Ante/intra/postpartum and neonate care

A nurse is teaching a client who is 24 weeks of gestation and scheduled for amniocentesis procedure. Which of the following clients statement indicates an understanding of the teaching?

" I must urinate prior to the procedure"

A young woman reports to the prenatal clinic for her 32 weeks gestational visit. Which of the following comments made by the woman must be reported to the physician?

"I can't get my wedding ring on this morning because my fingers are so swollen. "

The nurse is working in a clinic and is talking To a pregnant woman about using a seatbelt during the second trimester of pregnancy. The clients comment that would indicate she needs further teaching is:

"I should only wear the shoulder belt to prevent abdominal injury "

A nurse is teaching a client with diabetes about foot care which of the following instructions from the nurses correct?

"Try to avoid anything that can hurt the skin on your feet, such as walking barefoot "

A client has asked you to explain the MCH mean cell hemoglobin test to her while you counsel her to ask the attending physician for details, which of the following is an appropriate answer? Select all that apply

-A B C

A nurse is caring for four clients. The nurse should identify that which of the following clients is at risk for developing a dysrhythmia? Select all that apply

-A client who has metabolic alkalosis -A client who has COPD -A client who had a stent placement and a coronary artery

The client is receiving CLOPIDOGREL following a cardiac stent placement. The nurse should ensure that the client understands which of the following? Select all that apply

-A headache is a common side effect of this medication -bleeding and bruising are likely to increase with the drug -CLOPIDOGREL can be taken with or without food

The client is receiving hemodialysis. After some time, the client develops dyspnea and chest pain. When the nurse assessed as a client, she finds out there's reduce oxygen saturation, tacky piña and hypertension. Which is the best nursing actions? Select all that apply

-Administer oxygen -stop the hemodialysis -Notify the physician

Nurse is collecting data from a preschooler for suspected physical abuse. The nurse should identify that which of the following is an expected finding of physical abuse? Select all that apply

-Burns on bilateral hands -spiral fracture of the right forearm -Read and weld across the back

What are the core components of information technology used in clinical nursing practice? Select all that apply

-Data security -Data access -patient identification -Systems integration and network communication

A nurse is reviewing the medical record of a client who has syndrome of inappropriate antidiuretic hormone SIADH. Which of the following findings should the nurse expect? Select all that apply

-Decreased serum sodium -increased urine specific gravity -decreased serum osmolarity -Decrease the temperature

A nurse is assigned to care for a client who has a chest tube placed after a right Thoracotomy. Which of the following does the nurse expect when monitoring the clients chest tube? Select all that apply

-Fluctuation occurs intermittently in the water seal chamber -Chest drainage flows into chest chamber

The client is admitted with unstable Regina. The nurse expects all the following select all that apply

-If you were women than men present with classic signs of unstable Angina -pain poorly relieved by nitroglycerin -Pain lasting longer than 15 minutes

A nurse is collecting data from a toddler who has major burns and suspected septic shock. Which of the following findings indicate the Tyler is experiencing septic shock? Select all that apply

-Increased body temperature -Altered sensorium -Decreased urine output -Chills

A nurse is reviewing the medication records of several clients who have bipolar disorders. The nurse should identify that which of the following medications are mood stabilizers used to treat bipolar disorders? Select all that apply

-LAMOTRIGINE -lithium -VALPROATE -CARBAMAZEPINE

A nurse in an out patient clinic is collecting data from a client who reports night sweats, fatigue, cough, nausea, diarrhea. The client asked the nurse if it is possible he has HIV. Which of the following actions should the nurse take? Select all that apply

-Measure vital signs -Determine when manifestations begin -obtain a wait -Obtain a sexual history from the client

A nurse is reinforcing medication teaching with a client who has Addison's disease and has been prescribed hydrocortisone. Which of the following instruction should the nurse include? Select all that apply

-Notify the provider of any illness or stress -Report any episodes of weakness or dizziness -do not discontinue the medication suddenly

A nurse is reviewing the plan of care for a client who has a stomach lupus ERYTHEMATOSUS which of the following laboratory findings should the nurse anticipate? Select all that apply

-Positive ANA titer -2+ Urine protein -elevated BUN

Which nursing action are essential when finding a client experiencing a tonic clonic seizure? Select all that apply

-Rolling the body to the side -removing environmental hazards to protect the client -call in the respiratory therapy department

A nurse is caring for a client who is receiving parenteral therapy. What information should be documented when a client is receiving total parenteral nutrition? Select all that apply

-The amount of solution infused -to type and location of the IV -The condition of the insertion site

A nurse is assisting with planning an in-service for a group of elementary school teachers about identifying risk factors for maltreatment of children. Which of the following findings place a child at risk for Mel treatment? Select all that apply

-The child was born premature and has developmental delays -The child lives in a single parent home

A nurse notices that a coworker has left a computer screen on while still being logged into the system. The nurse left the screen as is and goes to find a coworker. A visitor is seeing reading the computer screen. Who is responsible for the health insurance portability and accountability act HIPPA violated? Select all that apply

-The nurse who found the screen -The nurses coworker who left the screen -The institution where the coworker works -The manager of the unit

A nurse is reviewing the laboratory data of four clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? Select all that apply

-Total cholesterol 245 -LGL 140

A nurse is assessing a client at 26 weeks gestation who complains of occasional contractions. Which of the following factors increase is the clients risk of preterm labor? Select all that apply

-Urinary tract infection -multifetal pregnancy -diabetes mellitus

A client is undergoing postoperative care for cystectomy and neobladder. Which of the following orders are most likely to be included in the clients standard of care? Select all that apply

-activity limited to semi Fowler's position for 24 hours -urethral stance should not protrude through the abdomen -strict Urethral catheter flushing/irrigation schedule

A nurse is caring for a client who suspects that she is pregnant and has presumptive signs of pregnancy. Which of the following findings should the nurse expect the client to report? Select all that apply

-amenorrhea -nausea and vomiting -quickening

The nurse is assigned six clients during the afternoon shift on a medical surgical unit. After receiving report on the following clients, arrange the clients in the most appropriate order of nursing assessment.

-an elderly client admitted with unstable angina who reports sternal chest pain -A new postoperative client being transferred by the nursing assistant into a bed

The nurse knows that the female client with cystitis must do which of the following? Select all that apply

-avoid tight pants -Wear cotton underwear

A nurse is preparing to teach a group of clients who are pregnant about some of the common discomforts of pregnancy. Which of the following findings should the nurse include in the teaching? Select all that apply

-breast tenderness -excessive salivation -epistaxis

Nursing ethics are based on principles of moral autonomy, BENFICENCE, Fidelity, justice, nonmalicious, and veracity. To which of the following to these principles apply? Select all that apply

-caregiving relationships between nurse and clients family members -Patients right to self-determination -Nursing responsibilities to dose management

The nurse knows that the following clients with peripheral vascular disease are at high-risk for amputation. Select all that apply

-cigarette smoker -poorly controlled diabetes -Elevated cholesterol

A nurse is reviewing discharge teaching with a client who had a total hip arthroplasty. Which of the following instruction should the nurse include? Select all that apply

-clean incision daily with soap and water -set an a straight back to armchair -Use a raise toilet seat

The nurse is currently involved in the care of an elderly client recently diagnosed with osteosarcoma, a tumor of the bone. The client has been complaining of acute pain, but the nurse sees no evidence or directive for pain management. The nurse approaches the attending physician regarding this concern. In this instance, the nurse is involved in which of the following:

-client deference -client advocacy -client caregiving

And nurse is reviewing the laboratory results of a client who is pre-operative. Which of the following results should the nurse report to the finder? Select all that apply

-creatinine -Blood glucose Wbc

A nurse is teaching an adolescent who has a growth hormone deficiency. Which of the following are complications of untreated growth hormone deficiency? Select all that apply

-delayed sexual development -short stature

A nurse is providing support to the family of a client who completed suicide. Which of the following strategies should the nurse implement to effectively assist clients family members? Select all that apply

-discuss positive and negative aspects of the family members relationships with the client -Identify how the client suicide has caused this organization in the family is coping

A nurse is assessing a client who is three days postoperative following a partial gastrectomy and has just completed a meal. Which of the following findings should the nurse identify as manifestations of dumping syndrome? Select all that apply

-dizziness -hypotension -Diarrhea

A nurse is caring for a client who has a central line in place. Which of the following action is indicated for a client safety when flushing a central line? Select all that apply

-do not apply force if resistance occurs with flushing -Flush the catheter before and after administering medication

A client is admitted with rheumatoid arthritis. Which of the following signs should the nurse monitor in the client? Select all that apply

-early morning pain and stiffness at the joints -Elevated rheumatoid factor and electrocytes sedimentation rate -Swollen at the joints

A nurse is caring for a client with a nursing diagnosis of impaired skin integrity, related to decreased mobility and mechanical factors. Which of the following interventions would be appropriate for this client? Select all that apply

-encourage food and fluid intake -Assisted client with ambulation and encourage mobility

Nurse is assessing a client with meningitis, which of the following symptoms are expected to be present? Select all that apply

-fever with chills -Head and heels been backward and body arches forward -Flexion of hip and knee in response to forward flexion of the neck

A nurse is assisting with admitting a child who has HIV. The nurse should identify which of the following findings as indications that the child is in the moderate symptomatic category B? Select all that apply

-herpes zoster -Bronchitis -Oral candidiasis

Nurse is preparing to provide care to a client who has hyper glycemic hyperosMolar state HHS. The nurse should identify that which of the following findings are risk factors for this diagnosis? Select all that apply

-history of recent myocardial infarction -bun 35 MG/DL -Takes calcium channel blocker -Age 65 years

A nurse is reviewing the medical history of a client who has Cushing's disease. The nurse should identify that clients who have Cushing's disease are at increased risk for which of the following conditions? Select all that apply

-infection -gastric ulcer -Bone fractures

A nurse is caring for a client who has an external fixation device for a bone fracture. Which of the following actions should the nurse take? Select all that apply

-keep the affected extremity above the level of the heart -use a separate cotton swab for cleansing each pin -Report loosening of the pins to the provider -Report increased redness at the pin sites

A nurse is caring for a client at a risk for falling. Which of the following components are part of a fall risk assessment? Select all that apply

-level of consciousness -Illumination status -Gate and ambulation

A nurse is providing care for a client who has diagnosed with abruptio placentae. Which of the following findings should the nurse identify as the wrist factors for this condition? Select all that apply

-maternal hypertension -cocaine use -Advanced maternal age -Cigarette smoking

A nurse on the psychiatric unit is caring for a client to exhibit aggressive behaviors. Which of the following environmental variables Is associated with increased risk of violence in this client? Select all that apply

-overcrowding -presence of staff new to the mental health setting -strict controlling behaviors by staff

Xui Has been assigned as a case manager and a large county hospital which of the following is in line with her duties and responsibilities? Select all that apply

-oversee a caseload of clients with similar disorders or treatment regimes -Focus on manage care of the client through collaboration of the healthcare team in both inpatient and post acute setting -Coordinate care provided by in interdisciplinary team

The nurse is preparing to irrigate the student side. What steps are appropriate in completing the arrogation? Select all that apply

-perform hand hygiene and put on gloves -offer the client a paper tissue -placed a solution unto the conjunctival sac

A nurse working in an outpatient clinic is caring for a client who has rheumatoid arthritis and reports increased joint tenderness and swelling which of the following findings should the nurse expect? Select all that apply

-recent viral infection -Decreased range of motion -Pain at rest

A nurse is caring for an adult client who is being discharged after stapedectomy . Which of the following instruction should be given by the nurse to this client? Select all that apply

-rest and sleep on two or three pillows -Avoid blowing the nose

A nurse is reinforcing teaching with a client who has major depressive disorder and a new prescription for iamb I PREMINE about indications of toxicity. Which of the following findings should the nurse include? Select all that apply

-seizures -agitation -Irregular pulse

A nurse is providing information to a 45-year-old client about risk factors for coronary artery disease which of the following modifiable risk factors should the nurse discuss with the client? Select all that apply

-smoking -Hypertension

A nurse is assessing a client who has rheumatoid arthritis. Which of the following manifestations should the nurse expect? Select all that apply

-swelling of bilateral joints -Ulnar deviation -crepitus -Morning joint stiffness

A nurse is assessing a client who has a gunshot wound to the chest. The nurse should identify that which of the following findings are manifestations of a pneumothorax? Select all that apply

-tachypnea -Deviation of the trachea -Subcutaneous emphysema

Hey 67-year-old female client on heparin therapy presents to your service with what you suspect is HIT, and immune medicated drug reaction. The client began receiving IV heparin 14 days prior and had her last dose a minister 24 hours ago. Which of the following conditions would you expect to be present? Select all that apply

-thrombocytopenia -hematuria

Which of the following symptoms should a client at risk for colon cancer report to his primary care doctor? Select all that apply

-unintended weight loss -bleeding from the rectum -changes in bowel routine

A nurse is caring for a client who has manifestations of dehydration while in the PAC you. Which of the following findings should the nurse report to the provider? Select all that apply

-urinal put less than 25 mL an hour -hematocrit 55% -BUN 30 -Tenting of skin over the sternum

The nurse is caring for a client in Rusch restaurant who has been attempting to extubate her self. Select all the actions that are appropriate for the nurse to do for this client: select all that apply

-verify that the order for the restraints has been signed by the physician within 24 hours -Evaluate the need for restraints every 1 to 2 hours

A nurse is caring for a client with diarrhea who has tested positive for C diff antigen in stool. Which of the following measures is indicated to prevent spread of this pathogenic organisms? Select all that apply

-wash hands with soap and water -Where are disposable gown while caring for the client

The nurse is caring for a client with a fractured pelvis who is to receive 50 mg of MEPERIDINE Demirel IM. The concentration on hand is 100 mg/mL. How many milliliters should the nurse give? Fill in the blank

0.5

The medication prescribed his Lasix 20 mg orally. The medication label reads Lasix 40 mg/tablet. How many tablets should the nurse administer?

1/2

A client is admitted with glaucoma. While reviewing Tonometry Results of the client in the chart, the nurse understands that the normal intraocular pressure is:

10 to 21

A nurse is preparing to administer blood transfusion to a client. The nurse should know that she should stay with the client after starting the transfusion four:

15 minutes

A pregnant client of 12 weeks gestation ask the nurse when she can start feeling the fetal movement the nurses tell the mother that it begins at _______weeks gestation.

16-20

The nurse is caring for a new mother who is breast-feeding her first baby. The nurse should tell the new mother that the colostrum will change to milk within:

2-3 days

The client with multiple fractures has been receiving 50 mg of Demerol every four hours IM. In preparation for discharge to home, the client will be converted to oral Demerol. The nurse will expect the equivalent oral dose to be:

200 mg PO

The intravenous prescription is 500 ML's of 0.9% normal sailing to run over six hours to drop factor is 15 drops per milliliter. The nurse plans to adjust the flow rate to how many drops per minute? Round the number to the nearest whole number

21

The physician has ordered amoxicillin 150 mg PO for a child with an infection. The medications available as a suspension of 250 mg over 5 mL. How many milliliters should the nurse give? Fill in the blank

3

If the nurse is giving an enema to an adult client, how far should the enema tip be inserted into the anal canal,

3 to 4 inches

Prior to administering frozen mind Lasix to an adult client, the nurse check the lab results to find the clients last year and potassium level. Which of the following findings would be of concern to the nurse?

3.2 mEq/L

A nurse is performing a cardio pulmonary resuscitation on a five-year-old child. The nurse should know that if she is alone, the compression to ventilation ratio in children is

30:2

The client at highest risk for skin cancer is:

48 year old mountain climber

The physician has ordered that the client received 50 mg of a certain medication. The drug is available any Joseph 10 mg/mL. How many milliliters should the nurse gift? Fill in the blank

5

The prescribing provider has written in order to give lactulose 2 ounces to decrease the clients ammonia level. How many milliliters well the nurse administer? Fill in the blank

60

A nurse is preparing to administer intramuscular injection to a client. The nurse should know that it should be administered add an angle of ____degrees

90

A nurse is leading a group discussion about the risk factors of family and community violence. This nurse should include which of the following clients has a risk factor for experience in violence?

A 25-year-old female who is pregnant with her first child

An LVN is caring for four clients any medical ward. Which client should be on the clear fluid diet?

A client scheduled for a colonoscopy the next day

An LVN is caring for four clients on a medical ward which clients would be on a clear fluid

A client scheduled for a colonoscopy the next day

A nurse is providing teaching to a group of nursing assistance who work in an extended care facility. The nurse should include that which of the following clients is the priority to observe during meals?

A client who has Parkinson's disease

A nurse and a medical unit is assigned to for newly admitted clients. Which of the following clients will require airborne precautions?

A client with a positive PPD and an abnormal chest x-ray

And otherwise normal mail client is currently improving from an acute infection. You are monitoring his white blood cell counts and should notice which of the following?

A decrease in WBC count overtime

A nurse is contributing to the plan of care for a client who has pre-renal acute kidney injury a K I found an acute myocardial infarction urinary output is 60 ML's in the past two hours and blood pressure is 92/58 which of the following interventions should the nurse anticipate a prescription for?

A fluid challenge with 0.9% sodium chloride solution

The physician has ordered penicillin for a client with a strep infection. The nurse should question the order if the client has:

A history of allergy to penicillin

The LVN is performing postoperative teaching for a client who was admitted for five days with pneumonia. Discharge teaching should include all the following except:

A list of all medications including medications being taken prior to admission

A license practical nurse is planning assignment of clients. Which of the following can be assigned to a nursing assistant?

A postoperative client who requires assistance with ambulation

The nurse is caring for a client with PYELONEPHRITIS. The nurse recognizes that this is:

A renal disease brought on quickly due to inflammation or infection of kidney

For collate bells are ringing at the same time. Which of the following request should the LVN fulfill first?

A request from a client on the commode who is complaining of dizziness and is asking for assistance in getting back to bed

A nurse is performing a neurological assessment every 30 minutes for a client admitted with a head injury. Which of the following findings indicates that the clients condition is satisfactory?

A score of 13 on the Glasgow, scale

The nurse is providing care for an elderly woman who had surgery on her right foot yesterday. The client had a fractured left arm three months ago and other diagnoses include osteoarthritis. Which of the following assistive devices will be most appropriate for this client?

A walker

Assessment, problem identification, goalsetting, implementation, and evaluation are the 5 quart tenants of client care planning. Which of the following sequence illustrates these principal correctly, respectively. Select all that apply

A, B, C, E,

A nurse is assisting with the planning a presentation for a group of clients at a health fair about measures to reduce the risk for amputation due to diabetes mellitus. Which of the following intervention should the nurse plan to include? Select all that apply

ABC

The Chargers is conducting a staff in-service about medication use during the care of a client who is experiencing acute alcohol withdrawal. Which of the following medication should be the charge nurse include in the discussion? Select all that apply

ABC

The charge nurse is reviewing information with a group of nurses but addition of a lipid the motion to total parenteral nutrition TPN which of the following statement should be the charge nurse include select all that apply

ABCD

Nurse is caring for a client who has chronic cancer pain and has been prescribed FENTANYL/BUPRIVACAINE to be administered through a permanent epidural catheter. The nurse should monitor the client for which of the following manifestations? Select all that apply

ABCE

A nurse is reinforcing teaching with a client who has rapid cycling bipolar disorder and a new prescription for carbamazepine. Which of the following information should the nurse reinforced in the teaching? Select all that apply

ABDE

A nurse is caring for a client who has chronic PYELONEPHRITIS. Which is fine actions should the nurse take? Select all that apply

ACDE

A nurse is reinforcing discharge teaching with a parent of a child who has HIV. Which of the following information should the nurse include? Select all that apply

ACDE

A nurse is teaching a client who has a new prescription for Depot mid Draco just restaurant acetate DMPA. Which of the following statements by the client indicates an understanding of the information? Select all that apply

ACE

Administration of insulin at which of the following site causes rapid absorption?

Abdomen

62-year-old female clients diagnosis severe osteoporosis. The nurse would give instruction regarding which exercise to avoid:

Abdominal sit ups

Which of the following is not true in regards to professional accountability?

Accountability includes blaming others for your own personal mistakes, rather than evaluating the outcomes of your own actions

A nurse is attending to an 85-year-old woman, who initiated conversation about end-of-life planning. She indicates her preference for more information about advance directives and minimal intervention in the case of a medical emergency. What is a proper sequence of events this nurse should follow and preparing to engage with this client?

Acknowledge the clients right to self-determination, provide guidance regarding advance directives, commence appropriate institutional protocols, and Shirley living will and other documentation enter the clients record, and inform attending physician

The client is brought to the emergency department with a suspected overdose of aspirin. The nurse should prepare to give:

Activated charcoal

A nurse is caring for a client who is receiving total parenteral nutrition TPN through a central line. The pharmacy notifies the nurse that the bag of solution will not be available for administration for two hours. Which of the following actions should the nurse take?

Administer 10% dextrose in water IV until the next bag is available

Before section and client with tracheostomy, which of the following actions should the nurse perform?

Administer 100% oxygen for one or two minutes

A nurse in the emergency department is caring for a child who has severe lead toxicity. Which of the following actions should the nurse plan to take?

Administer CHELATIO and therapy

A nurse is preparing to administer a morning dose of insulin a sport to a client who has type one diabetes Molite us. Which of the following actions should the nurse take?

Administer insulin to the client with a breakfast tray arrives

A nurse is collecting data on a client who has COPD and find absent breath sounds in the left lower lobe and dyspnea. Which of the following actions should the nurse take first?

Administer oxygen to the client

The LVN is working on a pediatric unit and it's a sign to care for a 10-year-old boy who has leukemia. The client is no longer eating or drinking, oral needs have been discontinued because the client is unable to swallow them and urine output is negligible. The physician expect that the client will expire within the next 24 hours. The client is semi conscious and this morning. Facial grimacing is almost a parent. The clients blood pressure is low and his respirations are eight per minute. The parents ask the LVN to administer an opioid because the client is morning and appears to be in pain what should the LVN do?

Administer the prescribed PRN medication

The practical nurse knows that the following ethnic group is most likely to develop

African-American

The nurse is caring for a client with tuberculosis. The nurse knows that the appropriate type of isolation for this client is:

Airborne

The practical nurse is Working with a client at risk for falls. She knows that all of the following people should know information about preventing Falls for this client. Select all of the correct answers.

All of them

Which of the following decreases the risk of sleep related deaths, including SIDS, in infants?

All of these

The nurse should understand that the mechanism Of action of the consent sodium Colace is to:

Allow fluid to enter the stool and soften it

A throat culture is ordered for an adult with a sore throat. The nurse asked the client if he has self medicated with any medications. Which medication if reported by the client would be your greatest concern to the nurse?

An Antibiotic

Which of the following clients is at greatest risk for developing a pressure ulcer?

An elderly woman who has just had abdominal surgery with a BMI of 17

A nurse is provided teaching to student nurses about cultural blindness my caring for clients and diverse of necessity. Cultural blindness is best described as

An inability to recognize cultural values and beliefs among different populations

The LVN is making staff assignments in a long-term care facility. Other staff on duty include another LVN and a new CNA. Which of the following clients can most safely be assigned to the CNA?

And 83-year-old with diagnosis of Alzheimer's and Parkinson's who is ambulatory with assistance

A nurse in the emergency department is caring for a client who has sustained a pelvic fraction in a motor vehicle collision. Which of the following would be a sign of hypovolemic shock in the client?

And Apple cup pulse rate of 140 BPM

The nurse is caring for a client who was ordered to be on bed rest for four weeks. What should the nurse include in care planning for the client to prevent venous stasis?

Antiembolism stockings to be worn at all times

And adult client is on a clear liquid diet. Which of the following is appropriate for the nurse to offer the client?

Apple juice

During the first 24 hours postoperatively after a cleft lip repair, the nurse would

Appliable restraints to the infant

A client is admitted with an eye that does not close completely. The most important intervention is to:

Apply an eyepatch over the affected eye

The client came to the emergency department with a nose bleed after a car crash which of the following should be the priority nursing action?

Apply direct pressure

The nurse is caring for a postoperative client who is at risk for deep vein thrombosis. In order to prevent DVT, the nurse should

Apply pneumatic compression stockings

A nurse is reviewing the laboratory results of a client who has thrombocytopenia. Which of the following actions should the nurse expect to take?

Apply prolong pressure to the puncture site when obtaining blood

Nurse is reinforcing discharge teaching with a client who has cellulitis of the leg. Which of the following information should the nurse include in the teaching?

Apply warm compresses to the affected area

The practical nurse is checking the episiotomy Site of a client 10 hours after delivery. The nurse notes of the side is swollen and slightly red. The most appropriate next action is:

Applying ice pack to the area

A client arrives at the emergency room with a heart rate of 120, your story rate of 48 and hemoptysis. And there should be a priority to:

Applying oxygen via mask

A preoperative client informs the nurse that the people from his church will be coming to pray with him and his semi private room. More than a dozen people arrive and begin loudly singing and praying, disturbing the clients roommate. The best response by the nurse is to:

Arrange for the preop client and his visitors to meet in the chapel or a conference room

A client with tuberculosis is taking Pyrazinamide. Which of the following side effects should the nurse monitor in the client?

Arthralgia

And unlicensed assistant personnel complains to a nurse that the client has been rude, demanding, and verbally abusive and refuses to care for the client due to his unpleasant behavior. Which of the following is the best initial response by the nurse?

Ask the USP For more information and ask the UAP to discuss possible solutions to the problem

A nurse is preparing to administer be Beclomethasone intranasally to a client who has a frontal sinus infection. Which of the following actions should the nurse plan to take?

Ask the client to blow their nose gently before the installation

A nurse is new to the residential care center and is in ministering HS medications one client is not wearing a readable name band. What is the most appropriate action for the nurse to take?

Ask the client to state his name

A nurse is caring for a client who has been hospitalized for eight days. The client is crying and express his feelings of guilt for being in the hospital. Which of the following is the most appropriate intervention by the nurse?

Ask the client to talk about her feeling of guilt

A nurse is teaching elevation client who has hypertension about selecting low sodium food choices. Which of the following actions by the nurse demonstrates cultural competency?

Ask the client what she likes to eat

The nurse is caring for a Cuban client who practices sent area. The clients family explains that he followers of Centauria look to the Santero for herbal and spiritual remedies for illness. Which of the following is appropriate response by the nurse?

Ask the family if the Synterra would like to be involved as a consultant

A nurse finds that the intake and output of a client calculated by a nurse assistant is in accurate. Which of the following actions should the nurse take?

Ask the nurse how she calculated it

A nurse find that intake and output of a client calculated by a nurse assistant is in accurate. Which of the following actions should the nurse take?

Ask the nursing assistant how she calculated it

The nurse is completing a pain assessment on a client who has chronic back pain. Which assessment is of the most value?

Asking the client to read his pain on a scale of 1 to 10

The nurse is preparing to administer and hazel gastric tube feeding to a client. Which of the following is essential prior to administering the feeding?

Aspirate contents from the nasogastric tube and check the pH of the contents

A nurse is caring for a client who has bipolar disorder and a new prescription for lithium. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?

Aspirin would be a better choice than ibuprofen

A resident of a long-term care facility has a history of repeated falls after attempting to get up from the wheelchair. Which instruction to the nursing team is most appropriate to prevent client falls?

Assess client needs on a frequent basis

A resident of a long-term care facility has a history of repeated falls after attempting to get up from the wheelchair. Which instruction to the nursing team is most appropriate to prevent client files?

Assess client needs on a frequent basis

A client is admitted to the hospital and his x-rays show fracture of the owner and a plaster cast is applied. Which of the following nursing interventions would be most important after the cast is in place?

Assess for capillary refill

A client is admitted with second-degree burns on his face, neck, anterior chest and hands. The nurses priority action would be

Assess for dyspnea and strider

A client collapses in the bathroom and the LVN find the client lying on the floor. What should the LVN do first?

Assess for responsiveness

A client with DNR order experiences cardiac arrest. Which of the following actions should the nurse take?

Assess the client for signs of death

An adult client has just returned to the nursing unit following abdominal surgery. She has an order for Meperidine IM PRN for severe pain or acetaminophen #3 po PRN From mild to moderate pain. The nurse asked the client if she is having pain and she states she is having pain. What is the most appropriate initial response for the nurse to take?

Assess the client further as to the location and degree of pain using a pain scale

An LVN is receiving a client from the OR. The client had an uncomplicated cholecystectomy and is still drowsy but rouses easily. Once the client has been transferred to the bed, the LVN should:

Assess the clients airway and breathing to ensure that the airway is not compromised

A nurse is performing in assessment of an unconscious client. The nurse must know that the Glasgow coma scale is designed to:

Assess the level of consciousness

In which of the following step of Nursing processes, the nurse gathers data about the client from different sources?

Assessment

A client experiences chest pain while walking. The nurse would perform which of the following interventions first?

Assist him to a sitting position

A nurse is caring for a client who has heart failure and reports increased shortness of breath. After increasing the clients oxygen, which of the following actions should the nurse take next?

Assist the client into high Fowlers position

The most effective nursing intervention to prevent atelectasis From developing in a post operative client is to:

Assist the client to turn, cough and deep breathe

Which of the following task can be safely delegated to the UAP unlicensed assistive personnel?

Assisting the client recovering from abdominal surgery to ambulate to the bathroom

The client least at risk for vaginal candidiasis is the client with Colin

Asthma

The practical nurse is working in a clinic caring for obstetrical clients. An asthmatic patient who is 16 weeks pregnant asked if she should continue her asthma medication. The most appropriate response for the nurse to make is:

Asthma medications do not cause harm to the fetus and should be continued during pregnancy

A nurse is assisting and ambulating a client with hemiplegia. Where should the nurse stand in relation to the client?

At the clients affected side

A nurse is preparing to administer an IM Injection to a client. The nurse should complete third and final medication check at which of the following times?

At the clients bedside before administration

The nurse is moving a client up in bed without any assistance. Where should the nurse place the clients pillow during the move?

At the head of the bed

When educated the client on the proper way to collect a 24 hour urine specimen, which of the following should be included?

At the starting of collection, have the client void and discard it

The client any postpartum unit begins to hemorrhage. The nurse quickly take charge and delegate tasks to other members of the working group. The leadership style would best be described as:

Autocratic

Which of the following leadership styles is to be implemented by the nurse in an emergency situation?

Autocratic

The client is scheduled for a surgery. The relatives of the client say that the client is afraid of transmitting infection through transfusion of blood. Which of the following to the nurse tell the client as the safest blood product?

Autologous production

The nurse is preparing to discharge an 80-year-old female who has a new prescription for warfarin Coumadin for the van thrombosis. Which of the following instructions should be included in the nurses discharge teaching

Avoid alcohol do to enhance anticoagulant effect

The client is admitted to the unit with a diagnosis of hepatitis C. Which intervention should be implemented to prevent transmission of the disease?

Avoid contact with blood and needles

A client has undergone an inguinal Hernia repair and is preparing for discharge. Which instruction by the nurse is most appropriate?

Avoid forceful coughing

When planning discharge instructions for a client who has had a prostatectomy, which information is most appropriate for the nurse to include

Avoid heavy lifting and strenuous exercise

Nurses giving instructions to a client with deep vein thrombosis. Which of the following with the nurse include?

Avoid prolong sitting

A client who has Ménière's disease came to the outpatient department experiencing vertigo. Which of the following instruction should the nurse give?

Avoid sudden head movement

Which of the following nursing orders is appropriate for the practical nurse to add to the care plan of a client who just underwent a modified mastectomy

Avoid taking blood pressure using the arm on the operative side

When you're getting the client eyes, which technique describes the best way to direct the flow if you were getting solution?

Away from the inner canthus

Which medication order is written correctly with all of the requirement elements for a save order?

B

The nurse is working in labor and delivery. The neonate that is delivered does not breathe spontaneously. The nurse knows that the following tasks Will be performed in what order:

B. The newborn Will be stimulated to cry C. The newborn will be suctioned D. The newborns heart rate will be assessed A. The umbilical cord will be cut

Nurse is caring for a child who has cerebral palsy who is experiencing painful muscle spasms. Which of the following medication should the nurse expect to administer?

BACLOFEN

A nurse in the inpatient psychiatric unit is caring for a client who is experiencing an acute manic state. Which of the following activities might be appropriate for this client? Select all that apply

BCD

Nurse is teaching a client about ETONOGESTREL, and implantable progestin. Which of the following manifestations should the nurse include as an adverse effect of this type of contraceptive? Select all that apply

BCD

A nurse is providing care for a client who has diabetic ketoacidosis. The nurse should expect which of the following manifestations? Select all that apply

BCDE

And nurse is collecting data from a 10-year-old client who has major depressive disorder. Which of the following findings should the nurse expect? Select all that apply

BCDE

A nurse is monitoring a client who is currently taking loxapine. Which of the following findings with the nurse identify as an extra perimeter symptom EPS? Select all that apply

BCE

A nurse in the emergency department is caring for a client who has experience a sexual assault. Which of the following actions should the nurse take? Select all that apply

BD

Nurse is collecting data from a client who has major depressive disorder. The nurse should identify which of the following client statements as a covert comment about suicide? Select all that apply

BD

A nurse is caring for a client who has schizophrenia and is taking haloperidol daily. Which of the following findings should indicate to the nurse that the client has developed tardive dyskinesia TD select all that apply

BDE

A school nurse is assisting with developing interventions for high school students to reduce the impact of recent student suicide. Which of the following interventions is an example of a tertiary prevention? Select all that apply

BE

The nurse is to install your drafts to an adult. To do this properly The nurse should pull the pinna or of the ear

Back and ip

The client is on his right side. When caring for this client who is unable to move on his own, the nurse should check all of the following except which for possible skin breakdown:

Back of head

And nurse is preparing to transfer a dead body to mortuary. Which of the following should be performed by the nurse before transferring?

Bathe and body

A nurse is preparing to transfer a dead body to the mortuary which of the following should be performed by the nursery for transferring?

Bathe the body

A nurse is providing care for a client who is at 28 weeks of gestation. The client has placenta previa and is actively bleeding. Which of the following medication should the nurse expect to provider to prescribe?

Betamethasone

A nurse is providing care for a client who is in preterm labor for 30 weeks of gestation. which of the following medications should the nurse expect a provider to prescribe to accelerate lung maturity

Betamethasone

A nurse in a clinic is caring for a client who has suspected uterine cancer. For which of the following procedures should the nurse prepare the client?

Bimanual pelvic examination

A nurse is caring for a client following a cardiac Catherine station that was inserted through the for moral artery. While turning the client, the nurse discovers blood underneath the clients lower back which of the following complications to the nurse suspect?

Bleeding from the incision site

A Nurse is preparing to administer capital METHERGINE to a client to treat postpartum hemorrhage. Before administering the drug priority action of the nurse is to check:

Blood pressure

A client was admitted with cataracts. Which of the following manifestations might the client complain of?

Blurred vision

834-year-old male is admitted to the hospital with a diagnosis of PHEOCHROMOCYTOMA. Which of the following symptoms with the nurse not expect to see during an attack?

Bradycardia

The nurse is assisting a breast-feeding mother. The nurse knows that all of the following are true except:

Breast-feeding of a newborn should occur every 6 hours

A nurse is preparing to insert urinary catheter to a client the nurse should tell the client to:

Breathe deeply

The nurse is caring for a client who will be taking Phenazopyridine hydrochloride For pain associated with urinary tract infection. The nurse should instruct the client of the medication will cause colon

Bright orange urine

A 50-year-old client is 15 days post hysterectomy. Which of the following symptoms should be immediately reported to the physician?

Bright red bleeding from the incision site or higher site

A nurse is assessing the clients nutritional status before surgery. Which of the following observations would indicate poor nutrition and a 5'7" female who is 21 years old

Brittle nails

Triage refers to the classification of injury severity during a disaster. Which of the following client should receive priority during triage?

Burns of the head and neck

In order to show pursed lip breathing to a client, the nurse should do these actions in the following order:

C ADB Relax and neck and shoulders

The nurse is caring for a client who begins have a seizure. In what order should the nurse do the following actions

CDBA Ensure that the client is safe from harm

Interested in reviewing Kubler Ross is five steps of grief which a group of student nurses which of the following stages should the nurse include in the discussion? Select all that apply

CDE

The nurse is preparing to suction a child with a tracheostomy. Put the following steps in order

CEDBFA Gather equipment

Before-year-old woman is in labor and is admitted With high blood pressure, Adema and PROTEINUR I a. She is started on magnesium sulfate. The nurses sure to keep which of the following drugs at her bedside?

Calcium gluconate

Inners is caring for a client who is receiving a magnesium sulfate IV infusion and exhibiting manifestations of magnesium toxicity. Which of the following medication should the nurse expect to administer?

Calcium gluconate

A nurse is providing care to a client who is diagnosed with multiple MYELOMA. Which of the following lab results should the nurse specifically note in this client?

Calcium level

A client is complaining of constipation. The nurse should identify that the following medication should be responsible for constipation

Calcium supplements

A nurse is giving care to an on responsive client. The nurse should

Call clients name and explain procedures

A client complained to the nurse that she can't fall asleep. Which of the following is the least appropriate for the nurse to try as an initial intervention?

Call physician to ask for a sedative

When a nurse is unable to log onto a computer to document care for a client, what action by the nurse is most appropriate in these circumstances?

Call tech-support, notify them of the situation

And adult is scheduled for surgery in less than an hour and has signed the preop consent. The nurse is ready to administer preoperative medication when the client states, "I change my mind. I don't want the surgery after all. "What is the best response by the nurse?

Call the clients physician

A postoperative client has an NG tube following bowel surgery and has a temperature of 101.4. The physician has left orders that read acetaminophen 650 PRN for fever of 101 what is the most appropriate action for the nurse to take?

Call the physician and question the order

The most common opportunistic infection in clients with HIV infection is?

Candidiasis

A client is learning to use crutches for the first time. When planning care for this client, which of the following is most important

Carefully assessing the clients activity level

The practical nurse knows that HPV can lead to

Cervical cancer

The nurse observes in nursing assistant doing each of the following. Which action should the nurse correct?

Change the dressing of a client with a surgical wound

A nurse is preparing to provide heat application to a client by using hot water bag. Which of the following statements is true?

Change the position of the bag as necessary

Which of the following task may be delegated to a nursing assistant in a mental health setting?

Check for harmful objects

The practical nurse is assigned a client who is confused and gets dizzy when ambulating. The most appropriate intervention for this client is to:

Check on the client regularly to assess the need to go to the bathroom

A client with diabetes Molite us experiences hunger, irritability, sweating, and weakness. Which of the following would be the initial nursing action?

Check the blood glucose level

The nurse is preparing to administer the daily dose of the Jackson to an adult client. What is the essential action for the nurse to take prior to administering this medication?

Check the clients apical pulse

The nurses to apply and it's wrapped with a client right lower leg. Which actions should the nurse take to ensure that the dressing is not too tight:

Check the pedal pulse

If the nurse find a client who has fallen out of the hospital bed which nursing action is best to perform initially?

Checking the clients physical condition

The client has Addison's disease and the nurse is planning for foods that are good source of sodium. If the following foods are available, which one should the nurse recommend?

Cheddar cheese

Your client is diagnosed with hepatitis A. The nurse teaches the client significant others that they can prevent infection with a virus by:

Cheerful handwashing and good sanitation

The nurse is caring for a client after a motor vehicle accident. The client takes several small breaths, followed by deep breath's, then 2 to 3 small breast followed by 10 to 15 seconds of apnea. The breathing pattern is called:

Cheyenne stokes respiration

An LVN is given an order by clients physician to administer pain medication to a client. The LVN believes that the dose of pain medication ordered by the physician is too high and is uncomfortable about giving this medication the LVN should:

Clarify the doors with the clients position, stating the concerns if necessary

A nurse is preparing to collect specimens for wound culture. The specimen should be taken from:

Clean, healthy looking tissue

Interest is planning to obtain data about a client who got admitted in her shift from primary source. Which of the following is a primary source?

Client

In which of the following situation should the nurse right the incident report?

Client falling down from the bed

A nurse is caring for a client who underwent laparotomy. What is the best example of a measurable goal?

Client is walking from the room to the end of the ward and back to bed

A nurse is caring for a client who underwent laparotomy. Which of the following is a best example for a measurable goal?

Client is walking from the room to the end of the ward and back to bed

An elderly client is admitted with stroke. Which of the following intervention helps to prevent formation of decubitus Ulcer in the client?

Client repositioned every two hours

A nurse is teaching a client who is a NTEPARTUM about ways to prevent a torch infection. Which of the following information should the nurse include?

Client should avoid consuming undercooked meat while pregnant

Which of the following is an example for correct documentation in a medical record?

Client skin is warm and dry

A nurse is changing the central line dressing of a client who is receiving total parenteral nutrition and notes redness at the site which of the following should be the nurses next assessment?

Clients temperature

The cancer most often linked to a diet high in fat is:

Colon

Activities of daily living a deal when performed by the client rather than a caregiver improve or maintain all of the following except

Communication

A nurse is preparing to administer I drive to a client. To which of the following site should the nurse administer it?

Conjunctiva sac

The nurse is caring for a client with a laryngectomy. The nurse knows that the client should do all the following except

Consume a low fiber diet

A nurse is caring for a client with a wood infection that is positive for MRSAwhich of the following is required to avoid transmission of this pathogen organism?

Contact precaution

A nurse finds the medication order written by the Healthcare provider is incomplete. Which of the following actions should be performed by the nurse first?

Contact the physician

A nine month old child weighs 20 pounds. And has sustained a fracture of the right femur. The client is admitted and placed in BRYANT's traction. The nurse knows that this type of traction is:

Continuous, skin

A nurse is caring for a client who is at 17 weeks of gestation and has a new diagnosis of molar pregnancy. Which of the following manifestations should the nurse expect?

Dark brown vaginal discharge

Which goal is most appropriate when the nurse managers the care of an older adult client who has osteoporosis

Decline will ambulate without falling

During the first three months of pregnancy, the need for insulin in an insulin dependent diabetic will often:

Decrease

And a client with respiratory problems, a corticosteroid may be prescribed two:

Decrease Adema in their ways

A client is experiencing diarrhea for three days which of the following indicates hypovolemia?

Decrease blood pressure

A nurse is reviewing the laboratory findings of a client who has a cute pancreatitis. Which of the following findings as a priority to report?

Decrease calcium

The cardiac client is being started on a beta blocker. The nurse knows that a beta blocker will likely cause:

Decrease in heart rate

A client is receiving IV gentamicin. Which of the following may indicate an adverse response to gentamicin?

Decrease urine output

A nurse in The providers offices review in the laboratory reports of a client who is being evaluated for Graves' disease. Which of the following laboratory results is an indication of Graves' disease?

Decreased thyroid stimulating hormone TSH

A nurse in the providers offices review in laboratory results for a client who has secondary hypothyroidism. Which of the following findings should the nurse expect?

Decreased triiodothyronine T3

A nurse is providing discharge teaching to who has undergone a kidney transplant. For which of the following signs or symptoms should the nurse advice The client to monitor for rejection of the transplant?

Decreased urinary output and high BP

A nurse has asked a new nursing assistant to take the temperature of a client using a temp panic thermometer. The nursing assistant replies, "I've never seen one of these, but I am good at figuring things out. "What is the best action for the nurse to take?

Demonstrate the proper use of the thermometer and turn demonstration by the nursing assistant before allowing her to use the equipment on the client

A nurse is an emergency department is a sign to care for a clay diagnosed with PENZODIAZEPINE ingestion. Which of the following actions should the nurse take first?

Determine the clients level of orientation

All of the following clients need the nurses attention which client should the nurse see first?

Diabetic client whose blood sugar is 40

A nurse is Montana client newly diagnosed with diabetes Molite us. Which of the following symptoms, if exhibited in the client, would indicate hypoglycemia and requires physician notification?

Diaphoresis

A nurse is monitoring a client who is receiving transfusion which of the following with the nurse expect if the client develop a blood transfusion reaction?

Diaphoresis

A new mother is two days postpartum. She is breast-feeding and is ready for discharge. She states she plans to use the diaphragm she was using prior to becoming pregnant for contraception. The nurses should base for a response on which of the following?

Diaphragms need to be refitted after the birth of a baby

A client with asthma is receiving DER I PHYLLIN. The nurse should know that it acts by:

Dilating the bronchi

Before administering oral potassium supplement, the nurse should know that it should be given:

Diluting with 4 ounces of juice

A nurse is assessing a client who has HIV. Which of the following findings should the nurse identify as manifestation of HIV associated muscle wasting?

Diminished strength

The nurse identifies the presence of redness, heat, and swollen at the IV insertion site. What action is appropriate?

Discontinue IV

A nurse identifies the symptoms of infiltration at the IV insertion site. What intervention the nurse would do?

Discontinue Ivy flow

The nurse is providing care for a client who is terminally ill. Upon admission the client has signed in advance directive stating she does not want any resuscitative measures taken. She is now in and out of consciousness. Her son arrives and tells the nurse he wants everything done for his mother if she stops breathing. What is the best response for the nurse to make?

Discuss the clients advance directive with the son

A Client has undergone cardiac Catherine station. The nurse should prioritize palpation of the pulse at which of the following sites?

Distal to the catheter insertion site

A client who is about to be discharge from the hospital is receiving warfarin Coumadin. Discharge planning should include which of the following?

Do not take any over-the-counter medication without checking with your physician

Do you put from your clients indwelling catheter is 500 mL for the past 10 hours the nurse should

Do nothing because you'll put is normal

Which question is essential for the nurse to ask before a client undergoes an intravenous PYELOGRAM IVP

Do you have any allergies to seafood

The primary purpose of changing a postoperative dressing are:

Do you inspect incision area for healing and for evidence of infection

A nurse is teaching the parents of a two-year-old how to instill ear drops into the child's ear. Which of the following is the correct instructions to the parents about moving the pinna of the year before and selling drops?

Down into the back

Which of the following actions should the nurse take when a mistake is made on recording clients condition?

Draw a line through the mistake and right mistaken entry and sign above it

A nurse is providing care for a client in her home for reports she has difficulty falling asleep at night. Which of the following would be the most helpful suggestions for the nurse to meet?

Drink warm milk before going to bed at night

The client is admitted with a diagnosis of influenza. The nurse should be sure that the client is admitted with what kind of precautions?

Droplet

The nurse admits a young adult with bacterial meningitis. The infection requires which type of precautions?

Droplet

Well awaiting the diagnostic test results for a client with possible meningitis, which transmission based precautions our best to implement?

Droplet precautions

A nurse in A providers office is providing teaching to the parent of a child who has allergic rhinitis and a new prescription for DIPHENHYDREMINE. Which of the following manifestations to the nurse and struck the parent to monitor for as an adverse effect of DIPHENHYDRAMINE?

Drowsiness

A nurse is caring for a client who has schizophrenia and as prescribed help her at all for agitation. For which of the following adverse effects should the nurse monitor?

Dysrhythmias

And your mother states that she is afraid to have a bowel movement because she remembers the discomfort she experienced after delivering her other child. The nurse should encourage her to:

Eat fresh fruits and vegetables, drink plenty of water, and ambulate

A nurse is caring for a client who has and I and TRAUTERINE device (IUD). The client reports abrupt, sharp, lower of Domino pain and bright red vaginal bleeding. The nurse should identify that these Our findings of which of the following conditions?

Ectopic pregnancy

And nurses caring for a client who underwent right radical mastectomy for the treatment of breast cancer. The nurse should place the clients right arm in which position

Elevated on a pillow

Which of the following tasks may be safely delegated by the LVN Do you certified nursing assistant under their supervision?

Empty in the urinal and record in the amount of urine emptied from the urinal

Nurse is caring for a client with mantle cell lymphoma who has been in hospice for several weeks. His death is expected within the next several hours. Which of the following is the most appropriate nursing intervention for the Klein at this time?

Encourage loved ones to remain with the client

The nurses using principles of rehabilitation when here she:

Encourages client address in street clothes

The nurse encourages a client with a wound to take a diet rich in vitamin C. The nurse should know that this it is too

Enhanced collagen formation

The practical nurse is working in the emergency department. And unconscious client with multiple lacerations with injuries is brought in by emergency medical service following a motor vehicle accident the first thing the nurse should do is:

Ensure a patent airway

A nurse is assisting with the planning of a group discussion about fractures which of the following information should the nurse recommend be included?

Epiphyseal plate injuries can require surgery

A client is being prepped for cardiac surgery and presents with a platelet count of 80,000. Which of the following should have likely been a part of the treatment regime prior to the invasive procedure?

Erythropoietin

An older adult client is coming at us and on life-support. The family asked that life support measures be discontinued. Which method is best for determining whether it is appropriate to carry out the families request?

Examining the specifications in the clients advance directive

The nurse is caring for a Native American client with a medicine bag hanging around his neck. The appropriate action for the nurses to:

Except the client believes that the bag helps him

The primary risk for oral cancer is?

Excessive alcohol

A pregnant client with no one HIV infection is admitted to the hospital in active labor. Which method for assessing the fetus is most appropriate for the nurse to perform at this time?

External fetal monitoring

The client with abdominal pain has been diagnosed with gallstones. The client asked about treatment to remove the gallstones with extracorporal lithotripsy. What is the best explanation of this method of treatment that the nurse can provide?

Extracorporal lithotripsy dissolves gallstones using shockwaves

The home care nurse is assisting an elderly client with hygienic Care. Which area should the nurse wash first?

Face

A client with knowndementia recovering from hip repair surgery becomes aggressive and confused, striking out, swearing and attempting to crawl out of bed. The LVN is concerned that the client will Hurt himself if he gets out of bed and falls. The LVN applies a posse restraint despite the fact that there is no order on the clients chart for a restraint to be applied. This is an example of:

False imprisonment

A nurse is assigned to care for a client admitted for treatment of cholecystitis. The nurse would expect the clients history to include intolerance to which of the following?

Fatty foods

Do you practical nurse is caring for a client who has had a stroke and is experiencing dysphasia. The nurse knows that all the following are critical for the safety of this client except:

Feed the client only thin liquids

A nurse is reinforcing information at a community center about screening for cancer prevention. Which of the following statements should the nurse include in the teaching?

Females will need to have an annual breast examination after the age of 40

Which food would be appropriate to serve to a Hindu select all that apply

Fish Beans

The client has a stasis ulcer on the right heel. The most important primary intervention for this client is to:

Float the client seals on a pill to prevent contact with the bed

A client is admitted with diabetic keto acidosis. While doing the nursing assessment, the nurse can expect which of the following skin findings?

Flushed

While giving care to an unconscious client, which of the following devices should be used by the nurse to prevent foot drop and the client?

Footboard

A postoperative client asked the nurse why performing leg exercises is important the best explanation is that leg movement that involves contracting and relaxing leg muscles helps to prevent which condition?

Formation of blood clots

A nurse is giving a dietary advice to a client with gout. Which of the following food can be recommended to the client?

Fresh fruits

A client who has hypo kalemia ask the nurse what food would help this problem. Which of the following responses is the best advice for the nurse to give?

Fruits, especially oranges, bananas and prunes

A client with osteoarthritis has a prescription for celecoxib. Before starting this drug, the client should be assessed for:

Gastric ulcer

A nurse is caring for a newborn who has necrotizing enterocolitis (NEC). Which of the following findings should the nurse recognized as a risk factor for this condition?

Gestational age of 35 weeks

A nurse is caring for a newborn who has necrotizing enterocolitis NEC. Which of the following findings should the nurse recognized as a risk factor for this condition?

Gestational age of 35 weeks

A nurse is working on a medical floor and smell smoke, caused by client smoking in the bathroom. The nurse discovers that the client is accidentally started a fire in the garbage can. What is the most appropriate initial intervention?

Get the clients to a safe area immediately

A client is scheduled for cataract removal. Prior to surgery, 1% atropine drops are instilled in the clients right eye. In which of the following conditions are atropine drops contraindicated?

Glaucoma

In compliance with universal precautions, blood and body fluids precautions, the nurse would wear which of the following when giving and I M injection?

Gloves

A client has an order of cyclosporine after liver transplant. The nurse should advise the client to avoid which of the following drinks with the medication?

Grapefruit juice

Which of the following to the nurse recognized as a cognitive behavior intervention to manage pain?

Guided imagery

A nurse in a providers office is caring for a client who has type two diabetes Molite us. The client asked the nurse why the provider bases his medication regimen On his HBA1C level instead of his morning fasting blood glucose results. Which of the following responses should the nurse make?

HBA one see indicates how well you have regulated your blood glue close over the past 90 to 120 days

A nurse is teaching a client who has a new prescription for PREMIPEXOLE to treat Parkinson's disease. The nurse should instruct the client to monitor for which of the following adverse effects?

Hallucinations

A client on a medical surgical unit has performed Clostridium difficile colitis. Which of the following measures should be instituted in order to prevent the spread of infection?

Hand hygiene should be performed immediately upon leaving the clients room

The single most effective means of preventing the spread of infection is

Hand washing

A client is advised to use a walker. How should the nurse adjust the height of the walker?

Handlebar just below the clients waste

A nurse should know that the client at risk for developing pressure sore is:

He 75-year-old male nourished bed ridden client

The nurse is providing care for a client who has right sided weakness and has been instructed to use a cane when ambulating. Which action by the client indicates he understands correct use of the cane while walking?

He carries a cane in his left hand and moves it at the same time he moves his right foot

A nurse is reinforcing teaching with a newly licensed nurse about hemodialysis for clients who have chronic kidney disease. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Hemodialysis returns a balance to serum electrolytes

What is a direct measure of oxygen carrying capacity of the blood?

Hemoglobin

A client is on Coumadin therapy. Which of the following is the primary concern for the client?

Hemorrhage

And LVN is reviewing the lab results for her clients. All of the clients are adult females. Which of the following results should be reported to the physician immediately?

Hey Siri potassium level of 2.8 mEq/L

A nurse is preparing to insert a nasogastric tube for a client with pancreatitis. In which of the following position should the nurse place the client?

High Fowlers

Hey Dr. preparing to remove the chest tube from a client. Before removing the tube, the nurse should instruct the client to:

Hold breath and bear down

Your caring for a client with terminal cancer who asked for information about home care. Which best describes the difference between hospice and palliative care?

Hospice care involves providing care at the end of life while palliative care promote comfort and ease his suffering at any time

The drug Are a MIPRIL is used to treat:

Hypertension

A nurse is caring for a client with heart failure who takes a diuretic. The client has an ECG electrocardio gram performed and his demonstrates you waves. They should alert the nurse to check laboratory values for which of the following electrolyte abnormalities?

Hypokalemia

A nurse is preparing a client before undergoing a myelogram. Which of the following statements by the client indicates a contraindication For this test?

I am allergic to shrimp

A nurse is giving preoperative teaching on deep breathing and coughing exercises to a pre-operative client. Which of the following statements of the client indicates a need for further teaching?

I have to inhale and exhale through the nose slowly

A nurse is providing teach into a client who has a new prescription for DOXEPIN. Which of the following statements by the client indicates an understanding of the teaching?

I might feel drowsy for a few weeks after starting this medication

A nurse is reinforcing postoperative teaching for the parents of a toddler who had bilateral tympanostomy tube is inserted. Which of the following statements by the parents and the kids and understanding of the teaching

I should answer to your plugs before my child swims in a lake or ocean

A nurse is teaching a client about the intake of SULFADIAZINE. Which of the following statements by the client indicates understanding about the medication?

I should not take it with milk or dairy products

A nurse is training an unlicensed assistive personnel to transfer client from the bed to her wheelchair which of the following statements by the UAP demonstrate understanding of proper lifting technique to avoid injury?

I should try not to twist my trunk when I am lifting someone

The nurse provided teaching to the parent of a school-age child who has iron deficiency anemia and a new prescription for a liquid iron supplement. Which of the following parents statements indicate an understanding of the teaching?

I will administer the medication to my child by using a straw

A nurse is reinforcing teaching with a client who has tobacco use disorder about the use of nicotine gum. Which of the following statements by the client indicated understanding?

I will avoid eating for 15 minutes prior to chewing the gum

And adult client newly admitted to the hospital tells the nurse that he does not want nursing students for medical students to provide his care. Which of the following statements by the nurse is the correct response to the clients statement?

I will make sure your physician and caregivers are aware of your request and your care is not assigned to students. You have a right to be informed of who is providing your care and to refuse treatment by students

A nurse is teaching a client who has a new prescription for clozapine. Which of the following clients statement indicates an understanding of the teaching?

I will need to get up slowly from a lien position while taking this medication

The practical nurse is working in the pediatricians office. A new mother is bringing her Weigle child to a first post natal check up. The mother reports that she is concerned because the infant breeze rapidly for several seconds then slows down. The most appropriate response the nurse is to:

I'm sure the parent that this is normal breathing pattern for an infant

The nurse is caring for a leukemia client who is having pain. The nurse should expect an order for any of the following medications except

Ibuprofen

The client has bruises on her arms and legs and reports to the home care nurse said her gums often bleed when she brushes her teeth. The client is taking all of the following medications. Which of the medications are most likely related to her symptoms?

Ibuprofen (Motrin)

A client who has returned from abdominal surgeries says that she is thirsty. The vital signs of the clients are normal. What would the nurse give initially for the client

Ice chips

An LPN makes a medication error that results in the client requiring further treatment. In this case, the purpose of the incident report is to:

Identify the circumstances leading up to the air and prevent it from happening again

Which of the following is correct regarding a DNR order?

If the client is in competent, the advanced directive or proxy decision maker For the client should make the decision

Nurse in the emergency department is caring for a client with a spinal cord injury. Which of the following intervention should the nurse prioritize?

Immobilize the clients head and neck

And planning nursing care for the client who has experience a several vascular accident, the nurse must keep in mind the clients with left hemisphere infarctions may have:

Impaired judgment

A nurse is monitoring a 30-year-old client confirmed with diagnosis of brain tumor following surgery of a tumor near the hypothalamus. The nurse should observe for

Inability to regulate body temperature

Anders is caring for a client with Crohn's disease who states I can't do this. I can't leave my house for more than an hour at a time. I just don't think I can deal with this anymore. Which of the following processes the nurse understand that this client is

Inadequate coping

A nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is DYSPNEIC and crackles are audible and auscultation. What additional signs could the nurse expect to know if the client if excess fluid volume is present?

Increase in blood pressure

A client with constipation is receiving laxatives. The nurse responsibility is to

Increase intake of fluids

The nurse is caring for a client who is receiving furosemide (Lasix) Expected effects of frost them I'd include the following

Increase you're in output

Your doctor ordered a lumbar puncture for a client. The nurse must be aware that the procedure is contraindicated in

Increased intracranial pressure

Serious side effect of lithium toxicity include all the following except

Increased thirst

A nurse is monitoring a postoperative client. The nurse should identify which of the following signs as an indication of potential complication?

Increasing restlessness

A client is seen with hypothyroidism. The nurse should be aware that a complication of hypothyroidism is:

Infertility

A client is feeling a burning sensation at the IV insertion site when the nurse assesses the site, it is cold and swelling is present. Nursing tournament which of the following occurred at the site?

Infiltration

A nurse Discovers that medication prescribed by the physician was not administered. What is the next action that the nurse to take next?

Inform the charge nurse

If physician prescribed injection tram at all I Mevery six hours as needed for pain. The client refuses to take the injection intramuscularly. Which actions should the nurse take?

Inform the physician and request analgesic that is not to be administered IM

The operating room nurse discovers that the surgical consent has not been signed for this elective procedure. The adult client received preop sedation less than five minutes ago the best response by this nurse is to:

Inform the physician the consent form has not been signed

A client had a hysterectomy 10 hours ago. The nurse assesses the client and finds that her blood pressure has abruptly fallen. What action by the nurse is most appropriate at this time?

Inform the surgeon about the clients condition

A nurse is specs at a coworkers abusing pain medication which should be administered to the clients. Which of the following actions should be performed by the nurse?

Inform to the nursing supervisor

A nurse is allowing a nursing student to witness the dressing change of a client without the clients consent. This action indicates violation of the following clients right except which one?

Informed consent

Which of the following is safe regarding computer documentation?

Informing accidental deletions from the computerized document to nursing supervisor

The major cause of nosocomial Infection in the hospital setting is:

Infrequent handwashing

A nurse is caring for a client who has sustained a full thickness burns on the arms, face, neck, and shoulders and is in the resuscitation phase. The nurse knows that the clients voice has become horse with a brassy cough and drooling. The nurse should identify these findings is indications that the client has which of the following?

Inhalation injury

To prepare a client for crutch walking, it would be most important for the nurse to:

Initiate muscle strengthening exercises for arms and shoulders

When assessing the abdomen of a client the nurse should follow the order:

Inspect, also Tatian, palpation, and percussion

When a client receives a permanent prosthesis, the nurse should teach the client to:

Inspected prosthesis daily for a loose or worn parts

The client has dysphasia. The nurse would include in the plan of care which of the following?

Institute special feeling precautions

The nurses working in labor and delivery and is caring for a full term client in labor who is midwife has just determined that the client cervix is dilated 6 cm. During a contraction, the client states that she is feeling the urge to push. The correct first response of the practical nurse is to:

Instruct her to pant during each contraction

A nurse is reviewing a clients laboratory results and notices a creatinine Level of seven MG/DL. The finding would lead the nurse to place the highest priority on assessing:

Intake and output

The nurse is working on a client when a client is brought in with an acute asthma attack. The nurse knows that immediate Treatment is needed when the client has :

Intercostal retractions

The client has returned to the nursing unit after cardiac Catherine station. When assessing the clients from Morrow Pauls, where should the nurse fingers be placed?

Into the inguinal area

The nurse is to give a manyoux test For Tuberculosis. The test is administered via a

Intradermal injection

A client returns after transurethral resection of prostate and is on continuous bladder irrigation. He tells that he feels that need to void. The most appropriate nursing action is

Irrigate the catheter

The attending physician has requested a PT prothrombin time time and has asked you to counsel the patient's spouse on the procedure. The clients PT findings are greater than 80 seconds how do you explain the test?

It is a measure of clotting ability and the clients clotting time is abnormally extended

Your client taking RIFAMPIN complains of red colored urine which of the following response of the nurse is correct?

It is a normal effect

Anthralin Is prescribed by a client with psoriasis. Which of the following information given by the nurse is incorrect?

It is a vitamin a derivative

A nurse is giving discharge instructions to a diabetic client, who has to take insulin at home regularly, regarding storage of insulin. Which of the following instructions is correct?

It should not be kept in direct sunlight

A nurse is caring for a client who is pregnant and has a torch infection which of the following findings should the nurse expect? Select all that apply

Joint pain rash Decreased appetite

A client has undergone total hip replacement and returns to the recovery room. What postoperative care should be given by the nurse?

Keep pillows between the legs

A nurse is preparing to assist a client into bed using the log roll method. Which of the following is indicated when assisting a client to use the log roll method to get in or out of bed safely?

Keep the client shoulders and hips together as a unit

Which Nursing instruction about heating pads is essential to include in the clients teaching plan?

Keep the heating pad on the low setting

Which leadership style leaves decision-making to the group, with the leader providing little or no feedback or guidance?

Laissez-faire

A physician orders blood transfusion for a client. Which of the following intravenous device should the nurse to use for transfusing blood?

Large bore catheter

A nurse is preparing to perform a non-stress test. Which position with the nurse recommend that the client be placed in?

Lateral position

A nurse is preparing to perform sectioning In an unconscious client. Which of the following position should the nurse play the client?

Lateral position

A nurse is preparing a client for a lumbar puncture to which of the following positions well the nurse assist the client?

Lateral position with head and neck flexed

A nurse is preparing a client for a lumbar puncture. Which of the following positions with the nurse provide to the client?

Lateral position with head and neck flexed

A nurse is checking For a pulse any client who is recovering from anesthesia after surgery. She checks the dorsalis pedis pulse. Which is the best description of the location?

Lateral to the tendon on the top of the foot

A nurse is caring for a client in preterm labor who is scheduled to undergo amniocentesis to evaluate fetal well-being and loan maturity. Which of the following test does the nurse understand will be used to assess feed a long maturity?

Lecithin/sphingomyelin (L/S) ratio test

A nurse is teaching can walk into a client with right sided weakness. The nurse should instruct the client to hold the cane with:

Left hand

A nurse is caring for a client with pregnancy - induced hypertension who is scheduled for a cesarean C-section. In which position should the nurse place the client before she is transferred to the delivery suite?

Left lateral

A nurse is preparing to administer an enema to a client. Which is a fun position should the nurse put the client in?

Left lateral

A nurse is preparing to administer glycerin suppository to a client. Which of the following position is to be given?

Left lateral

While assisting a client with right sided hemiparesis To ambulate, the nurse should stand on the clients:

Left side and hold one arm around the client waste

A nurse is preparing to insert a rectal tube and a client with abdominal distention. Which of the following positions show the client be placed in?

Left side recumbent

A client on assisted ventilation develops a right tension pneumothorax. Which of the following is associated with a right sided tension pneumothorax?

Left sided tracheal deviation

A nurse is teaching a client about manifestations to report to the provider while taking oral contraceptives. Which of the following manifestations to nurse instructed client to report?

Leg pain

The nurse must be extremely Careful and protecting the client with leukemia from any source of infection primarily because:

Leukemia seriously affects the blood forming system WBCs as its ability to ward off infection

A nurse is reviewing laboratory results of a client who has a WBC count of 20,000. The nurse should identify that the client has which of the following conditions?

Leukocytesis

The nurse should know that the drug that can be safely administered during pregnancy:

Levothyroxine

Acetaminophen is contraindicated in which of the following conditions?

Liver dysfunction

A nurse is discussing the routine follow-up needs with a client who has a new prescription for valproic acid to treat bipolar disorder. The nurse should provide written instructions to the client about the need for routine monitoring for each of the following?

Liver function

A client with multiple sclerosis is being treated with Dantrium. Which laboratory results should be monitored by the nurse to know whether the client is experiencing adverse reaction to this medication?

Liver function test

Acetaminophen Is one of the most widely used pain medications. You've been asked to cancel a client on one major long-term side effect. Which of the following applies?

Liver toxicity

A nurse is reviewing laboratory results of a client with diagnosis of Cirrhosis of the liver and notes that the serum ammonia level is elevated. Which of the following dietary advice should be given by the nurse?

Low protein diet

Your doctor orders Trendelenburg position to a client. The nurse should place the client and which of the following position?

Lower the head of the bed and raise the feet in straight incline

The nurse is administering a tap water enema when the client begins to complain of a domino cramping the nurse should:

Lower the height of the enema container

A pregnant client of 30 weeks gestation got admitted to prevent preterm birth. Which of the following medication should the nurse expect to administer?

Magnesium sulfate

When implementing seizure precautions, which nursing action is most appropriate?

Maintain the clients bed in the lowest position

Anders is caring for a client with a decubitus ulcer. The nurse would do all of the following except:

Massage affected area

A nurse is giving teaching regarding permanent artificial pacemakers. Which of the following statements of the client indicates the need for further teaching?

May engage in contact sports

The LVN is admitting a client to the unit. When asked whether the client has any religious preferences or concerns, the client identifies with the Jewish faith and reports following a strict kosher diet. The LVN knows that this means that the client cannot eat :

Meat and milk in combination

The nurse is caring for a client with a kidney stone who is writhing in pain which of the following is the priority nursing intervention?

Medicated for pain

The nurse is caring for a client with a kidney stone who is writhing in pain. Which of the following is the priority nursing intervention?

Medicated for pain

Handwashing is crucial in preventing the spread of infection's. This practice breaks the chain of infection during which phase of the cycle?

Method of transmission

A client is in ovo- vegetarian. Which of the following food items should not be kept in the clients tray?

Milk

The client has three of the four lobes of the parathyroid gland surgically removed. After the client returns from surgery and resumes eating the nurse should encourage the client to eat food from which food groups?

Milk and cheese

A nurse is trying to interview a client who is cognitively impaired. Which of the following activities would be most appropriate for communicating with the client?

Minimize distractions in the environment

The client describes his pain as six in America rating scale. The nurse should identify that his pain is

Moderate

In nurses caring for a client who has leukemia and thrombocytopenia. Which of the following action is the nurses priority?

Monitor the clients platelet counts

A client diagnosed with pancreatitis complains of pain. The nurse should know that the pain medication contraindicated in pancreatitis is:

Morphine sulphate

The nurse is caring for a client who is confused, getting out of bed, and wandering the halls. The most important intervention for this client is to:

Move her closer to the nurses station and increasing observation time

And nurse is teaching a client about using a walker. Which of the following instructions is correct?

Move the walker first and then walk

In which of the following conditions can the nurse provide heat application to the client?

Muscle spasm

An older adult diagnosed with Parkinson's disease is admitted to a nursing home for basic nursing care. The nurse educator provides an in-service program about Parkinson's disease. Which clinical manifestation is the educator most likely to include at the initial sign of Parkinson's disease?

Muscle tremors

A client is admitted with respiratory failure. The nurse is expecting possible development of respiratory acidosis in the client. Which of the following symptoms should the nurse observes for?

Muscular twitching

If the client worked at the following occupations, which one is most likely to have contributed to hearing loss?

Musician

Drugs which dilate the pupil are called:

Mydristics

Which of the following is an incorrect statement regarding handling of computerized client records?

Names and passwords to be displayed clearly and nurses station

An adult is admitted to the hospital with a head injury following an accident. He has a severe headache and is asking why he cannot have pain medication. Which of the following explanations offered by the nurse is correct related to narcotic analgesics?

Narcotics my decrease respirations, leading to acidosis and further brain damage

To implement procedures correctly, the nurse must understand the difference among various invasive procedures, that is, which can be carried out using clean technique. Which of the following procedures does not require sterility of equipment and solution used?

Nasogastric feeding

The expected effect of hydroxyzine is to decrease:

Nausea and vomiting

An older adult diagnose a Parkinson's disease is admitted to a nursing home for basic nursing care. The nurse initiated teaching plan for the clients with Parkinson's disease. Which instructions should be the nurses priority in the situation?

Need to remove all safety hazards

A staff member was given a tuberculin Skin test two days ago and now has a red and area 15 MM in diameter without induration. The nurse correctly identifies the test as:

Negative. Redness without induration is of no significance

A clients family member visit in the hospital you in a report to the nurse at the client fell down while walking because no one answered the call for assistance to the bathroom. Which of the following terms describes the staff's inaction

Negligence

The client tells the LVN caring for him that he is feeling more short of breath than usual. The LVN listen to the clients chess with the sides that the patient sounds the same as he did a few hours previously. The LVN is due to go on break. He tells the client that he will check on him when he returns from his break. 15 minutes later the client develops fulminant pulmonary Adema Which requires that the client is transferred to the ICU. In this case, the LVN could be found guilty of:

Negligence

And expectant mother test positive for chlamydia in her ninth month of pregnancy. She asked why she should be treated so she doesn't have any symptoms. The nurse explained she needs treatment to prevent complications due to the risk of which of the following conditions:

Neonatal ophthalmia

And adult female clients systolic blood pressure has risen from 80 to 115 MMHG following treatment and diet changes and has remained constant overtime. Should this caused immediate concern?

No it is within normal

A client with chronic pancreatitis has an order for CREON. The nurse should know that

Not to chew the drug

A nurse is preparing to administer a unit of blood to a client. I'll check in the vital signs, nurse identifies elevated body temperature. What should the nurses initial action?

Notify the physician

The physician orders hourly you earn I'll put measurement for a postoperative client. The nurse records the following amount for two consecutive hours 20 mL and 25 mL what may be the next nursing action?

Notify the physician

A client is being transferred to a larger hospital for testing. The receiving hospital is requesting copies of all the tests performed today, as well as a copy of the clients medication list and the history and physical dictated by the clients position. The nurse should:

Obtain client authorization before faxing any of the requested documents

A nurse has the following task to complete. Which one can see appropriately assigned to a CNA?

Obtain routine vital signs and a group of clients

A client who requires special eating utensils should consult which of the following healthcare personnel?

Occupational therapist

When the nurse observes a client having difficulty swallowing a capsule of medication, which nursing action is best to take?

Offer water before giving the capsule

In which of the following conditions should a nurse not respond call temperature/ice application to the client?

Open wounds

A nurse is teaching a client who is pregnant about a new prescription for iron supplements. With which of the following beverages should the nurse instruct the client to take the iron supplement?

Orange juice

A physician has prescribed iron supplements for an anemic client. The nurse should instruct the client to take the medication with:

Orange juice

A low sodium, high potassium diet has been ordered for a client. Which of the following menu selection is most appropriate for this client?

Orange juice, baked chicken, and a cucumber tomato salad

A clients physician has recommended that the client increase her daily intake of dietary iron which of the following menu selections would suggest to the nurse at the client understands recommendations?

Orange juice, toast and scrambled eggs

The practical nurse knows that all the following are true about tubal ligation As a form of birth control except:

Ovaries and tubes will be removed during this procedure

The practical nurses working in a prenatal clinic. The nurse knows that the following is true about ovulation:

Ovulation typically occurs on day 12 to 16 before the start of the next menstrual cycle

A client with a pyloric Obstruction is admitted to the hospital with vomiting. Which of the following blood gases with the nurse expect to see in the client with vomiting?

PH 7.47, PCO 240

Nurses care for a client who is withdrawing from alcohol and has a new prescription for propranolol. What of the following affects does the nurse expect as a result of this prescription?

PROPRANOLOL reduce his symptoms caused by central aDRENERGIC stimulation

A nurse is in certain it is a gastric too. Which of the following indicates proper placement of the tube in the stomach?

Page of aspirate is less than 6

A woman arrives on the obstetrical unit Reporting that her water broke and she is in labor. Which of the following symptoms and the kids the presence of placenta previa?

Painless bright red vaginal bleeding

A nurse is assessing the Patsy of a clients left arm arteriovenous fistula before hemodialysis. Which finding indicates that the fistula is patent

Palpation of a thrill over the fistula

The physician orders that the client may be out of bed to a chair. How should the nurse position in the chair to facilitate transfer in the client from the bed

Parallel with the bed

The nurse is preparing to give an adult he said cutaneous injection of heparin. Which of the following should the nurse checked prior to administering the heparin?

Partial thromboplastin time

A client is concerned that her overbearing, younger sister will have the final decision making authority on her end of life care. Which of the following statue ensures the clients right to direct her own care decisions?

Patient self-determination act

A four-month-old infant with developmental dysplasia of hip needs which of the following?

Pavlik harness

Nurses providing dietary instructions to a client with hypertension. Which of the following should the nurse recommend to the client?

Peach

Which of the following exercise the nurse can recommend to a pregnant woman with back pain?

Pelvic rocking

The nurse is extremely busy and all of the following tasks need to be completed. Which of the following Tasha the nurse assigned to a CNA?

Performing hygiene care for a patient who has had a CVA

The charge nurse enters the nursing diagnosis of risk for effective airway clearance related to an inability to swallow, on the care plan for a client with a tracheostomy. Which nursing intervention is most appropriate for managing the identified problem?

Performing oral suction

The nurse witness is a very pregnant woman choking during lunch after verifying that the woman needs help the nurses should do the following

Place one fist at the med sternum and use the other hand to provide in word chest thrusts

The client was admitted to the ER experience seeing grandma seizures. He was placed on seizure precaution. The nurse knows that an appropriate intervention for a grand mal seizure is:

Place the client in a lateral position

Nurses assisting with planning care for a client who is having a vertebral plasty of the thoracic spine. Which is a foreign intervention should the nurse recommend to include in the plan of care

Place the client in a supine position

A client admitted to the floor three days ago after a bowel Resection suddenly developed chest pain and shortness of breath. Assessment of the client reveals rails, BP 160/40, and severe tachycardia. The nurses first action should be two:

Place the client in high Fowlers position

When a client with a slow bleeding cerebral aneurysm asked for assistance to the toilet for a bowel movement, Which nursing response is appropriate?

Place the client on a bedpan

A typical eight-year-old girl will prefer to

Play with other girls her age

A nurse is performing an examination of a pregnant client in labor the nurse notes the umbilical cord protruding from the vagina. Which of the following is an initial nursing action?

Please client in Trendelenburg position

To determine standards of care for an institution, the nurse should consult which of the following?

Policy and procedure manual

The most common cause of nosocomial infection in the hospital is

Poor handwashing

A urinalysis is performed on a client suspected to have bacteriuria. Which of the following test is a common indicator?

Positive dipstick for leukocyte esterase or nitrates

A 25-year-old woman at 30 weeks gestation came to the outpatient department. Which of the findings by the nurse would indicate a possible complication?

Positive urine test for glucose and Ketones

They hospitalize client in heart failure receives for us of mine Lasix twice a day. As a nurse manager of the clients laboratory test values, which one should be reported to the physician immediately?

Potassium 3.0 mEq/L

A nurse is caring for a client with diarrhea which of the following diet the nurse what advice?

Potassium containing diet

A client with gout is discharged from the hospital. Which of the following might be described the dietary regimen on discharge from the hospital?

Potatoes, milk, increased fluids

A nurse is caring for a client who is pregnant and experiencing back aches. Which of the following Measures should the nurse tell the client to take to help relieve back aches? Select all that apply

Preform the pelvic tick exercise everyday Position the knees higher than the hips when sitting

And nurses teaching a client who has a new prescription for TIMOLOL ophthalmic drops. The client asked why she should press on the Nasolacrimal Duct when administering the drops. Which of the following response should the nurse make?

Pressing on the desk will prevent medication from being absorbed into the body

A client who underwent above the knee amputation has a pillow place along the outside of the infected side tie. The nurse should know that this is to

Prevent X ternal rotation

A nurse is caring for a client who has just undergone a surgical procedure. The nurse understands that assisting the client to take deep breath and cough is important for which of the following reasons?

Prevent atelectasis And clear secretions

An 18-year-old client sustained a compound fracture of the left tibia while skiing and is admitted to the ER. The rationale for cleaning the wound from the area least contaminated to the area of greatest contamination is to:

Prevent introduction of organisms into the wound

A postoperative client has an order for Zofran. The nurse should know that it is given to

Prevent vomiting

The nurse correctly identifies that the most important need for the client with left hemisphere infarction is:

Prevention of injury

Privacy and confidentiality our principal components of the right of patients and clients. Which of the following statements correctly distinguishes between both, respectively?

Privacy is the right of individuals to keep information about themselves from being disclosed; confidentiality is how the nurse and other care team members treat private information once it has been disclosed

Privacy and confidentiality our principal components of the right of patients and clients which of the following statements correctly distinguishes between both respectively:

Privacy is the right of the individuals to keep information about themselves from being this close; confidentiality is the how nurses and other care team members treat private information once it has been disclosed to them

A client at 28 weeks gestation has been admitted to the obstetric unit for preeclampsia. Her blood pressure has been ranging from 140/100 to 160/110. She has 3+ proteinuria and Generalized edema, and has been complaining of a headache. Which care environment would be most appropriate for this client?

Private room, bed rest with bathroom privileges, vital signs with fetal heart tones every four hours, regular diet

And adult client is admitted to the hospital with gastroenteritis. The physician has ordered prochlorperazine 10 mg PO three times a day PRN or prochlorperazine 5 mg suppository every six hours PRN and loperamide 2 mg POPRN. The client has an episode of diarrhea and complains of nausea. What should the nurse administer

Prochlorperazine po and loperamide

A nurse reviewed the clients laboratory reports and notes at the serum calcium level is 5.2 MG/DL which is low. Which of the following with the nurses note on the electric cardiogram base on the laboratory value?

Prolonged ST interval

Hey sequential compression device is apply to a client after hip replacement. The nurse should know that the device is used to:

Promote venous return

All of the following are true about warfarin Coumadin except?

Protamine sulfate can be given as an antidote for warfarin

A nurse is caring for a client that are going preoperative assessment for tonsillectomy the next day. Which of the following laboratory tests does the nurse expect the surgeon to assess in this client?

Prothrombin time

The nurse is contributing to the plan of care for a client who has hepatitis B with jaundice. Which is a fun intervention should be the nurse recommend

Provide high calorie, high-protein diet

Hey 75-year-old client has a prostatectomy For cancer of the prostate. After surgery, which nursing action is essential to include in the clients care plan?

Provide perineal care after each bowel movement

A nurse is caring for a client with cervical disc herniation. Which of the following measures can reduce muscle spasms in the cervical region?

Providing hot application

The LVN is performing preoperative teaching an assessment. Which of the following would be the lowest priority in terms of assessment?

Psychological functioning

A nurse is preparing to administer your drops to a two-year-old child. The nurse should "

Pull the pinna down and back

After an oral surgery or radical neck surgery, hemorrhage can occur. What may be the most immediate nursing action if this occurs?

Put pressure over blood vessels in the neck

A client who is receiving hydantoins (Dilantin) Reports to the nurse that his urine is pink. What action should be taken by the nurse?

Reassure the client that this occurs often people who are taking theDilantin

An elderly client is severely dehydrated. Which of the following is the best way for The nurse to assess the effectiveness of fluid restoration therapy?

Record the clients weight daily

The nurse should instruct the client with uric acid can you some Subway which of the following foods?

Red meat

A client with rheumatoid arthritis has a prescription of acetyl salicylic acid. The nurse should know that it is to

Reduce inflammation

They are in charge nurse gives the LVN a syringe filled with medication that they are in his just drawn up and asked the LVN to administer this to a client. What is the best response by the LPN?

Refused to administer the medication

An adult is receiving chemotherapy for cancer. Metoclopramide (Rehlan) is also prescribed. The client wonders why she is receiving the Reglan what is the best way for the nurse to respond?

Reglan helps to prevent any nausea and vomiting that may occur as a side effect of your other medication

The nurse caring for a client with osteoarthritis knows that the following is true about regular exercise:

Regular exercise helps to move synovial fluid through the Cartlidge

A nurse witness is a motor vehicle accident and stops to provide emergency assistance to the injured motorists. To reduce the risk of liability, which of the following is most appropriate action for the nurse to take?

Remain with the accident victim and tell paramedic arrive

The nurse is providing home care to a blind client which of the following safety precautions is most appropriate for this client?

Remove all throw rugs

A nurse prepares a client for magnetic resonance imaging MRI city of Breen which of the following nursing intervention should be done?

Remove or document all metal objects worn on/in the body

And if you notice the smell of alcohol and colleagues breath while working. The LVN should:

Report suspicions of alcohol use while working to the nursing supervisor

The LVN arrives to work and is told that she must report to the TELEMETRY unit for the day because the unit is understaffed. The LVN has never worked on this unit before and it's never been trained in reading the monitors. What is most appropriate action?

Report to the Telemetry Unit and identify tasks that the LVN can safely perform

A pregnant client in the third trimester calls the OB office and report to the nurse that she has had a severe headache for the past two days what nursing action is most appropriate?

Request that the client come to the office immediately

Nurse is caring for a client who has severe preeclampsia and is receiving a magnesium sulfate IV infusion. The nurse should monitor the client for which of the following manifestations as a sign of magnesium sulfate toxicity? Select all that apply

Respiratory rate less than 12/min Decreased level of consciousness

The nurse is assessing a client on antibiotic therapy. Examination reveals swollen lips and tongue. Which of the following may have caused the clients current condition?

Response to antigen

A nurse is assessing a four-year-old child who presents with his parent for evaluation of a cough that kept a child up all night. Select all the assessment findings that should lead the nurse to suspect respiratory distress in a four-year-old. Select all that apply

Restlessness Use of accessory muscles Sweating in a cool environment

Which technique should the nurse plan to use one giving perineal care to an uncircumcised mail client

Retract the foreskin; the wash the glans penis

A nurse is administering a lipid emulsion parent Terrell nutrition PN solution to a client and no it's a layer of fat floating in the IV solution bag. Which of the following actions should the nurse take?

Return the bag to the pharmacy

A client Rh Antibody tighter indicates that she has not been sensitized to the RH factor. The nurse should anticipate that which of the following will be given after the delivery?

Rho (D) immune globulin (RhoGAM)

Which of the following is not considered a client right?

Right to know the names and addresses of the persons caring for them

A client with hypertension is taking DILTIAZEM. Which of the following instructions should the nurse gift to the client?

Rise for me sitting or standing position slowly

A nurse is performing an assessment on a client with congestive heart failure. Which of the following abnormal sound might be expected on auscultation of the heart?

S3 ventricular Gallup

A French chairs with a nurse about being engaged to be married. The nurse knows that the friends fiancé us as a positive for HIV. What is the nurses legally obligation to do?

Safeguard information in the fiancé's history of health

A friend shares with a nurse about being engaged to be married. The nurse knows that the friends fiancé has tested positive for HIV. What is the nurses legally obligation to do?

Safeguard information in the fiancé's history of health

The nurse is caring for a cardiac client with an elevated serum cholesterol, the nurse should reinforce the dietitians instructions to decrease

Saturated fats

The client is receiving valproic acid for seizures. The nurse knows that one of the common side effects of this medication is:

Scalera yellowing

The practical nurse is caring for a client who has been receiving factor VIIII concentrate. The nurse should be concerned about the risk of hepatitis if the client exhibits:

Sclera yellowing

When providing nursing care for client after is sub total thyroidectomy which position is best?

Semi Fowler's

A client has an intracranial pressure of 22MMHG high. The nurse would position the client in?

Semi Fowler's position

A nurse is caring for a 10-year-old child who has a cute post shift a cockle glomera loaf nephritis a APSGN. Which of the following findings is the priority of the nurse to report to the provider?

Serum creatinine 1.3 MG

The physician has ordered fludrocortisone acetate (Florinef) For a client. What blood test with the nurse expect to be ordered while the client is receiving this medication?

Serum electrolytes

A nurse is caring for a child who has short stature. Which of the following diagnoses test should be completed to assess growth hormone deficiency?

Serum insulin like growth factor 1 (I GF-1)

The client is taking Streptomycin, Isoniazid, and rimactsne. Which of the following indicates toxicity to usoniazid

Sharp pains in the legs

A nurse should know that a client who is allergic to intravenous contrast agents may be allergic to

Shellfish

The nurse is caring for a client with Graves' disease. Which finding would indicate a complication of the clients disease?

Shortness of breath

The practical nurse is working and the gynecologist office. The nurse knows that a Pap smear:

Should be done beginning at age 21 unless otherwise indicated

A client is receiving chlorpromazine to treat his Psychosis. Which of the following indicates he is experiencing pseudoparkinsonism?

Shuffling gait and tremors

And adult client who has low back pain will most likely be most comfortable in which of the following positions:

Sideline with the knees flexed

A nurse is documenting the clients condition. Which of the following can be done during the documentation?

Signing and titling each entry

Which of the following position is given to a client for examination of Repton?

Sims

A client begins to fall during ambulation. To prevent client from injury, the nurse should:

Slide the client down nurses body to floor

A 48-year-old client has a diagnosis of dumping syndrome after gastric surgery it would be most important for the client to:

Small frequent meals

A client with seizure has a prescription for taking phenytoin. The nurse should instruct the client to report which of the following?

Sore throat

Your mother asked the nurse what toy might be appropriate for her four month old child. The nurse knows that the most appropriate toy would be

South washable toys

Well transferring a client from bed to chair how should the nurse position themselves

Space in the feet further apart

To increase stability during client transfer, the nurse increases the base of support by:

Spacing feet further apart

When monitoring the treatment responsive a client with diabetes insipidus, which component of the urinalysis is most important for the nurse to assess?

Specific gravity

A client with stroke has dysphasia. Which of the following healthcare personnel is responsible for testing swallowing and finding out what the possibilities of aspiration?

Speech language therapist

A client is discharged after diagnosis of iron deficiency anemia. Which of the following dietary food should be suggested by the nurse?

Spinach

Inverse is caring for an unconscious client. Which of the following should the nurse used to prevent risk deformities?

Splint

Interest is caring for a client was experiencing chest pain. The nurse should identify that which of the following characteristics distinguishes of China from a myocardial infarction?

Stable Adina is relieved with rest and nitroglycerin

A nursing assistant voice his concern for personal safety when assigned to care for a client with aids. Which information from the nurse is best for Allaying the nursing assistance fears?

Standard precaution can prevent HIV transmission

The preoperative teaching for prevention of postoperative complications include leg exercises. The nurse teaches leg exercises preoperative to gallbladder surgery to help prevent:

Stasis and clot formation

When is schizophrenic client claims to see demons in the room, what is the best documentation the nurse should make for the record?

States, seeing demons in my room

A nurse is caring for a bed ridden client. Which of the following complaints of the client indicated that he is developing a complication related to immobility?

Stiffness of new joint

A client is receiving a blood transfusion. After 30 minutes, the client develops seven fever. Which of the following is the most appropriate initial response of the nurse?

Stop the transfusion

A nurse is caring for a client who states I have been under a lot of stress lately as a result of financial problems which of the following is a true statement regarding stress

Stress is a response to the situation that is seen as threatening to a person's well-being

Surgical wound infections are the second most frequent type b of nosocomial Infection found in hospitals. Health personnel could best reduce these infections by:

Strictly adhering to the principles of effective handwashing

A nurse is auscultating the lungs of a client. Which of the following should be immediately notified to the physician?

Stridor

An infant is delivered after a rapid labor and delivery. The mother requested infant be allowed to stay with her for as long as possible before being taken to the nursery. What nursing action takes priority in the immediate newborn.?

Suctioning with a bulb syringe

A nurse is teaching a client who has schizophrenia about strategies to manage the anti-call allogenic effects of FLUPHENAZINE. Which of the following strategies should the nurse include?

Sugarless gum to moi's in the mouth

A nurse is teaching the parents of an adolescent who has a new prescription for desipramine To treat depression. Which of the following adverse effects should the nurse instructed the parents to report to the provider mediately?

Suicidal thoughts

The nurse is caring for a pregnant client who is in labor and receive an epidural anesthesia. Which position should the nurse avoid and positioning this client?

Supine

The client is admitted with vertebral injuries and cervical traction. Which of the following position should the nurse place the client in?

Supine position

A nurse is caring for a client who is on a mechanical ventilator and who receives nutrition through a feeding tube. Which position should most likely reduce the risk of this client develop an aspiration pneumonia?

Supine with the head of the bed elevated 30 to 45°

The client has an order to take supplemental iron for anemia. The nurse knows that the client should take iron with:

Supplemental vitamin C

The client reports a Keto and cramping in her calves when she is walking for exercise. An activity that the nurse might suggest to the client to prevent this pain is

Swimming

A 55-year-old client is currently being treated with albuterol for an acute asthma episode. You notice the clients breathing and pulse rate has increased dramatically. Which of the following adverse effects is most likely occurring?

Tachycardia

A nurse is assisting a physician who is removing a client central line. Which of the following to the nurse tell the client to do as the physician remove the catheter?

Take a deep breath and hold it

Which of the following instruction should the nurse give to a client taking Lugol's solution?

Take medication with juice

A nurse is caring for a client with a hemodialysis shunt AV fistula in his right arm. Which of the following is a correct measuring action when caring for the client?

Take the blood pressure in the left arm

And nurses teaching to client about the intake of the drug LEVOTHYROXINE. Which of the following instructions correct?

Take the drug an empty stomach

A nurse is providing teaching to a client who has a new prescription for levodopa to treat Parkinson's disease. Which of the following statements should the nurse include in the teaching?

Take this medication with food

A nurse is reinforcing teaching with a client who has psoriasis and is to receive for chemotherapy and ultraviolet light therapy which of the following instruction should the nurse include in the teaching?

Taking PSORALEN medication two hours before the scheduled light treatment

A nurse is performing an assessment on a client who has a PICC line place in his left arm for infusion therapy at home. The nurse uses the clients right arm to measure blood pressure. Which of the following best describes reason to take the clients blood pressure measurements in the right arm?

Taking a blood pressure over a PICC line can cause damage to the van or formation of a blood clot

Which activity should be encouraged during menstruation?

Taking over-the-counter pain medication for cramping

Which of the following action is most likely to create a sense of empowerment and a newly diagnosed diabetic client

Teaching the client to check their own blood glucose levels

Preoperatively, which information is important to teach the client before the sub total thyroidectomy?

Technique for changing positions

A client in the hospital has an order for triazolam Halcion 0.25 mg at hs. When the nurse take some medication to the clients room, the client asked the nurse to leave it at the bedside because she is still visiting with her family. What is the best action for the nurse to take?

Tell the client to call when she is ready for the medication

A nurse is taking care of a man and a semi private room. When a new client arrives and is admitted to the room he asked the nurse what's his problem? The best response for the nurse is which of the following:

Tell the man all clients diagnoses are confidential

An LVN is assisting in the emergency room and a real hospital following an accident that brought multiple victims into the ER. They LVN has been assigned to assist with a badly injured client. Which of the following injuries should take priority?

Tension pneumothorax

A client is admitted complaining of epigastric pain that he described as burning and nine after meals. I guess your culture is a likely diagnosis. Which of the following is true concerning diagnosis of gastric ulcer

Testing forH. Pylori infection is essential in all client with peptic ulcer disease

A nurse is preparing to start an IV on her client and has found a vein that she believes will work well. The client asked the nurse where she was planning to start the IV and the nurse replies I'm going to use your cephalic vein. Which location best describes this vein?

The anterolateral aspect of the forearm near the antecubital fossa

A client receiving blood transfusion develops transfusion reaction. The nurse should send the blood bag and tubing to which of the following departments?

The blood bank

And 18 month old is admitted for repair of a fractured femur and is placed in Bryants traction. Which finding by the nurse indicated that the traction is working properly

The buttocks are 15 degrees off the bed

A client underwent transurethral resection of prostate and has a triple lumen indwelling catheter and isn't continuous bladder irrigation. The nurse notes that the 1000 ML's of fluid was instilled in 600 ML returned. The nurse should understand that:

The catheter is occluded

When caring for a child with hemophilia, which assessment findings should the nurse report to the physician?

The child has discomfort from joint pain

A nurse at a long-term care facilities preparing to administer medication to a client. Which of the following client identifiers should the nurse used to identify the client?

The client did a birth

A nurse is reviewing the medical record of a client who has a new prescription for BUPROPION to treat major depressive disorder. Which of the following findings is the priority for the nurse report to the provider?

The client had a motor vehicle crash last year and sustained a head injury

A woman who is in labor is being treated for pre-eclampsia. How can the nurse determine if the woman develops eclampsia

The client has a seizure

When I nursed cares for a client with nasogastric tube immediately after gastric surgery, which of the following is essential to report to the charge nurse or physician?

The client has bright red drainage in the tube

An adult client in acute care hospital asked the nurse to see his chart. The nurse bases her response on which of the following statements regarding clients record:

The client has the right to see his record and to have information that he does not understand explain to him

A clients blood pH has recently fallen to 6.0 which of the following accurately describes the clients medical state?

The client is acidotic

A home health nurse is providing care to a frail elderly client in the client's home. Which of the following should the nurse report to her supervisor as a potential indication of abuse?

The client is frequently left in bed, at home alone, for several hours at a time

A nurse assist the physician for a lumbar puncture. Which of the following is the most appropriate client position for this procedure?

The client is in the side lying position with the knees drawn up and back flexed

A nurse is working with a client who is experiencing severe anxiety after an injury that occurred at work. Which of the following is a clinical manifestation the nurse expects in a client with severe anxiety?

The client is placed in the hallway and tells the nurse he has a feeling of impending doom

A nurse is assigned to care for four clients which of the following clients with the nurse check first?

The client on ventilator

Which of the following would be most important to include in a change of shift report?

The client required to breakthrough doses of pain medication and eight hours

All of the following are true about hip replacement except:

The client should not lift more than 4 pounds

A home care nurse is assessing an elderly client in his home for the first time. The client was referred by concern family members who worried that the client who lives alone, is at risk for a fall which of the following is the most important factor in fall risk in the elderly?

The client takes seven different medications that are packaged and delivered by the neighborhood pharmacy, and some of them cause drowsiness

A 75-year-old client comes to the diabetic clinic for a scheduled visit. We're just been fighting and the kids at the client with diabetes requires additional teaching?

The client trims calluses with a nail clipper

Which goal is most appropriate when the nurse managers to care for an older adult client who has osteoporosis?

The client will ambulate without falling

Informed consent may not be needed if:

The clients life is in immediate danger

The nurse is working on an oncology unit and is caring for a client with radium implant. The nurse knows that the following is true about the client receiving this treatment

The clients nurse or restrict time in the room to 30 minutes

A nurse is caring for a 19-year-old client who would like to get a prescription for an oral contraceptive. She is covered under her parents insurance but does not want her parents to know that she is asking for birth control. According to HIPAA rule, which of the following should the nurse tell the client concerning her parents write to her health information?

The clients parents may not be the medical record but may learn from the prescription from their insurance billing receipt

A nurse working in a rural care facility cares for a client of all ages. The nurse understands that the age group at highest risk for death from a fall and which of the following?

The elderly

A nurse is performing an initial home visit to an infant born three days ago. Which of the following findings should prompt the nurse to speak to the primary care provider who is caring for the mother in infant?

The infants anterior fontanel is bulging

The nurse is treating a client who has been exposed to anthrax on his hands resulting in skin lesions on his hands. The nurse knows that:

The lesion on the clients hand may form eschar that will fall off in about 10 days

At 10 AM on the first post partum day, the nurse notes that his clients fun this is firm and that there is a continuous flow of vaginal blood with no clots. As she gets out of the bed, the client notices a gushing from her vagina and pass is a small blood clot. She become scared the nurse should explain to her:

The lochia The pools into the vagina while she is lying in the bed drains when she stands

When discussing disease, incidence is defined as:

The number of new cases in a period of time

A client requires gastric decompression. Immediately after a Salem some tube is inserted, which nursing action is correct?

The nurse checks the two for proper placement

A nurse is caring for a client diagnosed with COPD. Which of the following actions of the nurse indicated violation of client confidentiality?

The nurse discusses about the clients condition with a relative over the phone

A nurse prepared morning medications for the client and then was called off the unit for an emergency before he was able to administer them. Who made administer the medication to the clientsnow?

The nurse who prepared the medications

When a hospitalized client diagnosed with Graves' disease is scheduled for a sub total thyroidectomy what is the best reason that the nurse omits palpating the thyroid gland?

The nurses actually can cause a thyroid storm

A nursing assistant is asked to care for a five-year-old child with a cute lymphoblastic leukemia. Which of the nursing assistance action indicates the additional teaching is needed?

The nursing assistant assesses the child's temperature rectally

The nurse observes a nursing assistant Assign to a client who just returned from having a bronchial scope. Which action by the nursing assistant would prompt the nurse to intervene?

The nursing assistant offers a client some water

A nurse reading medication order IV HydroCortisone stat the nurses next action should be based on the knowledge that:

The order should be clarified with the physician

After an upper G.I. x-ray, which of the following is most important for the nurse to monitor?

The passage of stool

If you're my client is currently being prepared for surgery, and you have been monitoring her vital signs. You deserve that her hemoglobin levels are 9G/DL. Which of the following should be told to the healthcare provider?

The patient is anemic

Who is responsible for writing do not resuscitate order?

The physician

And nursing team consist of registered nurse an LVN and a certified nurses aide. Which of the following client would be appropriate to assign to the LVN?

The postoperative client requiring twice daily sterile dressing changes

The nurse has crackles as she is osculating lung sounds on an elderly client who is bedbound. What is the best interpretation of this finding?

The presence of crackles indicate the client need to take deep breath's

A nurse is reinforcing teaching with a client who is having back pain and dysuria and has prescription for an x-ray of the kidneys, ureter, And bladder KUB which of the following statements should the nurse include?

The procedure determines whether you have a kidney stone

The nurse massages the uterus of a postpartum client. Which assessment findings is the best indication that the intended effect of this nursing action has been achieved?

The uterus becomes firm

The best time in the menstrual cycle for a woman to perform breast self examination is:

The week after menstruation

The nurse is caring for a client with pancreatitis who object to being questioned about his alcohol use. The nurse should explain to the client that the most important reason for collecting this information is that:

There is a known link between alcohol use and pancreatitis

A nurse is reinforcing teaching with a family of a client who has acute respiratory distress syndrome a RDS and is receiving VECURONIUM. The nurse should identify that which of the following statements by the family member indicated understanding of the teaching?

This medication is given to decreased resistance to the ventilator

A nurse is preparing to administer immune globulin to a client who has been exposed to hepatitis B which of the following statement should the nurse made?

This medication provided an immune response more quickly than your body can produce it

A laboring woman prefers to lie in the supine position during labor. The nurse instructed her is not a good position during labor for what reason?

This position may cause her blood pressure to drop, causing the babies heart rate to decline

A nurse is monitoring a client who is on vincristine Therapy. Which of the following symptoms should the nurse identify as a specific to vincristine administration?

Tingling and numbness in the fingers and toes

A nurse is administering Vancomycin To a client with methicillin resistant staph a caucus aureus. Which of the following is an adverse effect of vancomycin that should be reported immediately to the healthcare provider?

Tinnitus

A nurse is going through a preoperative checklist with a client who is undergoing elective surgery. The nurse understands that it is important to determine if the client has dentures or Bridges IV which of the following reasons?

To avoid damage to the dentures or bridge during the procedure

A nurse is giving dietary instructions to a client with osteoporosis which of the following instructions should the nurse include?

To increase intake of dietary products

A nurse is caring for a client admitted to the ICU who has a prescription for a footboard. Which of the following best describes the purpose of a footboard?

To keep the feet and Dorsey flexion to prevent contractures

The physician orders Dilantin and phenobarbital for a client who was admitted with a CVA. The nurse knows these drugs are administered for what purpose

To prevent seizures

A 45-year-old client receiving a kidney transplant, was in reverse isolation postoperatively. The purpose for this type of isolation is:

To protect the client from outside infections from others on the unit

And adult who has hypertension is taking Lasix and has been placed on a low sodium, high potassium die. What is the basis for the high potassium alteration to the diet?

To replace potassium loss from the kidneys

A nurse is preparing to remove nasogastric tube what instructions did the nurse give to the client?

To take deep breath and hold it

A client is experiencing neurogenic pain after spinal cord injury. Which of the following alternative therapy is most beneficial and treating this type of pain?

Transcutaneous electrical nerve stimulation

And unconscious mail client with head injury is brought to the emergency department. Surgery is required to save the life of the client. With regard to the informed consent, which of the following action should be taken?

Transport the patient to the OR for surgery immediately

An 18-year-old woman is admitted with preterm labor. The LVN over here is the clients boyfriend be radiant the client, stating that it is "her fault "that she is in the hospital. Upon entering the room, the LVN find the patient crying. The LVN ask the clients boyfriend to leave but he refuses. What legal tort can the boyfriend be charged with should he refused to leave?

Trespass to land

Which of the following laboratory test can be used to diagnose or monitor myocardial infarction specifically?

Troponin

A nurse is reviewing the laboratory findings of a client who had a myocardial infarction. The nurse should identify that which of the following cardiac enzymes can confirm the MI occurred 10 days ago?

Troponin T

Defectiveness of an ant acid increase if the medication is taken:

Two hours after other medications

A client has been given a diagnosis of hepatitis A. The nurse would use which of the following precautions to prevent the transmission of disease to self and others?

Universal precautions

A postpartum client asked the nurse how long her vaginal discharge will last. The nurses best response would be to explain that it will last:

Until the placental site has healed

Most breast tumors are found in the:

Upper outer quadrant

A nurse is reviewing the laboratory values of a client who has severe hyperemesis gravidarum. Which of the following laboratory findings should the nurse identify as a manifestation of this condition?

Urine ketones present

A 33-year-old client is undergoing peritoneal dialysis for acute renal failure. To prevent one of the most common complications of peritoneal dialysis the nurse:

Use strict aseptic technique

It is important to maintain a normal vaginal PH. The nurse knows that which of the following may change the pH of the vagina?

Vaginal douching

A client of 30 weeks gestation is diagnosed as placenta previa which of the following should not be performed by the nurse?

Vaginal examination

Dinners is preparing to insert an IV cannula to an adult client. Which of the following sites should be first selected by the nurse?

Veins in the hand

A nurse is caring for a client with COPD who has a prescription for a precise oxygen concentration. Which of the following is the best oxygen delivery system for this client?

Venturi mask

Which of the following is a responsibility of the nurse with regard to informed consent?

Verify that the physician has explained about the procedure

Which of the following is an antidote for warfarin

Vitamin K

Acyclovir 200 mg Orly five times a day is ordered for a client. The nurse should tell the client that it may cause:

Vomiting

A nurse should be aware that the best way to prevent wound infection in postoperative clients is:

Wash hands before care

The nurse is caring for an infant who has been diagnosed with sepsis. The nurse knows that the parents should do all of the following except

Wear a mask when holding the infant

A nurse is caring for a client with hepatitis A. Which of the following precautions as indicated on caring for this client?

Wear gloves when emptying the clients urinal

The nurse is providing instructions to a group of teens who are preparing to take a weekend camping trip in the woods. Which of the following essential information should be included in the teaching?

Wear long pants and long sleeve shirts to prevent tick bites

A nurse is teaching an adolescent client who has a new prescription for FLUOXETINE to treat OCD. Which of the following instruction should the nurse include?

Wear sunscreen went outdoors

The nurse is caring for a client with Reynards pnenomenon. The nurse should emphasize that the client can reduce symptoms of this disease by:

Wearing gloves when handling frozen foods

A nurse is providing diabetic teaching to an overweight client who has recently diagnosed with type two diabetes. Which of the following will have the greatest impact on achieving normal blood glucose levels?

Weight loss

A nurse is instructing a client on how to step down stairs using a cane. Which of the following is a correct advice?

What came first, Then injured leg, followed by an injured leg

A client has recently been diagnosed with diabetes and is struggling with management of her disease. She has recently come under your care due to swelling, blurred vision and weakness after self administered treatment. Which of the following is likely?

What is hypoglycemia following insulin administration

The attending physician has called for a B1 test and has asked you to explain to the family with this test evaluates. Which of the following would be an appropriate explanation?

What is the blood urea nitrogen test, often used to measure blood urea nitrogen levels, an indicator of kidney function

A nurse is caring for a client who follows a vegan diet. Which of the following food should the nurse offer the client?

Wheat toast with peanut butter

And which client care situation on a general care unit should surgical asepsis Be used?

When inserting a urinary catheter

Well assist in the physician, during which component of the exam should the nurse provide the physician with a topical anesthetic agent?

When measuring intraocular pressure

For a client with a lower respiratory tract infection, when is the best time for the nurse to perform postural drainage?

When the client has an empty stomach

A client who is in mechanical restraints ask the nurse when they can be removed. Which of the following is the best response by the nurse?

When your behaviors under control and you are no longer of a danger to yourself or others

They hospitalize client diagnosed with cancer has a sealed source of radiation inserted into the vagina. Which information is most important job team to ensure the safety of the nurse assigned to care for the client?

Whether the assigned nurse is pregnant

When teaching a female client the proper technique for cleaning the perineum before intermittent self-catheterization, the nurse will teach her to separate the labia and :

Wipe from front to back

The nursing care plan indicates that the client must be weighed every day. When direct in the nursing assistant to where the client, which instruction is most important for obtaining accurate data?

With a client at the same time each day

A client with urinary tract infection is taking SULFADIAZINE. Which of the following instruction should the nurse gift to the client?

With all the medication if a rash appears

A nurse is administering preop medication to an adult client who is scheduled for surgery. The client tells the nurse she does not want to receive blood transfusions during surgery even if they are needed since it is against her religion. The client has already signed consent for surgery how should the nurse respond?

With hold the medication and contact the clients physician

A nurse in a surgical unit becomes aware that a client who is about to undergo a surgical procedure does not fully understand the associated risks. Which of the following is the duty of the nurse in obtaining information consent? Select all that apply

Witnessing the client signature on the informed consent Acting as an advocate to ensure the client has all of the necessary information to make an informed decision

The physician orders a cooling blanket to reduce the fever of a client with meningitis. When implementing the order which nursing action is most

Wrapped a cooling blanket and a light cloth cover

An LVN is reviewing the lab results of a group of clients. All of the clients are adult females. Which of the following results should be reported to the physician immediately?

Yes you're in potassium level of 2.8

You measure an adult clients direct conjugated Bilirubin Levels and find the value to be 1.3 MG/DL. Should you be concerned?

Yes. Normal levels are 0.1 to 0.3 and increase levels may be associated with liver disease

A nurse is reinforcing medication teaching with a client who has major depressive disorder and a new prescription for a.m. I TRIPTYLINE. Which of the following information should the nurse include?

You might experience constipation while taking this medication

A nurse is providing discharge teaching to a client who is going home with a pick line. The client asked the nurse about how to shower when the PICC is in place. Which of the following response is most appropriate?

You should cover the end of the pick line with a water resistant dressing when you shower

A client arrives in the emergency department with chemical eye injury. The initial nursing action will be to?

You sterile sailing to get the eye

A nurse is reinforcing teaching with a client who is scheduled for a cardiac Catherine station. Which of the following statement should the nurse include in the teaching?

You'll need to keep your affected leg straight following the procedure

Which of the following should the nurse identify as at bedtime and the medication order

h.s.

The nurse working in a gynecologist office is positioning the client for a vaginal exam. The correct position for the exam is:

lithotomy

A nurse is reinforcing discharge Teaching with a client who has a new prescription for corticosteroid cream to treat mild psoriasis. Which of the following instructions should the nurse include in the teaching? Select all that apply

— apply thin layer of medication to damp skin -apply gloves before putting the medication on -avoid applying in skin folds -tell the provider if redness or pain increases after medication use