Comprehensive A

A home health nurse is providing teaching to a client who has Hep A. Which of the following instructions should the nurse include? -Use hydrogen peroxide to clean kitchen surfaces -Seal nonwashable items in a plastic bag for 2 weeks -Wear a surgical mask when in public -Limit family visits to 30 min periods

Use hydrogen peroxide to clean kitchen surfaces - The client should clean kitchen surfaces with hydrogen peroxide to kill the virus and prevent transmission

A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which of the following findings should the nurse identify as a contraindication for the client to receive clozapine? -BP 150/87 mm Hg -WBC count 2,800/mm3 -Auditory hallucinations -Nausea

WBC 2,800/mm3 - Clozapine can cause agranulocytosis, which can be life-threatening. Therefore, a EBC count of less than 3,000/mm3 is a contraindication for the client to receive clozapine. The nurse should withhold the medication and notify the provider of the client's WBC count.

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. Which of the following interventions should the nurse include in the plan? -Encourage friends and family to visit the child -Withhold administering the varicella vaccine to the child -Collect a daily urine specimen from the child to check for proteinuria -Provide a low-protein diet for the child

Withhold administering the varicella vaccine to the child - A child who has sever immunodeficiency should not receive a live vaccine due to the risk of developing the disease. Inactivated vaccines can be administered to children who are immunosuppressed.

A nurse is providing teaching about improving gnutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? (Select all that apply) -"A speech pathologist will be performing a swallowing study for you." -"You should rest before eating a meal." -"You should restrict foods that are high in vitamin D." -"Reduce your intake of dietary fiber." -"Thicken your beverages before drinking."

"A speech pathologist will be performing a swallowing study for you." - The nurse should instruct the client that a swallowing study will be performed to determine that client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis. "You should rest before eating a meal." - The nurse should encourage the client to rest before each meal. Clients who have MS often report weakness and are easily fatigued. "Thicken your beverages before drinking." - The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of MS.

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Which of the following statements by the client indicates that this therapy is having the desired effect? -"I have not had any food cravings." -"The spotting I was having stopped." -"I don't feel depressed anymore." -"I have not vomited as much recently."

"I have not vomited as much recently." - Using an acupressure band on the wrists is a type of complementary and alternative therapy that applies pressure to a specific part of the body and can be used to alleviate n/v.

A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? -"I will make sure my 4-year-old child wears a helmet when using a skateboard." -"I should have my child avoid sun exposure between 10 am and 2 pm." -"I can give my 2-year-old child a whole hotdog on a bun." -"When my infant in in the carrier, I will place it on a raised, flat surface whenever possible."

"I should have my child avoid sun exposure between 10 am and 2 pm." - To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400.

A nurse is teaching the parent of a school-age child about administering ear drops. Which of the following responses by the parent indicates an understanding of the teaching? -"I should administer the ear drops as soon as I remove them from the refrigerator." -"I should pull the top of the ear upward and back while instilling the medication." -"I should massage behind the ear after I instill the drops." -"I should have my child lie on the affected side for a few minutes after I put the drops in the ear."

"I should pull the top of the ear upward and back while instilling the medication." - The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years of age to straighten the ear canal and allow the medication to reach the entire canal. For children younger than 3 years of age, the parent should gently pull the pinna downward and back.

A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? -"I should report a change in the color of my stools." -"I can take acetaminophen to treat a headache." -"I will take a calcium supplement while taking this medication." -"I will return in a month to have my blood tested."

"I should report a change in the color of my stools." - The nurse should inform the client that red, black, or tarry stools can indicate bleeding, an adverse effect of warfarin, and the client should report these findings to the provider.

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. The nurse should identify that which of the following client statements indicates and understanding of the teaching? -"I should avoid eating smoked meats, cheese, and ripe avocados while taking this type of medication." -"I should watch for common reactions like dry mouth and constipation." -"I will be at increased risk for high blood pressure while taking this medication." -"I will take my daily dose of this medication every morning before breakfast."

"I should watch for common reactions like dry mouth and constipation." - The nurse should reinforce that increasing dietary fiber, fluid intake, and chewing sugar-free gum can alleviate the anticholinergic effects of dry mouth and constipation.

A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? -"I can resume my daily aspirin therapy." -"I will contact my provider if my eye feels itchy." -"I will bend at my knees when picking an object up off the floor." -"It's okay for me to pick up my grandchild who weighs 20 lbs."

"I will bend at my knees when picking an object up off the floor." - The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object.

A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? -"You will need to draft a health care proxy so a designee can make this decision for you." -"I will make sure that no one performs any lifesaving measures if your heart stops." -"Your provider determines if you should have lifesaving measures if your heart stops." -"I will provide you with information about medical treatment to include in your living will."

"I will provide you with information about medical treatment to include in your living will." - The nurse's responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themselves by providing information about what end-of-life preferences to document.

A home health nurse is providing teaching about infection prevention to a client who has cancer and is receiving chemotherapy. Which of the following statements by the client indicates an understanding of the teaching? -"I will leave my drinking water out of my refrigerator for at least 1 hour so it will be room temperature." -"I will clean my toothbrush in my dishwasher once each month." -"I will take my temp once each week and let my Dr know if its high." -"I will walk for short distances throughout the day."

"I will walk for short distances throughout the day." - The client should ambulate for short distances as tolerated throughout the day. This will help to reduce pulmonary stasis and prevent the development of respiratory infections.

A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make? -"Your mother might still know you are here." -"Why do you feel that way?" -"It seems like you feel your visits are a waste of time." -"Are you sure you would not want to see your mother again?"

"It seems like you feel your visits are a waste of time." - The nurse is using a clarifying technique that facilitates the nurse's understanding of the adult child's feelings.

A nurse is caring for an adolescents client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization? -"Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer." -"Let's go on that family vacation we've got planned. We will deal with this when we return." -"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." -"This isn't possible. Just last week the doctor said that the cancer was responding well to treatment."

"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments." - By justifying the adolescent's prognosis by searching for a more personally acceptable explanation for the impending loss, the parent is using the defense mechanism of rationalization.

A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner should the nurse identify as the priority? -"Will my husband be able to continue as the executor of his parents' estate?" -"One of my husband's coworkers visited last week to tell me my husband might lose his job." -"Do you think it is necessary to postpone out daughter's wedding until my husband is feeling better?" -"My husband doesn't know that I've already moved out of the house and filed for a divorce."

"My husband doesn't know that I've already moved out of the house and filed for a divorce." - A lack of a social support and isolation indicates the client is at greatest risk for another suicide attempt. Therefore, this is the priority concern that the nurse should report to the provider.

A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? -"Place your baby's car seat at a 30 degree angle." -"Your baby's car seat should be rear-facing until he is 6 months old." -"Swaddle your baby in a light blanket before placing him in the car seat." -"Secure the retainer clip at the level of your baby's armpits."

"Secure the retainer clip at the level of your baby's armpits." - The nurse should instruct the parents to secure the retainer clip at the level of the newborn's axillae. The bones of the rib cages and sternum provide protection to underlying organs in the event of a collision. Placing the clip on the abdomen increases the risk for injury to internal organs.

A nurse is teaching a client who has opioid use disorder about methadone. Which of the following information should the nurse include in the teaching? -"If you suspect you are pregnant, stop taking this medication." -"You cannot become physically dependent on this medication." -"Sedation is a common adverse effect of this medication." -"If you forget a dose, you can double your next dose."

"Sedation is a common adverse effect of this medication." - Sedation and drowsiness are common adverse effects of methadone. Sedation most frequently occurs at the beginning of treatment or during dosage increases.

A nurse is providing teaching to a client about newborn safety. Which of the following statements should the nurse include in the teaching? -"Set your hot water heater temp at or below 120 degrees F." -"Cover your baby with a light blanket while sleeping." -"Make sure the slats on the baby's crib are no more than 3 inches apart." -"Place your baby's car seat rear-facing until the age of 1 year old."

"Set your hot water heater temp at or below 120 degrees F." - The nurse should instruct the client to set the maximum water temperature to no more than 49 C (120 F). The nurse should also instruct the client to test the temperature of the bath water with her elbow prior to bathing the newborn.

A nurse is caring for a client who is at 28 weeks of gestation. The client asks the nurse to explain what causes her to have constipation. Which of the following responses should the nurse make? -"Estrogen levels decrease during pregnancy, causing the stool to become hardened." -"Decreased water absorption in the intestine during pregnancy causes constipation." -"The intestine absorbs iron less efficiently during pregnancy, leading to constipation." -"The enlarged uterus compresses the intestines and causes constipation."

"The enlarged uterus compresses the intestines and causes constipation." - During the second and third trimesters, the size and weight of the growing uterus cause both displacement and compression of the intestines. These changes cause a decrease in motility, leading to constipation.

A nurse receives a request from a client to review the information in his medical record. Which of the following responses should the nurse give? -"There's a protocol for reviewing your medical record, and I can initiate the process." -"The medical record has a lot of medical terminology, and it might be difficult for you to understand." -"You should really talk to your provider of you have any questions about your treatment." -"Some parts of your medical records are restricted, but I can show you the parts that you are allowed to see."

"There's a protocol for reviewing your medical record, and I can initiate the process." - The client's record is the legal property of the facility, but the client has a right to access the record, obtain a copy of the record, and request corrections to the document if there are discrepancies. According to HIPAA, the nurse is responsible for following the facility's policy when providing the client with access to the medical records.

A nurse is teaching the parents of a preschooler about sleep promotion. The parents report that their child is demonstrating reluctance in going to bed at night and states, "I'm not tired." Which of the following statements by the parents indicates an understanding of the teaching? -"We will let our child watch a favorite video before bedtime." -"We should read a story together every night before bedtime." -"We can let our child fall asleep in our room, and then move to her own bed." -"We should change the bedtime to be an hour later."

"We should read a story together every night before bedtime." - Preschoolers respond to rituals that prepare them for bed, such as hearing a story or taking a bath.

A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child can return to school. Which of the following responses should the nurse make? -"When the lesions no longer itch." -"Three days after the lesions appeared." -"When crusts have formed on every lesion." -When the lesions disappear."

"When crusts have formed on every lesion." - The child should return to school once all the lesions have crusted over. Varicella is no longer contagious after crusts have formed on all lesions.

A nurse is teaching a newly admitted client who has HF about advance directives. Which of the following statements should the nurse make? -"You don't need advance directives now because you are competent and can make decisions for yourself." -"You must wait for a period of 6 months after your diagnosis before initiating advance directives." -"You will have to speak to an expert who works in the social service department." -"You should complete advance directives in the event you cannot express your own wishes."

"You should complete advance directives in the event you cannot express your own wishes." - The client should prepare advance directives to make their wishes known should they be unable to communicate them in the future.

A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child? -"You should leave your glasses off throughout the testing." -"You should stand 15 feet away from the chart." -"You should get three symbols on a line correct to pass the line." -"You should keep both eyes open during the testing."

"You should keep both eyes open during the testing." - The nurse should instruct the child to keep both eyes open during visual acuity testing.

A nurse is providing teaching to an adolescents following insertion of a tunneled central venous catheter without a pressure-sensitive valve. Which of the following information should the nurse include in the teaching? -"You should flush the catheter with 0.9% NaCl solution daily when not using it regularly." -"You should keep the catheter clamped when not in use." -"You should swim twice weekly to prevent tissue from adhering to the cuff." -"You should change your dressing every 10 days."

"You should keep the catheter clamped when not in use." - The adolescent should keep the catheter clamped to prevent blood backflow. Not all tunneled catheters have a pressure-sensitive valve that prevents blood reflux.

A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? -"This type of nutrition is more effective than eating by mouth." -"You will receive finger sticks for blood glucose testing." -"TPN is a way to provide vitamins and minerals without increased calories." -"Taking TPN can increase the risk of developing a latex allergy."

"You will receive finger sticks for blood glucose testing." - A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring.

A nurse is preparing to administer heparin 5,000 units subq. Available is heparin injection 10,000 units/mL. How many mL should the nurse administer per dose?

0.5 mL

A nurse is preparing to administer diazepam 0.3 mg/kg IV bolus to a toddler who weighs 22 lb and is experiencing a grand mal seizure. Available is diazepam solution for injection 5 mg/mL. How many mL should the nurse administer?

0.6 mL

A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse recommend as having the highest amount of vitamin A? -1 medium raw carrot -1/2 cup cooked spinach -1/2 cup cooked butternut squash -1 cup sliced cantaloupe

1 medium raw carrot - The nurse should identify that 1 medium raw carrot contains 2,025 mcg/dL of vitamin A and is therefore the best food to recommend to the client.

A nurse is caring for 4 clients. Which of the following clients should the nurse assign to an AP to assist with meals? -A client who has Alzheimer's disease and is demonstrating aphasia -A client who has asthma and an increased respiratory rate -A client who had a stroke and is to start oral intake -A client who had diabetic ketoacidosis and is difficult to arouse

A client who has Alzheimer's disease and is demonstrating aphasia - Aphasia impairs the client's ability to communicate but does not interfere with nutritional intake of place the client at an increased risk for aspiration while eating. Therefore, assisting the client with meals is within the AP's range of function.

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? -A client who has DM and has had repeated hospitalizations for diabetic ketoacidosis -A client who has alcohol use disorder and has decided to start attending AA meetings -A client who was admitted for dehydration and is receiving a continuous IV infusion -A client who has a history of two prior miscarriages and has ruptures membranes at 38 weeks of gestation

A client who has DM and has had repeated hospitalizations for diabetic ketoacidosis - A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support.

A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? -A client who is alert and has a 2.5 cm (1 in) laceration on the forehead -A client who has a significant head trauma and agonal respirations -A client who has an open fracture of the right forearm -A client who is unconscious and has a rapid, thready radial pulse

A client who has a significant head trauma and agonal respirations - The nurse should place a black tag on a client who has significant head trauma and agonal respirations because this client is not likely to recover or will require extensive resources for care.

A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report? -A client's IV pump delivers an inadequate dose of medication -A nurse follows a client's advance directives and discontinues enteral feedings -A nurse discards unused, expired bags of IV fluids -A client refuses an IV bolus of pain medication

A client's IV pump delivers an inadequate dose of medication - The nurse should complete an incident report to record occurrences which resulted in a medication error, such as a failure of the IV pump, as part of the quality improvement process. Other situations requiring an incident report includes significant complaints about care quality and visitor or client injury.

A nurse is caring for a client who is 12 hr postop, is receiving PCA for pain control, and requires a BP check in 10 minutes. Which of the following staff members should the nurse assign to collect this information? -An RN who is monitoring a client who started receiving a blood transfusion 5 min ago -An AP who just began performing a bed bath -An LPN who is reinforcing discharge instructions with a client -An AP who is assisting a client to return to bed

An AP who is assisting a client to return to bed - Performing a BP check is within the range of function of an AP, and the AP should be available to obtain a BP within the specified time.

A community health nurse is reviewing the medical records of four newly diagnosed clients. The curse should identify which of the following clients as having a nationally notifiable infectious condition? -A client who is pregnant and has cytomegalovirus (CMV) -An adolescents client who has foodborne botulism -A child who has erythema infectiosum -A young adult client who has herpes simplex virus type 1 (HSV-1)

An adolescents client who has foodborne botulism - The nurse should report botulism to the CDC because this information is necessary for the prevention and control of this disease. Clients who ingest the botulism toxin can develop dysphasia, drooping eyelids, and vision changes, and in 12 to 36 hrs can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment.

A nurse is performing tracheostomy care for a client who is postop following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway? -Withdraw the catheter if the client begins coughing -Apply suction for 10 seconds -Advance the catheter 2 cm (0.8 in) after resistance is met - Use medical asepsis when preforming the procedure

Apply suction for 10 seconds - The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss.

A nurse working on a med-surg unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's parent. Which of the following actions should the nurse take? -Ask the caller for verification of their identity -Give the caller limited information about the client -Transfer the phone call to the client's room -Inform the caller that they should obtain permission from the client's provider

Ask the caller for verification of their identity - According to HIPAA, if someone request information about a client it is the nurse's duty to protect that information. Therefore, the nurse should inform the caller that nurses cannot release any client information over the phone without the permission of the client. The nurse should ask for verification of the caller's identity to determine if they have been authorized by the client to receive information.

A client who is 24 hr postop following abdominal surgery refuses to ambulate. Which of the following actions should the nurse take first? -Ask the client to rate their pain level -Assist the client in changing positions -Administer a PRN analgesic medication -Explain the importance of early ambulation

Ask the client to rate their pain level - Using the nursing process, the first action the nurse should take is to assess the client's level of pain. If indicated, the nurse should administer analgesic, then wait 30 to 45 minutes to allow the analgesic to take effect before encouraging the client to ambulate. Management of the client's pain is a priority for encouraging postop activity.

A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? -Refer the nurse to the procedure manual -Use a diagram to explain the procedure to the nurse -Demonstrate the procedure to the nurse -Ask the nurse about their knowledge of the procedure

Ask the nurse about their knowledge of the procedure - The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs.

A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first? -Ask for help with a two-person assist transfer -Assess the client for functional limitations -Request a mechanical lift device -Medicate the client for pain

Assess the client for functional limitations - When using the nursing process, the first action the nurse should take is to assess the client's functional limitations to determine how much the client can assist with the transfer

A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider? -Urine output 120 mL in 4 hr -Systolic BP 12 mm Hg lower than the preop level -Audible stridor -NSR with an occasional PVC

Audible stridor - A high-pitched sound heard in the client's airway indicates edema, laryngeal spasm, secretions, or some type of airway obstruction that could become life-threatening. The nurse should report this finding to the provider.

A nurse is planning care for a client who is receiving hemodialysis via an established AV fistula in the right arm. Which of the following interventions should the nurse include in the client's plan of care? -Notify the provider if a thrill is palpated at the fistula -Auscultate the affected extremity for a bruit -Discourage range-of-motion exercises on the affected extremity -Perform venipuncture in the affected extremity

Auscultate the affected extremity for a bruit - The nurse should auscultate the AV fistula q 4 hrs to ensure a bruit is present, which indicates patency.

A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care? -Avoid venipuncture when possible -Restrict visitors to family members -Limit oral fluid intake to between meals -Prohibit fresh flowers in the client's room

Avoid venipuncture when possible - Clients who have thrombocytopenia have a decreased platelet count and are at risk for bleeding. To reduce the risk for bleeding, the nurse should avoid venipunctures when possible.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? -Slightly blue hands and feet -Respiratory rate of 40/min -Axillary temp of 36.2 C (97.2 F) -Apical pulse 136/min

Axillary temp of 36.2 C (97.2 F) - The expected reference range for the axillary temp of a newborn is between 36.5 C to 37.5 C. An axillary temp of 36.2 C or below in a newborn who is 2 hr old indicates cold stress and should be reported to the provider.

A nurse is assessing a client who has Raynaud's disease. Which of the following findings should the nurse expect? -Butterfly rash over the cheeks and nose -Report of pain in the joints of the lower extremities -Blanching of the fingers and toes -Scaly patches over the knees and elbows

Blanching of the fingers and toes - A client who had Raynaud's disease can have blanching of the fingers and toes in response to exposure to cold or emotional stress. Pallor develops first, then cyanosis, followed by redness or heat as the vessels reperfuse, before the skin returns to the client's baseline tone.

A nurse is caring for a newborn whose parents asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? -Bleeding -Potassium deficiency -Infection -Hyperbilirubinemia

Bleeding - The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding.

When caring for a child, a nurse plans to use nonpharmacological interventions to enhance the effectiveness of pain medication. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort? -Coloring with crayons in a coloring book -Deep breathing and "going limp as a rag doll" -Blowing bubbles with liquid soap to "blow the hurt away" -Taking a warm bath and playing with a bath toy

Blowing bubbles with liquid soap to "blow the hurt away" - Having the child blow bubbles is a visualization technique that can help to decrease the child's discomfort. The child can visualize the pain as the bubble that they blow away from themselves and into the air.

A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? -Intermittent cramping -Moderate lochia rubra -Boggy uterus -Perineal edema

Boggy uterus - When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should immediately intervene to stimulate uterine contractions and prevent blood loss. If the uterus becomes relaxed during the postpartum period, the client will rapidly lose blood because no permanent thrombi have formed at the placenta.

A nurse is preparing to administer a long-acting insulin to a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? -Teach the client reportable adverse effects from medication -Check the insulin dose with another licensed nurse -Administer the insulin at a 90 degree angle -Clean the insertion site

Check the insulin dose with another licensed nurse - The greatest risk to the client is injury due to a medication error. Therefore, the priority action is for the nurse to validate the correct dose of insulin with another licensed nurse prior to administration. Insulin is a high-alert medication and incorrect dosages can be fatal for the client.

A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following? *Audio* "Big, bat, bop. The boat is bouncing back." -Clang association -Echolalia -Neologisms -Word salad

Clang association - Alteration in speech in which the client uses words based on their sound, rather than their meaning. Clients who have neurological disorders can also have this alteration in speech.

A nurse is planning care for a client who has a deficit with CN II. Which of the following actions should the nurse plan to take? -Keep the client resting in bed -Ask the client to restate directions -Clear objects from the client's walking area -Evaluate the client's ability to swallow

Clear objects from the client's walking area - The nurse should plan to clear objects from the client's walking area because CN II is the optic nerve and a deficit can result in visual impairment which can lead to falls.

A nurse is teaching a client who is to start taking misoprostol and currently is on long-term therapy with NSAIDs for arthritis. The nurse should provide the client with which of the following information? -Increase intake of fluids and fiber to prevent constipation -Complete a serum pregnancy test before taking this medication -This medication coats stomach ulcers so they can heal -Take a magnesium-containing antacid along with this medication

Complete a serum pregnancy test before taking this medication - Misoprostol can induce uterine contractions. Clients of childbearing age must rule out pregnancy before taking it.

A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions should the nurse implement? -Airborne -Droplet -Contact -Protective environment

Contact - The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA

A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? -Contact -Droplet -Airborne -Protective equipment

Contact - The nurse should initiate contact precautions because clients transmit HSV by direct and indirect contact with others and the environment. The nurse should wear gloves when in close contact with the newborn.

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take? -Continue observing the fetal heart rate -Assist the client to a knee-chest position -Prepare the client for continuous internal monitoring -Prepare for an emergency cesarean birth

Continue observing the fetal heart rate - Early decelerations indicate the progression of labor and are an expected finding. The nurse should continue to monitor the fetus by observing the fetal heart rate and tracing.

A nurse is caring for a client who has a potassium level of 3 mEq/L. For which of the following manifestations should the nurse monitor? -Increased bowel sounds -Dry, sticky mucous membranes -Decreased DTR -Numbness and tingling of the extremity

Decreased DTR - A client who has hypokalemia can have muscle weakness and decreased DTR.

A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect? -Increased intraocular pressure -Floating dark spots -Decreased central vision -Double vision

Decreased central vision - The nurse should expect a client who has macular degeneration to have a decrease or loss of central vision due to bleeding into the macula or yellow spots under the retina.

A nurse is caring for an older adult client. Which of the following findings should the nurse recognizes as a physiological change associates with aging? -Decreased BP -Increased CO -Increased oral temp -Decreased lung expansion

Decreased lung expansion - Older adult clients are more likely to have decreased lung expansion due to decreased mobility of the ribs.

A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? -Assist the client with contacting individuals form the client's support system -Give the client information about available community resources for shelter -Suggest the client obtain mental health counseling -Determine the client's perception of the personal impact of the crisis

Determine the client's perception of the personal impact of the crisis - The first action the nurse should take using the nursing process is to assess the client. Therefore, the first action the nurse should take is to determine the client's feelings and understanding of the natural disaster and its personal impact.

A nurse in an emergency department is preparing to discharge a client who had experienced intimate partner violence. Which of the following actions should the nurse take first? -Offer a referral to the client for social services -Develop a safety plan with the client -Encourage the client to reach out to family and friends -Provide the client with a list of support groups

Develop a safety plan with the client - The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is the develop a safety plan with the client.

A nurse in an emergency department is assessing a client who reports taking MDMA. Which of the following findings should the nurse expect? -Lethargy -Diaphoresis -Bradycardia -Cough

Diaphoresis - This is an expected finding of MDMA. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects.

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend? -Popcorn -Diced steamed carrots -Whole celery sticks -Marshmellows

Diced steamed carrots - Diced steamed carrots are a safe food choice for toddlers because they are soft and do not present a choking hazard

A nurse in a mental health unit is caring for a client who tells the nurse that she does not want to receive a scheduled dose of lorazepam IM. Which of the following actions should the nurse take? -Document the client's refusal of the medication -Administer the medication that the provider prescribed -Request consent from the client's family to administer the medication -Administer an oral dose of the medication

Document the client's refusal of the medication - The client has the right to refuse medication. The nurse should document the refusal in the client's medical record.

A nurse is teaching home wound care to the family of a child who has a large wound. Which of the following interventions should the nurse recommend? -Apply an OTC cream if the wound becomes infected -Clean the wound twice a day with povidone-iodine -Apply heat to the wound for 10 min, four times per day -Double-bag soiled dressings in plastic bags for disposal

Double-bag soiled dressings in plastic bags for disposal - The client should double-bag soiled dressings in plastic bags to prevent the spread of micro-organisms to other household members

A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? -Dry the newborn. -Assign the first Apgar score to the newborn. -Place an identification bracelet on the newborn. -Obtain the newborn's weight.

Dry the newborn - The greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take is to dry the newborn.

A nurse is planning care for a client who is receiving heparin to treat deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care? -Maintain the client on bed rest -Restrict the client to 1 L of fluid per day -Place cool compresses on the edematous area -Elevate the affected leg

Elevate the affected leg - The nurse should elevate the client's affected extremity to reduce edema and decrease the risk of chronic venous insufficiency.

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. Which of the following should the nurse include in the toddler's plan of care? -Encourage the parents to bring toys from home -Use a visual analog scale to rate the toddler's pain -Inform the toddler about the procedure 1 week before hospitalization -Stress to the parents the need for maintaining the hospital's daily routine

Encourage the parents to bring toys from home - To help decrease the toddler's anxiety, the nurse should encourage the family to bring familiar objects from home, such as toys, blankets, and feeding utensils.

A nurse is preparing to administer 2 units of fresh frozen plasma (FFP) to a client. Which of the following actions should the nurse plan to take? -Allow the plasma to warm for 30 min before transfusion -Confirm the client's identification by checking the room number -Enter the plasma product number into the client's medical record -Administer each unit of plasma over 4 hr

Enter the plasma product number into the client's medical record - The nurse should complete documentation following blood product therapy, which includes recording the type of product, amount administered, product number, infusion time, and client response.

A nurse is caring for a client who has an STI that must be reported to the state health department. Which of the following actions should the nurse take? -Tell the client to self-report to the state health department -Require that the client speak with a public health nurse -Explain to the client why the information will be shared -Refer the client to a social worker for counseling

Explain to the client why this information will be shared - It is the responsibility of the nurse to advocate for the client, provide confidential information, and explain legal requirements. Reporting communicable disease occurrences helps with identifying outbreaks and overall disease trends.

A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? (Select all that apply) -Nystagmus -Facial flushing -Diplopia -Nasal congestion -Headache

Facial flushing - The nurse should expect a client who has autonomic dysreflexia to have facial flushing. Flushing occurs from the point of the lesion upward. Nasal congestion - The nurse should expect a client who has autonomic dysreflexia to have nasal congestion. Headache - The nurse should expect a client who has autonomic dysreflexia to have a severe headache.

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect? -Fever unresponsive to antipyretics -Pain in weight-bearing joints -Decreased heart rate -Peeling of the soles of the feet

Fever unresponsive to antipyretics - The nurse should expect a child who has acute Kawasaki disease to have a high fever that is unresponsive to antibiotics or antipyretics.

A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? -Naloxone -Flumazenil -Acetylcysteine -Atropine

Flumazenil - The nurse should anticipate administering flumazenil, a competitive benzo receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to support the client's respirations with a BVM.

A nurse is administering medications to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent clogging of the tube? -Flush the client's gastrostomy tube with 30 mL of water before administering the medication -Crush the client's medications and mix them in with the tube feeding formula prior to administration -Change the client's feeding bag every 72 hr -Administer multiple prescribed medications at the same time

Flush the client's gastrostomy tube with 30 mL of water before administering the medication - The nurse should flush the gastrostomy tube with at least 30 mL of water before and after medication administration to clear the tube of any residuals and to ensure patency.

A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? -Ensure that the staff nurse changes the dressing -Notify the nurse manager -Complete an incident report -Gather more information about the staff nurse's actions

Gather more information about the staff nurse's actions - The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action.

A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following manifestations should the nurse expect? -Hypersensitivity to criticism -Fears of abandonment -Grandiose delusions -Reclusive behavior

Grandiose delusions - Clients who are in the manic phase of bipolar disorder typically exhibit behaviors that appear to be euphoric. Clients can also have abrupt mood changes, expansiveness, unlimited energy, poor impulse control, and grandiose delusions.

A nurse in an outpatient mental health clinic is working with a client who has PTSD and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? -Spinal manipulation -Acupuncture -Therapeutic touch -Guided imagery

Guided imagery - Helping clients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist clients who have PTSD by relieving anxiety and pain.

A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? -Hypotension -Headaches -Bruising -Oliguria

Headaches - The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events.

A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? -Diminished reflexes -Hematuria -Hyperglycemia -Hearing loss

Hematuria - The nurse should identify hematuria as a manifestation of vaso-occlusive sickle cell crisis resulting from ischemia of the kidneys.

A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? -Decreased activity -Hemoptysis 275 mL/24 hr -Fever -Weight loss 2.3 kg (5 lbs)

Hemoptysis 275 mL/24 hr - Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Therefore, this is the priority finding for the nurse to report.

A nurse is assessing a client who has OSA. For which of the following complications should the nurse monitor? -Weight loss -Urinary retention -Hypertension -Hyperglycemia

Hypertension - The nurse should assess the client for hypertension, a complication of OSA from hypoxia. Other complications include heart failure and cardiac dysrhythmias.

A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? -Identify health-related issues within the community -Develop measurable health goals for community residents -Create safety education classes for the program -Enlist volunteers from the rural community to promote the program

Identify health-related issues within the community - The first action the nurse should take when using the nursing process is to assess the clients living in the community to identify the prevalent health problems.

A charge nurse is preparing to administer 0900 medications and is told by the pharmacy staff that the medications are not available. Medication availability has been an ongoing problem, and the charge nurse has previously discussed this issue with the pharmacy staff. Which of the following actions should the charge nurse take first? -Document the actual time of medication administration -Notify the risk manager -Complete an incident report -Inform the nurse manager of the issue

Inform the nurse manager of the issue - The greatest risk to clients is injury from not receiving medications on time and developing a medical complication. Therefore, the priority intervention the charge nurse should take is to follow the chain of command and contact the nurse manager.

A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? -Check the client's temp q2hr -Initiate fall precautions for the client -Monitor the client's urine for discoloration -Limit the client's fluid intake to 1 L per day

Initiate fall precautions for the client - The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take? -Include chicken broth in the toddler's diet -Feed the toddler the BRAT diet -Initiate oral rehydration therapy for the toddler -Offer the toddler flavored gelatin

Initiate oral rehydration therapy for the toddler - Infectious gastroenteritis can lead to dehydration. The nurse should treat the toddler with oral rehydration therapy to replace fluids lost by diarrhea. Soft or pureed foods can be given along with the oral rehydration therapy. After adequate rehydration has occurred, a regular diet can be resumed.

A nurse is preparing the administer 15 units of regular insulin along with 20 units of NPH insulin. Which of the following actions should the nurse plan to take? -Inject 20 units of air into the NPH insulin vial -Shake the NPH insulin vial vigorously to mix the insulin -Use a new needle to draw up the insulin from the second vial -Draw the longer-acting insulin into the syringe first

Inject 20 units of air into the NPH insulin vial - The nurse should inject 20 units of air into the NPH insulin vial and withdraw the needle without touching the insulin, then proceed to inject 15 units of air into the regular insulin vial.

An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN? -Collection of a stool specimen -Preparation of a client's postoperative bed -Preparation of a teaching plan about pneumonia -Insertion of an NG tube

Insertion if an NG tube - The nurse should delegate the insertion of an NG tube to the LPN because this task is within the LPN's scope of practice.

A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which of the following instructions should the nurse include? -Install a raised toilet seat at home -Maintain the hip at an angle greater than 90 degrees -Minimize the use of a walker -Place a pillow under the knees when lying down

Install a raised toilet seat at home - The client should use a raised toilet seat at home to minimize hip flexion and prevent hip dislocation.

A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? -Provide the infant with 1 cup of cereal -Give the infant 240 mL (8 oz) of juice per day -Introduce new foods one at a time over 5 to 7 days -Give whole milk first, then small amounts of solid food

Introduce new foods one at a time over 5 to 7 days - The parents should introduce new foods one at a time over 5 to 7 days to identify potential food allergies

A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? -Investigate environmental factors that might be contributing to client injury during these hours -Review the performance evaluations of nurses who work during these hours -Implement a plan to transition from team nursing to primary care nursing during these hours -Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours

Investigate environmental factors that might be contributing to client injury during these hours - When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the client's falls. This can include environmental factors that might be causing the problem.

A nurse is caring for a client who requires physical therapy following discharge. Which of the following actions should the nurse take? -Initiate the referral at the time of discharge -Have the client contact a physical therapist when feeling ready to begin therapy -Verify that insurance will pay for outpatient physical therapy -Involve the client in selection of a physical therapy provider

Involve the client in selection of a physical therapy provider - The nurse should involve the client in the referral process, including selection of the physical therapist and the location.

A charge nurse is observing a newly licensed administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicated an understanding of the procedure? -Instills 100 mL of air into the NG tube after checking for residual -Flushes the NG tube with 0.9% NaCl irrigation q 2 hr -Adds 20 mL of blue dye to each feeding to help detect aspiration -Keeps the head of the bed elevated to 45 degrees for 1 hr after feedings

Keeps the head of the bed elevated to 45 degrees for 1 hr after feedings - The nurse should keep the client's head elevated to 30 to 45 degrees for 1 to 2 hours after feedings to decrease the risk for aspiration.

A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? -Lack of remorse -Sensitivity to rejection -Extreme mood swings -Self-mutilating behavior

Lack of remorse - A client who has antisocial personality disorder is more likely to show a lack of remorse

A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? -Ketonuria -Fecal impaction -Latex allergy -Tachycardia

Latex allergy - The nurse should assess the client for a latex allergy prior to the insertion of an indwelling urinary catheter due to the risk of an allergic reaction.

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction? -Bradycardia -Low back pain -Hypertension -Distended jugular veins

Low back pain - The nurse should expect low back pain in a client who is having a hemolytic transfusion reaction

A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? -Give an antiemetic 30 min after medication administration -Monitor blood glucose levels -Maintain hydration with liberal fluid intake -Monitor for tumor lysis syndrome

Maintain hydration with liberal fluid intake - The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication.

A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which of the following medications to reduce intracranial pressure? -Propranolol -Phenytoin -Lorazepam -Mannitol

Mannitol - The client should receive mannitol, an osmotic diuretic, to reduce intracranial pressure caused by cerebral edema.

A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? -Mark the edges of stairs for contrast -Cover exposed extension cords with throw rugs -Use 40-watt bulbs in lighting fixtures -Instruct the client to obtain vision testing once every other year

Mark the edges of stairs for contrast - Marking the edges of stairs with paint or colored tape for contrast can help older adult clients who have impaired vision prevent injury by decreasing the risk of falls

A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first? -Administer oxygen -Initiate an infusion of oxytocin -Massage the uterus to expel clots -Obtain a CBC

Massage the uterus to expel the clots - Using the EBP approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleading

A nurse is caring for a client who is immediately postop following a total vaginal hysterectomy. Which of the following actions should the nurse take first? -Measure the client's vital signs -Reposition the client -Encourage the client to use an incentive spirometer -Administer pain medication

Measure the client's vital signs - The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4 hr for the next 48 hr.

A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and sexual references. Which of the following actions should the nurse take first? -Provide an opportunity for the client to express their feelings -Move the client to a quiet place away from others -State expectations that set limits on the client's behavior -Administer a PRN dose of haloperidol to calm the client

Move the client to a quiet place away from others - The client's behavior indicates the greatest risk is injury to others. Therefore, the first action the nurse should take is to prevent harm to other clients by moving the client to a quiet place away from others.

A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? -Constipation -Nausea -Wheezing -Muscle rigidity

Nausea - The nurse should instruct the client to monitor for and report manifestations of digoxin toxicity, such as nausea, anorexia, abdominal pain, bradycardia, and visual changes.

A nurse is assessing a client who is 2 hr postop following a cardiac catheterization. Which of the following information should the nurse report to the provider? *Data* O2 saturation 94% Insertion site pain level of 6 on a scale of 0-10 Urinary output 70 mL/2 hr 0900 Neuro Check: responds to verbal stimuli, speech slurred, hand grasps weak and unequal Lab Results: hemoglobin 15 g/dL, hematocrit 45% Cardiac Cath Report: stenosis of the right coronary artery -Pain level -Neurological status -Laboratory results -Urinary output

Neurological status - This client is experiencing slurred speech and extremity weakness, which are indications of a stroke, a potential complication of cardiac catheterization. The nurse should report these findings to the provider.

A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse should recommend that which of the following actions takes place first when implementing an emergency preparedness plan? -Contact the triage officer -Implement the client tracking system -Ask the communications officer to release a press statement -Notify the incident commander

Notify the incident commander - The first action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy and maintain order.

A nurse is assessing a client who has MS. Which of the following manifestations should the nurse expect? -Abdominal striae -Masklike face -Nystagmus -Ptosis

Nystagmus - Involuntary eye movement and muscle spasticity are both manifestations of MS.

A nurse is caring for a client who has HTN and is taking captopril. Which of the following tasks should the nurse delegate to and (AP)? -Obtain the client's blood pressure before the nurse administers medication -Initiate a referral with a dietitian for the client -Inform the client about the adverse effects of the medication -Recommend a salt substitute

Obtain the client's blood pressure before the nurse administers medication - The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of function for an AP.

A nurse is planning teaching about allowable foods for a client who has a history of uric acid-based urinary calculi formation. Which of the following foods should the nurse include in the teaching? -Liver -Oranges -Chicken -Red wine

Oranges - A client who is prone to uric acid calculi formation can eat citrus fruits.

A nurse is caring for a client who has had N/V for the past 2 days. The nurse should identify which of the following findings as an indication the client is experiencing fluid volume deficit? -Shortness of breath -Visual disturbances -Decreased BUN levels -Orthostatic hypotension

Orthostatic hypotension - Clients who have a fluid volume deficit can experience orthostatic hypotension, which is a result of the body's inability to maintain adequate blood pressure following position changes.

A nurse is assessing a client who has a stage II pressure injury. Which of the following wound characteristics should the nurse expect? -Muscle damage -Partial-thickness skin loss -Visible subcutaneous tissue -Tendon exposure

Partial-thickness skin loss - The nurse should expect to see partial-thickness skin loss or blister formation in a client who has a stage II pressure injury.

A community health nurse is assisting with the development of a disaster management plan. The nurse should include which of the following nursing responsibilities in the disaster response stage of the plan? -Performing a rapid needs assessment -Organizing an immunization campaign -Identifying the specific roles of disaster workers -Conducting home visits to identify health hazards

Performing a rapid needs assessment - Disaster management includes prevention, preparedness, response, and recovery stages. The nurse should perform a rapid needs assessment during the response phase of the disaster cycle. A rapid needs assessment allows the nurse to identify the severity of the incident, the health needs of the community, and the priority actions needed during the response stage.

A nurse is caring for a client who is at 37 weeks of gestation and is experiencing abruptio placentae. Which of the following findings should the nurse expect? -Persistent uterine contractions -Bright red vaginal bleeding -Hyperactive DTR -Fundal height of 40 cm

Persistent uterine contractions - The nurse should expect a client who has abruptio placentae to experience persistent uterine contractions, board-like abdomen, and dark red vaginal bleeding.

A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort or engorgement? -Allow the newborn to breastfeed temporarily -Relieve pressure by expressing milk daily -Place ice packs on the breasts for 15 min several times per day -Sleep with a loose-fitting bra to prevent nipple stimulation

Place ice packs on the breasts for 15 min several times per day - The client should place ice packs on the breasts to reduce swelling and relieve the pain caused by engorgement.

A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? -Place the BP cuff in a labeled bag to send it for decontamination -Immediately rinse the BP cuff in hot running water -Dispose of the contaminated BP cuff in the bag lining the trash can -Clean the BP cuff with a chlorine bleach solution

Place the BP cuff in a labeled bag to send it for decontamination - The nurse should place the BP cuff in a labeled bag before removing it from the client's room and sending it to the proper facility location for decontamination.

A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? -Cleanse the skin at the stoma site with povidone-iodine for 15 seconds -Dampen the skin before applying the skin barrier and ostomy pouch -Place the skin barrier over the stoma and hold it for 30 seconds -Cut the skin barrier opening 0.6 cm (0.25 in) larger than the stoma

Place the skin barrier over the stoma and hold it for 30 seconds - The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds

An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? -Uses a draw sheet to move the client to the left side of the bed -Raises the total height of the bed to waist level -Places a pillow under the client's right arm -Lowers the side rails on the left side of the bed

Places a pillow under the client's right arm - The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder

A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? -Uric acid crystals -Protein -EBCs -Nitrites

Protein - A client who had glomerulonephritis has increased glomerular permeability, which allows protein to filter into the urine. Therefore, the nurse should expect proteinuria on the urinalysis report.

A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan? -Remove the client's restraints while sleeping -Document the client's status every 60 min -Check for a new prescription every 6 hr -Provide a staff member to stay with the client continuously

Provide a staff member to stay with the client continuously - A staff member must remain continuously with a client who is in restraints or view the client via audiovisual equipment, if necessary, due to the risk of injury.

A nurse is caring for a client who is receiving TPN solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump? -Administer TPN solution at the same rate using manual drip tubing -Offer the client oral fluids in place of the TPN solution -Infuse 0.9% NaCl solution using manual drip tubing at 30 mL/hr -Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr

Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr - The nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water at the same rate as the TPN solution.

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate the staff's acceptance of this change, which of the following actions should the nurse manager take first? -Provide information about scheduling issues to the staff -Ask staff members to participate in a trial of the new scheduling system -Encourage staff to offer alternate scheduling solutions -Develop goals to implement the new scheduling system

Provide information about scheduling issues to the staff - The first stage of the change process is the unfreezing stage, when the nurse should inform the staff about the current staffing issues. This can increase their understanding of why changes are necessary.

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which of the following assessment findings should the nurse expect? -Carotid bruit -Tracheal deviation -Pulsus paradoxus -Heart murmur

Pulsus paradoxus - The nurse should identify pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration, as an expected finding of cardiac tamponade, along with jugular vein distension, bradycardia, and hypotension.

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? -Projecting blame -Excessive clinging -Rapid speech -Social awkwardness

Rapid speech - Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns

A nurse working in a long-term care facility is assessing an adult client. Which of the following findings places the client at risk for development of a pressure injury? -Report of persistent constipation -Hgb 14 g/dL -Albumin 4.2 g/dL -Recent weight loss

Recent weight loss - Weight loss can increase the risk for pressure injury. Inadequate nutrition will cause decreased nutrients for the skin and tissues and increased the chance for shearing against the bony prominences.

A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies." Which of the following actions should the nurse take? (Select all that apply) -Refer the client to a community-based social worker -Initiate a consult with a home health care provider -Provide the client with information about the American Red Cross -Postpone the discharge until someone can stay with the client -Give the client information about local support groups

Refer the client to a community-based social worker - A social worker is necessary to help a client with self-care, as well as assist in locating agencies who can help the client face challenges with self-care and paying for necessary ostomy supplies Initiate a consult with a home health care provider - A home health nurse can assist the client in learning to care for the colostomy as well as provide medication management and emotional support Give the client information about local support groups - A client who has cancer and a new colostomy can get help with coping from a support group and possibly receive assistance obtaining supplies from local agencies

A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. *Put in order* Clean the stoma with 0.9% NaCl irrigation Remove the inner cannula Change the tracheostomy collar Remove the soiled dressing

Remove the inner cannula Remove the soiled dressing Clean the stoma with 0.9% NaCl irrigation Change the tracheostomy collar

A nurse is initiating discharge planning for a client who had a stroke and is experiencing right-sided weakness. Which of the following actions should the nurse take first? -Ask a social worker to identify the client's insurance eligibility for rehabilitation services -Request a referral for the client to receive PT -Arrange for the delivery of prescribed medications to the client's home -Provide the client with a list of community resources

Request a referral for the client to receive PT - The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for PT.

A nurse is assessing a 2 month old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? -Stroke the infant's cheek -Depress the infant's tongue -Turn the infant's head to one side -Tap on the bridge of the infants nose

Stroke the infant's cheek - The nurse should stroke the infant's cheek to assess the rooting reflex, which should cause the infant to turn towards that side and suck.

A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? - Displacement -Regression -Suppression -Sublimation

Sublimation - The client is exhibiting behaviors consisting with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior

A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the past 36 hr. Which of the following findings should the nurse identify is an indication that the client has developed oxygen toxicity? -Wheezes -Tachycardia -Restlessness -Substernal Pain

Substernal pain - The nurse should identify substernal pain as a manifestation of oxygen toxicity due to the increased work of breathing, such as in preschoolers who has cystic fibrosis

A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? -Apologize to the client for the nurses' actions -Advise the nurses that they are being insubordinate -Tell the nurses to stop the discussion -Document the incident in the client's medical record

Tell the nurses to stop the discussion - The nurses are violating client confidentiality by having the discussion in a public hallway. The charge nurse should tell the nurses to stop the discussion to prevent any further breach of confidentiality.

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene? -Informs the provider about a client's suicide plan -Notifies the health department of a client's diagnosis of chlamydia -Reports suspected child maltreatment to social services -Tells the hospital chaplain a client's diagnosis

Tells the hospital chaplain a client's diagnosis - Discussing a client's diagnosis with the hospital chaplain is a breach of client confidentiality and a violation of HIPAA.

A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? -Temp 39.4 C (102.9 F) -Headache -Constipation -Dry mouth

Temp 39.4 C (102.9 F) - The greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temp, dysrhythmias, decreased LOC, and a labile BP. Therefore, the priority finding for the nurse report to the provider is a fever.

A charge nurse is teaching a newly licensed nurse how to identify true labor. Which of the following should the nurse include in the teaching? -Contractions will be felt primarily in the upper abdomen -The cervix transitions to an anterior position -Contraction intensity decreases with ambulation -The cervix progressively thickens

The cervix transitions to an anterior position - In true labor, the cervix transitions to an anterior position and begins to dilate in preparation for birth.

A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? -The client's partner tells the nurse that the client understands the procedure -The nurse locates the provider's prescription for the surgical procedure -The nurse witnesses the provider's explanation of the procedure -The client is able to accurately describe the upcoming procedure

The client is able to accurately describe the upcoming procedure - The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent form

A night shift nurse is giving change-of-shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? -The client needs assistance when transferring from the bed to a wheelchair -The client will have a visit by a home health nurse tomorrow -The client's partner will bring clothes for the client to change into prior to discharge -The client often needs encouragement to engage in personal hygiene activities

The client needs assistance when transferring from the bed to a wheelchair - The greatest risk to this client is injury due to fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers

A nurse is caring for a client who has a fractured femur and has had a fiberglass leg cylinder cast for 24 hr. Which of the following assessment findings should the nurse identify as the priority? -The client reports leg itching under the cast around the mid-upper thigh area -The client reports increased pain when the leg is lowered below the level of the heart -The client's cast became wet during a sponge bath -The client's heel is redden and tender

The client's heel is redden and tender - The greatest risk to this client is injury from a pressure injury. Therefore, the priority assessment finding the nurse should identify is a reddened and tender heel.

A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for donating their organs. Which of the following information should the nurse plan to include? -Choosing to donate organs can delay the timing of the child's funeral -The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body -The family should understand that an autopsy is mandatory prior to organ donation -The nurse should introduce the option of organ donation to the parents when first discussing the child's impending death

The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body - Removal of organs does not damage or violate the child's body in a way that would prevent an open casket funeral.

A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lbs) and is being breastfed. Which of the following findings indicates effective breastfeeding? -The newborn nurses every 4 hr during the day and sleeps through the night -The newborn has six to eight wet diapers per day -The newborn's current weight is 3.18 kg (7 lb) -The newborn has sticky, greenish stools

The newborn has six to eight wet diapers per day - Measuring the number of wet diapers per day is an effective measurement of adequate intake. Six to eight wet diapers each day after the fourth day of life indicates effective breastfeeding.

A charge nurse is observing a newly licensed nurse performing a physical assessment on a client. Which of the following actions by the nurse indicates that the charge nurse should intervene? -While performing a breast examination, the newly licensed nurse discusses techniques of breast self-exam with the client -The newly licensed nurse writes detailed notes while performing a H2T assessment -The newly licensed nurse uses a penlight to assess for changes in the contour of the body -The newly licensed nurse uses the dorsal surface of the hand to assess skin temperature

The newly licensed nurse writes detailed notes while performing a H2T assessment - The newly licensed nurse should record brief notes during the assessment to avoid delays and write more detailed notes after completing the assessment.

A nurse is preparing to administer enoxaparin to a client. Identify the area the nurse should use to administer the injection.

The nurse should recognize that enoxaparin is administered into the subcutaneous tissue, specifically in the preumbilical area.

A nurse is reviewing laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? -Amylase -Troponin T -Low-density lipoprotein -Homocysteine

Troponin T - Troponin T is a myocardial muscle protein that is released into circulation after cardiac injury. The nurse should expect increases in the client's troponin level within 2 to 3 hrs following a MI.