Comp 23

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

"I will check my oxygen equipment at least once daily."

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

- " I lost my balance and fell when I got out of bed to go to the bathroom."

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

- "Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom."

Active Shooter

- -run, hide, fight, call 911 when safe to do so

A charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

- A client who is one day post-operative following a vertebroplasty

A nurse has just received a change of shit report for four clients. Which of the following clients should the nurse assess first?

- A client who was just given a glass of orange juice for a low blood glucose level

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

- A nurse discovers that a clients family member has administered a PCA dose

A nurse is reviewing confidentiality with a group of newly nurses. Which of the following situations should the nurse as an example of breach in confidentiality?

- A nurse tells the chaplain that a client has a new diagnosis of cancer

A client is collecting nutritional data from a group of adult clients. Which of the following clients should the nurse recommend an inter-professional conference with dietician?

- BMI of 32

A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching?

-Wash the bed linens in hot water. Clean the child's toys with 1:10 bleach solution.

NGN 28 A nurse is caring for a 75-year-old client who was admitted to the medical Surgical unit.

Action 1- Assess for Homan's sign Action 2- Request a prescription for a lower extremity(something)Condition experiencing- Deep vein thrombosis Parameter 1- PT/INR and platelet count Parameter 2- Signs of bleeding ater anticoagulation indication

A nurse is reinforcing with a client who has pernicious anemia. Which of the following statements by the client indicated an understanding of the teaching

I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize

A nurse is reinforcing teaching with a parent of a newborn about home safety precautions.Which of the following statements by the parent indicates an understanding of the teaching?

I will make sure that I can fit one finger between the mattress and the side of my newborn's crib

nurse delegates a task to an AP and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?

Report the AP to the risk management OR discuss what's wrong

A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching?

- "I will use a cool mist vaporizer in my baby's room."

A nurse is reinforcing teaching about home safety with the parents of a 6-week-old infant. Which of the following instructions should the nurse include?

- - "Keep one hand on your baby's abdomen if you must turn away while he is on the changing table."

A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching

- -Information regarding client health can be emailed if encrypted

A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following clients should the nurse identify as the priority?

- A client has full thickness burns to face and trunk

A nurse in a mental health facility receives a change of shit report on 4 clients. Which of the following clients should the nurse plan to assess first?

- A client placed in restraints for aggressive behavior

A nurse is reviewing the medical records of five clients. Which of the following events should the nurse write an incident report? (Select All That Apply)

- A client received an 0900 daily medication at 1000 - A client fell when ambulating to the bathroom alone

A nurse is assisting with discharge planning for a group of clients during a mass casualty incident which of the following client should the nurse recommend for discharge

- A client who had diabetic ketoacidosis and has a blood glucose level of 120 mg/dL

A nurse is receiving a change of shit report for a group of clients. Which of the following clients should the nurse plan to assess first?

- A client who has a hip fracture and a new onset of tachypnea

A nurse is recommending a client for discharge to allow for admission of a client following a tornado disaster. Which of the following clients should the nurse recommend for discharge?

- A client who has a sodium level of 140meq/L ater one episode of diarrhea

A nurse is receiving change of shift reports from four clients. Which of the following clients should the nurse see first?

- A client who has cirrhosis and hematemesis

A nurse is receiving change of shift report on four clients. Which of the following clients should the nurse plan to see first?

- A client who has femur fracture and reports numbness of the toes

A nurse is assisting with the planning of an in service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

- A peer reviewed journal article

A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?

- A social worker who is assigned to an involuntarily committed school age client

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?

- Advance directives include a living well

A nurse is delegating client care assignments. Which of the following tasks should the nurse assign to an assistive personnel?

- Apply anti embolic stockings for a client who is 2 days postoperative.

A nurse is preparing to admit a 6-year-old with varicella to the Pediatric clinic. Which of the following actions should the nurse take?

- Assign a child to a negative air pressure room

A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

- Assist in discharging stable clients to home.

A nurse at long term care facility is reviewing the plan of care who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to assistive personnel?

- Assist the client with range of motion exercises of the hands

A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?

- Check the client's status every hour.

A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

- Complete post mortem care for a client who has died.

A charge nurse is observing a newly licensed nurse who is having difficulty finishing all client care activities by the end of his shift. Which of the following statements should the nurse make to help the newly licensed nurse improve his time management skills?

- Complete the task for one client before moving onto the next client

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?

- Determine if the client's Health Care surrogate is aware of the risks and benefits of the procedure

A nurse is assisting with the development of an education program for a group of adult clients. Which of the following actions should the nurse take first?

- Determine the literacy level of participants

A nurse on a medical surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

- Determine the medical needs of incoming clients through the emergency department

nurse is providing a client with IV fluids and finds that the IV pump screen us malfunctioning. Which of the following actions should the nurse take?

- Discontinue use and tag the IV pump

A nurse delegates a task to an assistive personnel (AP) and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?

- Discuss the AP's concerns about performing the task.

A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?

- Dry hands thoroughly from fingers to wrist

A nurse is caring for a client who has peptic ulcer disease and is schedule to undergo esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

- Ensure that the clients gave informed consent

A home health and nurse is caring for a child who has Lyme disease. which of the following is an appropriate action for the nurse to take.

- Ensure the state department has been notified

A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

- Fidelity

A nurse and an assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions?

- Flex his hips while pulling the client.

A nurse in a long-term care facility is observing an assistive personnel (AP) who is performing hand hygiene. Which of the following actions by the AP requires intervention?

- Holding his hands up and elbows down while washing his hands

A nurse is reinforcing teaching with a client about advance directives and a healthcare proxy which of the following client statements and the kids and understanding of the teaching

- I do not need to name a relative as my designee in my health care proxy

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching?

- I need to keep the cap in place for at least 6 hours after intercourse

A nurse is reinforcing discharge teaching with a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching?

- I should throw away my used tissues in a closed plastic bag

The nurse on a mental health unit is caring for a client who has anorexia nervosa. Which of the following statements by the nurse promotes the ethical principle of client autonomy

- I will only discuss your medical information with the healthcare team

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

- I will wash my baby's face with a warm, wet washcloth without soap

A charge nurse is concerned about a recent increase in facility acquired catheter infections. Which of the following actions should the nurse take first?

- Identify possible precipitating factors related to the infections

A nurse is caring for a client who has a prescription for acetaminophen 300mg with codeine 30mg, 1 tablet every 3 to 4 hr. PRN for pain. Th nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

- Incident report

A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching?

- Information regarding client health be e-mailed if encrypted

A nurse is reinforcing teaching about hand hygiene with a newly licensed news which of the following information should the nurse include in the teaching

- Interlace the fingers while rubbing hands together

A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states "I can't seem to do anything right. What should I do?" which of the following responses should the nurse make?

- Let me show you how to swaddle and cuddle him, then you try.

A home health nurse is collecting data from a client who has advanced dementia and whose caretaker recently passed away. The client is not violent or suicidal. For which of the following treatment settings should the nurse recommend a referral for this client?

- Long term nursing care center

A nurse is preparing to apply a thigh-length sequential compression for a client who is postoperative. Which of the following actions should the nurse take?

- Measure the circumference of the client's upper leg

A nurse in a long-term care facility is delegating care for a group of clients for the upcoming shift which of the following tasks the nurse delegate to assistive personnel (select all that apply)

- Measure vital signs for a client who requires contact precaution - record urine output for a client who has a super pubic catheter - trees for a client who is receiving radiation therapy to radiology

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

- Move the client's bed to the main floor of the house

A nurse is supervising assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

- Oral suction equipment

A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practitioner nurse?

- Perform a sterile dressing change for a client who has an abdominal wound

A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention

- Place the client in a room that is ventilated to the outside.

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

- Place the shoulder harnesses at the level of the infants' shoulders

A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

- Plan to remove the restraints as soon as the clients is calm

Anurseisreinforcingteachingaboutcarseatsafetytotheparentsofanewborn. The nurse should instruct the parents to place the car seat in a....

- Rear-facing position in the back seat.

A nurse's developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

- Remind the client to use an incentive spirometer

A nurse is reinforcing teaching about home safety precautions with the parents of a 3- month-old. Which of the following instructions should the nurse include in the teaching?

- Remove bibs when the infant is going to sleep.

While performing a routine assessment, a nurse notices praying on the electrical cord of a client's continuous passive motion (CPM) device. Which of the following actions should the nurse take first?

- Remove the device from the room

A nurse is caring of a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

- Remove the restraints from the client's wrists every 2 hr.

A nurse is caring for a client who speaks a different language than the nurse. The clients partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the ff actions should the nurse take?

- Request the services of an interpreter to determine the clients wishes

A nurse is planning a health- promotion program for high school students. Which of the following facts about smoking is likely to be most effective in changing the adolescent's attitudes toward smoking

- Smoking causes unattractive stains on the teeth and hand.

A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. e nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?

- Speak directly to the client

A nurse manager in a long-term care facility is discussing evidence-based practice with a group of staff nurses which of the following activities should the nurse manager identify as an example of evidence-based practice

- Staffing the unit based on client acuity and needs

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

- Supplement spoken language with pictures. Or review the facility policy about the use of an interpreter

A nurse is assisting with care of a client who is receiving chemotherapy and radiation for advances breast cancer. The client states "I am thinking about stopping the treatment. Which of the following responses should the nurse make?

- Tell me more about what are you thinking

A nurse is observing assistive personnel take a client tympanic temperature which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure

- The AP pulls the pinna up and back

A nurse is preparing to delegate client care to an assistive personnel AP. Which of the following information should the nurse verify prior to delegation?

- The AP's job description

A nurse is participating in an inter-professional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

- The client is unable to grasp eating utensils

A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching?

- The infant is lying in the crib with a stuffed animal.

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

- Wash hands with soap and water for 20 seconds.

A nurse is reinforcing teaching with the client family about home oxygen use via nasal cannula which of the following statements by a family member indicates an understanding of the teaching

- We will frequently check the top of his ears for sores

A nurse is admitting a client who is hesitant to create Advanced directives due to concerns about legal representation. which of the following statements should the nurse make

- advanced directives can be a verbal agreement between you and your provider until legal review can be obtained.

A nurse is caring for a post-op client. Which of the following interventions will reduce the risk of DVT?

- apply venous plexus boots

A nurse is planning to teach a client and their family about home oxygen therapy. which of the following information should the nurse plan to include in the teaching

- avoid using nail polish remover around the client

a nurse is reviewing the medical records of four clients the nurse should identify that which of the following client findings require follow-up care

- inclined who is taking Warfarin and has an INR of 1.8

Breach of confidentiality question

- nurse tells Chaplin pt has cancer

A nurse is teaching a new parent about breastfeeding her 2 week old infant. Which of the following statements by the parent indicates an understanding of teaching?

- the more my baby is at the breast sucking, the more milk I will produce

A nurse working in a provider's office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is correct?

-"When all the blisters are scabbed over"

A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching?

-"You should increase fluid intake to relieve dysuria"

A nurse is caring for a client who has AIDS. which of the following solutions should the nurse use to disinfect the clients overbed table following a blood spill

-Bleach

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the inter-professional team?

-Case manager

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks," Why is colostrum so important for my baby?" Which fox of the following responses should the nurse make?

-Colostrum provides many important antibodies that the newborn lacks

A client who has type 1 diabetes mellitus asks a nurse about beginning an exercise regimen. Which of the following instructions should the nurse include

-Eat a piece of fruit before exercising

A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car seat. Which of the following statements by the parent indicates an understanding of the teaching?

-I can place a rolled towel on each side of my newborn's head until he can hold his head up.

A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse's role in obtaining informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching

-It is my responsibility to obtain informed consent from the client prior to the procedure

A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?

-hacking cough

The nurse helps minimize an older adult patient's risk of developing pernicious anemia by which of the following actions?

-suggesting supplementing vitamin A

A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?

-whooping cough