Check the FHR.

A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report?

Client found lying on the floor near the bedside table.

A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?

Compare blood pressure in both arms every 2 hr.

Client who is 8hr postoperative following a right-modified radical mastectomy - which findings to report to provider? (SATA)

Coughing Frothy, pink secretions

Client recovering from closed head injury assumes a decerbrate posture in response to stimuli

D lying flat ?? (Extentend extremities) The client rigidly extends his arm

Creating and activity plan for a home bound older adult client. In the planning, the nurse considers the physiologic changes that may affect pulmonary function r/t the normal aging process

Decreased blood oxygenation

A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic

Determine the client living situation

A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

Determine the client's pain level.

A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

Dim the lights in the room prior to the examination.

A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take?

Discard opened cans of formula after 24 hr.

Difficulty falling asleep at night

Eat a bedtime snack (containing carbohydrates??)

A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include?

Eat a dry carbohydrate before getting out of bed.

A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include?

Educating the client how to cover nose and mouth with tissues when coughing

Discharge teaching about disease prevention to a client who has active Tb

Educating the client how to cover nose and mouth with tissues when coughing

A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

Elevated pulmonary artery pressure

Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3-min tonic-clonic seizure 2 wks after sustaining a mild concussion. EEG

Explain that the client may not have coffee prior to the EEG

Education about ECT major depressive disorder

General anesthetic admin prior ECT treatments(This treatment are for pts who aren't responding to their pharmaceutical meds)

A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include?

Gently massage the skin under the straps once per day.

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?

Head compression

A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

Healthy weight

A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?

Identify the reason for the client's refusal.

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postoperative post procedure period which of the following is the priority nursing actions?

Immobilizing the affect extremity

A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

Improve joint functioning.

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?

Inform the client of available community resources.

After evaluating the morning lab results on several clients, the provider writes prescriptions for 4 clients assigned to the nurses care?

Infuse 10 meQ/l potassium chloride IV over 1 hr to a client who has potassium of 3.2

Discussing a living will with a client

It communicates my wishes for end of life care

A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating?

Justice

A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care?

Maintain the head at a midline position.

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Measure the amount of gastric drainage every 2 hr.

A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include?

Place the infusion pump cord against the baseboards.

A client who has a diagnosis of com acenta is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take?

Prepare the client for a cesarean section.

Diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36wks gestation w/ contractions 5 min in frequency and 1 min in duration

Prepare the client for c-section

Dietary intervention for a client who is immobile due to pelvic and femur fractures

Provide a high-protein diet

A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

Pulse 54/min

A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment?

Pulse oximeter

Client who has a left femur fracture and is skeletal traction. The clients reports pain due to muscle spasms in affected leg

Realign the extremity in traction

AP reports to the nurse that another ap has spent the entire morning on the phone and has not completed the morning assignment

Redirect the AP to discuss the issue with the other AP

A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.)

Repeats the words of others when speaking Speaks in word salad Has a blunt affect Experiences delusions

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

Rephrase sentences the client does not understand.

A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take?

Report to the nurse manager.

A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take?

Review deep breathing and coughing exercises.

A nurse is caring for a client following insertion of a subclavian prescription to initiate an IV infusion of Ringer's lactate at 150 ml per hr. Prior to starting the infusion, which of the following actions should the nontunneled percutaneous central venous catheter (CVC). The provider writes a nurse take?

Review the chest x-ray report.

Community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house

Review the effects of secondhand smoke w/ family members

Discussing care w/ newly licensed nurse for a client who practices orthodox Judaism - which food not given?

Roast beef and ice cream

A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe?

Sertraline

After making morning round, the charge nurse on a surgical unit delegates the follow tasks to the AP.

Set up a room for an expected postoperative admission

A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis?

Sputum culture

A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?

Swollen lips

A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder (OCD). Which of the following is appropriate for the nurse to include in the plan of care?

Teach the client to meditate about obsessive thoughts.

A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?

The tubing may be kinked.

Client following an open colectomy

Uncontrolled pain

DI w/ severe head injury

Urine output 250

A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI?

Urine output of 250 mL/hr

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

Use a designated stethoscope when caring for the toddler.

A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Viewing the newborn's actions to be uncooperative

A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

Wear an N95 respirator.

A nurse is performing change-of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first?

A client who has gastroenteritis and is lethargic and confused

A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?

A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding

A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first?

A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days

A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include?

A client who has a history of MRSA can still transmit the infection,

A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

0900

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

1 cm of water present in the water seal

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?

A client who had a stroke 2 days ago and needs help toileting

the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of

Abdominal rigidity

Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea

Admin an antiemetic (Aprepitant for nausea)

Caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse "Am I dying?"

Admin pain meds

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer pain medication to the client.

A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching?

Administer the medication with a glass of orange juice.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins.

A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching?

Avoid foods that have high levels of oxalates.

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

Monitoring the insertion site for infection

A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider?

No bowel movement for 3 days

A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action?

Notify the facility

A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?

Open the client's windows.

A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Ototoxicity

A nurse is planning care for a client who has a gambling disorder. Which of following instructions should the nurse provide to the client?

Participate in a 12-step program.

A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?

Pedal pulses 2+

nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

Pertussis

A nurse is caring for client who has schizophrenia. Which of the following findings is the nurse's priority?

The client reports hearing voices.

A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

The client takes aspirin daily.

A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

The nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The provider's prescription should include the

A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Withhold digoxin.

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is

asymmetric, with variegated coloring.

A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan?

lodine

A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include?

relieved by position change

A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?

series of four hepatitis vaccines is recommended to prevent viral hepatitis.

Child who has pediculosis capitis

store non-washable items in plastic bags for 14 days

A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave client who signs an informed consent form should understand the treatment plan." "A client who signs an informed consent form should be competent." "The nurse should disclose the purpose of the treatment before the client signs the consent form."

A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication this medication?

Нерatitis C