Comprehensive Comprehensive

A nurse is preparing to admit a six year old with varicella to the pediatric unit. Which of the following action should the nurse take? a. Assign the child to a negative air pressure room b. use droplet precautions when caring for the child c. assess the child for koplic spotsd. administer aspirin to the child for fever

Assign the child to a negative air pressure room

And nurses containing the temperature of a newborn. Which of the following sites should the nurse use? a.Rectal b. Tympanic c. Axillary d. Oral

Axillary

case study

case study

A nurse enters our clients room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right. Placing them in the order of performance. Use all the steps) RACE 1. transport the client to another area of the nursing unit 2. Activate the facilities fire alarm system 3. Close all nearby windows and doors 4. use the units fire extinguisher to attempt to put out the fire

1. transport the client to another area of the nursing unit 2. Activate the facilities fire alarm system 3. Close all nearby windows and doors 4. use the units fire extinguisher to attempt to put out the fire

A nurse and an assistant personnel AP are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse? a. A client who requests assistance to use the bedside commode b. A client who has a prescription for compression stockings and did not receive them c. a client who requests to sit in the bedside chair while watching TV d. a client who consumes all the food from their meal tray

A client who has a prescription for compression stockings and did not receive them

A nurse is teaching a client about advanced directives. Which of the following statements by the client indicates an understanding of the teaching? a. A living will is a document that includes my wishes about health care decisions b. my provider will make my healthcare decisions if I complete advanced directives c. advanced directives outline who inherits my material possessions in the event of my death d. my partner needs to be present as a witness when I sign a living will

A living will is a document that includes my wishes about health care decisions

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port? A non coring needle An angio catheter A butterfly needle A 25 gauge needle

A non coring needle

A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hours ago. Which of the following findings indicates a positive test? a. An induration measuring 10mm b. an induration measuring 5mm c. A reddened area measuring 10mm d. A reddened area measuring 5mm

An induration measuring 10mm

A nurse is caring for a client who has heart failure. Which of the following manifestation should the nurse expect? a. Crackles in the lungs b. decreased thirst c. tachycardia d. poor skin turgor

Crackles in the lungs

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy period which of the following findings should the nurse identify as the priority? a. Dysphagia b. excoriation of the skin in the neck and chest c. xerostomia d. client reports a pain level of six on a scale from zero to 10

Dysphagia

A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is a priority for the nurse to report to the provider? a. Tachycardia b. dry cough c. Dyspnea d. Hypotension

Dyspnea

A nurse manager is planning a staff in service to address advocacy and client care period the nurse should promote which of the following practices during the in service? Select all that apply. a. Encouraging clients to seek further information from the provider b. honoring family requests to withhold medical information c. addressing client needs when providing resources d. making decisions about health care on clients behalf e. promoting health care access

Encouraging clients to seek further information from the provider addressing client needs when providing resources promoting health care access

37. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the clients to increase in her diet to prevent a neural tube defect? a. Calcium b. zinc c. Iron d. Folate

Folate

Case Study, HELLP syndrome assessment findings

HELLP syndrome : - Hemoglobin - Alanine aminotransferase (ALT) - Platelet count Preclamspsia : - blood pressure

A Hospice nurse is visiting with the son of a client who has terminal cancer. The Sun reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? a. It is always difficult caring for someone who is terminally ill b. you should consider taking a sleeping pill before bed each night c. I can give you information about respite care if you're interested d. I am sure you're doing a great job taking care of your mother

I can give you information about respite care if you're interested

A nurse is teaching a prenatal class about infection prevention at a Community Center which of the following statements by a client indicates an understanding of the teaching? a. I should take antibiotics when I have a virus b. I can visit my nephew who has chicken pox five days after the sores have crusted c. I can clean my cat's litter box during my pregnancy d. I should wash my hands for 10 seconds with hot water after working in the garden

I can visit my nephew who has chicken pox five days after the sores have crusted

A nurse charged nurse is monitoring A newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN) which of the following statements by the newly licensed nurse indicates an understanding of the procedure? a. I will hang a new bag of TPN and IV tubing every 24 hours b. I will obtain the client's weight every other day c. I will monitor the client's blood glucose level every eight hours d. I will increase the rate of the TPN infusion to ensure the correct amount is given

I will hang a new bag of TPN and IV tubing every 24 hours

A nurse is providing preoperative teaching to a client about the administration of morphine via PCA pump. Which of the following statements by the client indicates an understanding of the teaching? a. Using this machine increases my risk of overdose b. I can get pain medication anytime as long as I press the button c. my partner can press my pain medication button for me if I am sleeping d. I will receive a limited amount of pain medication when I press the button

I will receive a limited amount of pain medication when I press the button

A nurse is caring for a client who is in labor. Select the five actions the nurse should take. a. Increase the flow rate of the maintenance IV fluid b. have the charge nurse notify the provider c. place the client in a trendelenburg position d. exert upward pressure on the presenting part e. attempt to push the umbilical cord back into the cervix f. administer oxygen at 10L/min via non rebreather face mask

Increase the flow rate of the maintenance IV fluid Have the charge nurse notify the provider Place the client in a trendelenburg position Exert upward pressure on the presenting part Administer oxygen at 10L/min via non rebreather face mask

A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor? a. Liver function test b. kidney function test c. hemoglobin and hematocrit d. serum sodium and potassium

Liver function test

Case Study client is 4 days postpartum following a cesarean birth assessment findings

Mastitus : - painful tender breast - temperature - chills Endometritus : - foul smelling lochia - temperature - chills

A nurse in an emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take? a. Prepare to assist with intubation b. obtain a throat culture c. suction to child's oropharynx d. prepare a cool mist tent

Prepare to assist with intubation

Case Study assessment findings

Psychosis : - Hallucinations - Lack of sleep - Disorganized thought process - Pressured Speech Mania : - Excessive Spending Habits - Hallucinations - Lack of sleep - Disorganized thought process - Pressured Speech

A nurse is assessing a client who has a possible right pneumothorax. Which of the following findings should the nurse expect the? a. Reduced right sided breath sounds b. intercostal retractions c. High pitched stridor d. paradoxical chest movement

Reduced right sided breath sounds

A nurse is caring for a client who has a new diagnosis of chlamydia trachomatis Which of the following actions should the nurse take? a. Report the infection to the state Department of Health b. administers attracts the phone via intermittent IV bolus c. schedule the client for retesting in one week d. instruct the client to abstain from sexual intercourse for one month

Report the infection to the state Department of Health

A nurse is performing a neurological examination on a client as a part of a complete physical assessment. The nurse should identify the cranial nerve XI is intact when the client performs which of the following actions? a. Shrugs his shoulders b. sticks his tongue out c. frowns symmetrically d. identifies as our taste

Shrugs his shoulders

25. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? a. Swelling on the face b. bleeding gums c. urinary frequency d. faintness upon rising

Swelling on the face

A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching? a. Take your temperature immediately after waking and before getting out of bed b. take your temperature within 30 minutes after your first morning void c. take your temperature one hour after getting out of bed d. take your temperature every night before going to bed

Take your temperature immediately after waking and before getting out of bed

A nurse is caring for a client who is near the end of life and is on a complete bed rest. The client states that he needs to have a bowel movement. The nurse offers a bed pan. The client states "I ve always used the bathroom". Which of the following responses should the nurse make? a. Tell me what concerns you have about using a bedpan b. make sure to use a nearby furniture to support yourself when walking to the bathroom c. I will have the physical therapist ambulate you to the bathroom d. you have to use the bedpan for your own safety

Tell me what concerns you have about using a bedpan

Complete the following sentence by using the list of options. The provider has admitted the client to the inpatient obstetrics and written prescriptions based on the client's condition.

The action the nurse should take first is Evaluating the heart rate tracing followed by inserting an indwelling urinary catheter

Complete the following sentence by using the list of options.

The child is at high risk for developing Compartment syndrome as evidenced by the child's paresthesia

The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? a. The client engages in quiet activities in their room b. the client slept 5 hours the previous night c. the client consumes 8 ounces of high calorie fluids each hour d. the client takes 2 short naps during the day e. the client appears to listen to unseen others

The client engages in quiet activities in their room the client slept 5 hours the previous night the client consumes 8 ounces of high calorie fluids each hour

Drag one condition and one client finding to fill in each blank in the following sentence.

The client is most likely experiencing mania as evidenced by the clients Euphoric mood

Drag words from the choices below fill in each blank in the following sentence.

The nurse should anticipate a prescription for Surgical consultation and Pain medication

Complete the following sentence by using the list of options.

The nurse understands that the patient has likely developed Lithium toxicity and will need to be monitored for seizure activity

A nurse is planning teaching for a client who has a nearly implanted implantable cardioverter/ defibrillator. Which of the following information should the nurse include? a. Expect to have a rapid pulse rate for the first few weeks b. Wear loose fitting clothing c. return in two weeks for a follow up MRI d. resume tub baths and swimming after 24 hours

Wear loose fitting clothing

The nurses teaching a client who is pregnant and has genital herpes simplex virus HSV. Which of the following statements should the nurse include in the teaching? a. You will need to have a cesarean birth if there are any visible lesions b. you can apply a cortisone cream to the lesions twice each day c. you should take 600 milligrams of ibuprofen every eight hours for discomfort during an outbreak d. your baby's cord blood will be tested to determine if she has contracted HSV

You will need to have a cesarean birth if there are any visible lesions

a nurse is reviewing change of shift report for a group of clients which of the following clients should the nurse plan to assess first? A. Our client who has epidural analgesia and weakness in the lower extremities B. a client who has a hip fracture and a new onset of tachypnea C. a client who has a sinus arrhythmia and is receiving cardiac monitoring D. a client who has diabetes mellitus and an HbA1c of 6.8%

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

A nurse is providing an in service about client evacuation during a fire. Which of the following client should the nurse instruct the staff to evacuate first? a. a client who is ambulatory and receiving oxygen b. a client who has a fracture in is imbalance suspension traction c. a client who is bedridden and wears a hearing aid d.a client who uses a wheelchair and is confused

a client who is ambulatory and receiving oxygen

A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who has narcissistic personality disorder and is mocking others during group therapy b. a client who has obsessive compulsive disorder and is upset about a change in daily routine c. a client who has depressive disorder and requires assistance with ADL's d. a client who is taking clozapine to treat schizophrenia and reports a sore throat

a client who is taking clozapine to treat schizophrenia and reports a sore throat

The nurse is assessing the client. Select the four findings that require immediate follow up. EXHIBIT 1 A 52 year old client brought to the emergency department by adult child. Client is alert and oriented to person and time but does not know where they are. No history of substance use according to the client's adult child. Client exhibits constant movements and poor concentration here in clothing are unclean appears to be listening to unseen others skin turgor poor. EXHIBIT 2 The client's adult child reports the client has not slept for two days and has become obsessed with cleaning the house and hosting parties. At times the client is overly joyous and has a very elevated sense of self-confidence. The adult child states that the client has also demonstrated very impulsive spending habits and expresses concerns about the client giving away large sums of money to others. The client's speech is very pressured, dis

a. Hallucinations c. sleep pattern d. skin turgor e. hygiene

The nurse is indicating the client's plan of care period which of the following interventions should the nurse implement? a. Provide a low stimulation environment b. maintain bed rest c. given anti hypertensive medication d. monitor intake and output hourly e. administer betamethasone f. Obtain a 24 hour urine specimen g. perform a vaginal examination every 12 hours

a. Provide a low stimulation environment b. maintain bed rest c. given anti hypertensive medication e. administer betamethasone

Review the three priority actions that the nurse should take? a. Review cast care instructions with the child's parents b. administer ibuprofen 200 milligrams PO c. place a non adherent dressing on the right knee abrasion d. explain the cast application procedure to the child e. apply ice packs to the fingers and along the right forearm f. elevate the affected form with pillows

a. Review cast care instructions with the child's parents b. administer ibuprofen 200 milligrams PO f. elevate the affected form with pillows

31. A nurses came for a client who is pregnant. The nurse is reviewing the client's medical record. Select four findings that indicate a potential prenatal complication. a. Urine protein b. fetal activity c. blood pressure d. urine ketones e. respiratory rate f. report of headache g. gravida/parity

a. Urine protein b. fetal activity f. report of headache g. gravida/parity

22. A nurse is planning care for a school age child who is 4 hours postoperative following appendicitis period which of the following should the nurse include in the plan of care? A. Give cromolyn nebulizer solution every eight hours B. administer analgesics on a scheduled basis for the first 24 hours C. apply a warm compress to the operative site once daily D. offer small amounts of clear liquids 6 hours following surgery

administer analgesics on a scheduled basis for the first 24 hours

A nurse is preparing an in service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice? a. Documenting communication with a provider in the progress notes of the client's medical record b. placing a yellow bracelet on a client who is at risk for falls c. leaving a nasal gastric tube clamped after administering oral medication d. administering potassium via IV bolus

administering potassium via IV bolus

A nurse is teaching a group of school aged children about healthy snack options. Which of the following snacks should the nurse include? a. Cheesecake b. air popped popcorn c. milkshake made with whole milk d. baked potato chips

air popped popcorn

Case Study A nurse on the impatient mental health unit is planning care for the client. Specify if the providers prescription is anticipated or contraindicated

anticipated : - encourage the client to avoid napping during the day - provide the client with high calorie fluids every hour contraindicated : - Place the client in a room away from the nurses station - weigh the client each day

A nurses came for a client whose child died from cancer. The client states it's hard to go on without him which of the following questions should the nurse ask the client first? a. What has helped you through difficult times in the past b. has anyone in your family committed suicide c. is there anyone you would like involved in your care d. are you thinking about ending your life

are you thinking about ending your life

A nurse is speaking with a caregiver of a client who has Alzheimer's disease. The caregiver states, providing constant care is very stressful and it is affecting all areas of my life. Which of the following actions should the nurse take? a. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client b. recommend allowing the client to have time alone in their room throughout the day c. discuss methods of how to communicate with the client about resolving problem behaviors d. assist the caregiver to arrange for a daycare program for the client

assist the caregiver to arrange for a daycare program for the client

99. A nurse is caring for a client who is alert anterm-114d oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, not distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following? a. Second degree heart block b. sinus tachycardia c. Ventricular asystole d. atterm-112rial fibrillation

atrial fibrillation

70. A nurse is reviewing the clients electronic medical record. Which of the following findings require follow up? Select all that apply. a. Potassium level b. breath sounds c. WBC count d. temperature e. blood pressure

breath sounds WBC count temperature

A nurses preparing to initiate intravenous fluids via infusion pump to our client. Which of the following actions should the nurse take? Obtain a surge protector that can accommodate the pump and several other appliances verify that the extension cord for the pump is ungrounded report the pump has a frayed cord and proceed with the infusion check the expiration date on safety inspection sticker of the pump

check the expiration date on safety inspection sticker of the pump

A nurse is discussing discharge plans with an older adult client who lives alone and has left sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss? a. Reviewing information about support groups for individuals who have had a stroke b. obtaining an alert system to get help in case of a fall c. providing information about available transportation resources d. choosing an agency to provide home physical therapy

choosing an agency to provide home physical therapy

A nurse is admitting a client to a medical surgical unit. When performing medication reconciliation for the Client, which of the following actions should the nurse take? a. Encourage the client to make his own list after he returns to his home b. include any adverse effects of the medications the client might develop c. exclude nutritional supplements from the list of medications the client reports d. compare new prescriptions with the list of medication the client reports

compare new prescriptions with the list of medication the client reports

A nurse is conducting an initial assessment of a client and notices A discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Contact the charge nurse to see if the prescription was changed b. complete an incident report and place it in the client's medical record c. submit a written warning for the nurse involved in the incident d. compare the current infusion with the prescription and the client's medication

compare the current infusion with the prescription and the client's medication

A nurse is assessing a client who has type one diabetes mellitus and was administered insulin lispro one hour ago. Which of the following manifestations indicates that the client might be experiencing hypoglycemia? a. Hot dry skin b. acetone breath c. confusion d. polydipsia

confusion

A nurse is planning care for a group of clients and is working with one licensed practical nurse LPN and one assistant personnel AP. Which of the following actions should the nurse take first to manage her time effectively? a. Delegate tasks to the APP b. determine goals of the day c. develop an hourly time frame for tasks d. schedule daily activities

determine goals of the day

A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following action should the nurse take first? a. Refer the family to a grief support group b. determine the roles of individual family members c. encourage the family to assign specific task to individual family members d. assist the family to establish a daily routine

determine the roles of individual family members

A nurse is caring for a male who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care? a. Wash the penis from the scrotum to the tip using a spiral motion b. use water with no soap to prevent skin irritation c. discard the washcloth after cleansing the urethral meatus d. don't sterile gloves to prevent infection

discard the washcloth after cleansing the urethral meatus

A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include? a. Encouraged the client to avoid wearing shoes at home b. place a throw rug over electrical cords c. mark the edges of the doorway to the house with tape d. ensure that area rugs have rubber backs

ensure that area rugs have rubber backs

81. A nurse is caring for a client is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client? A. Posting swallowing precautions at the head of the client's bed B. nothing changes in the treatment plan and the client's medical record C. recording the client's progress and the nurses notes D. having interdisciplinary team meetings for the client on a regular basis

having interdisciplinary team meetings for the client on a regular basis

Case study, evaluating the clients response to therapy

improved : - deep tendon reflexes - blood pressure no change : heart rate

Which of the following interventions should the nurse include in the plan of care? Select all that apply a. increase oxygen flow rate to 4L/min b. assess the clients breath sounds c. perform chest percussions and vibration d. Restrict the clients fluid intake e. instruct the client to perform diaphragmatic breathing f. place the client in a supine position

increase oxygen flow rate to 4L/min assess the clients breath sounds perform chest percussions and vibration

case study, client diagnosed with schixophrenia

indicated : - ask the client about the content of their hallucinations - instruct the client on expected hygiene practices - access the client for suicidal ideation contraindicated : - allow the client to watch tv at a high volume - place the client in a room near the activity room

A charge nurses teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? a. Avoid preparing medications for more than two clients at one time b. complete and incident report if a client vomits after taking a medication c. inform the client about the action of each medication prior to administration d. Read medication labels at least twice prior to administration

inform the client about the action of each medication prior to administration

A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first? a. Obtain a prescription for pain medication b. collect blood cultures c. transport the child to obtain a CT scan d. initiate seizure precautions

initiate seizure precautions

A nurse is implementing seizure precaution for a client who has had a clonic tonic seizure. Which of the following intervention should the nurse include in the plan of care? a. Provided tracheostomy tray at the bedside b. place the client in supine position c. insert an IV saline lock d. A plastic tongue depressor at the client's bedside

insert an IV saline lock

The nurse is providing teaching about lithium to the client and clients adult child. Select three statements the nurse should include. a. Blurred vision is an expected adverse effect of this medication b. it will take at least a week before this medication reaches a therapeutic level c. this medication can cause nausea and drowsiness d. you will be placed on a low sodium diet while taking this medication e. this medication can cause weight gain

it will take at least a week before this medication reaches a therapeutic level this medication can cause nausea and drowsiness this medication can cause weight gain

A nurses planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take? a. Place the clients head of bed flat b. apply heat to the client's abdomen c. keep the client on NPO status d. administer A laxative to the client

keep the client on NPO status

58. A nurses came for a client who is receiving brachytherapy for an endometrial cancer. Which of the following actions should the nurse take? a. Discard the radioactive source in the client's trash can b. place the client soiled bed linen in a biohazard bag outside the client's room c. where in isolation gown when caring for the client d. keep visitors at least six feet (1.8m) away from client

keep visitors at least six feet (1.8m) away from client

A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take? a. Perform the cleansing procedure with a swab 2 times b. pick up the catheter 13 cm (5 in) from its tip c. cleanse the tip of the penis in a side to side motion d. lift the penis so that it is perpendicular to the client's body

lift the penis so that it is perpendicular to the client's body

A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following intervention should the nurse include to support the clients nutritional requirements? a. Maintain calorie intake at 1500 per day b. provide a low protein, high carbohydrate diet c. make a calorie count for foods and beverages d. schedule meals at six hour intervals

make a calorie count for foods and beverages

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 minutes. The nurse should identify which of the following conditions is a possible cause of fetal bradycardia? a. Chorioamnionitis b. maternal fever c. fetal anemia d. maternal hypoglycemia

maternal hypoglycemia

A nurse is assessing a client who received hydromorphone 4 milligrams IV 15 minutes ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications? a. Acetylcysteine b. Protamine c. naloxone d. flumazenil

naloxone

A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure? a. Administer nitroglycerin 0.4mg SL 30 minutes before the procedure b. draw blood specimens for culture and sensitivity c. obtain a CBC with differential d. transport the client to radiology for a CT scan

obtain a CBC with differential

A nurse is collecting A sputum specimen for a client who has tuberculosis. Which of the following actions should the nurse take? a. Wait one day to collect the specimen if the client cannot provide sputum b. where's sterile gloves to collect the specimen from the client c. ask the client to provide 15 to 20 ML of sputum into the container d. obtain the specimen immediately upon the client waking up

obtain the specimen immediately upon the client waking up

A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? a. Replace the carpet with hardwood floors b. encourage physical activity prior to bedtime c. wear clothing with zippers instead of buttons d. place the locks at the tops of exterior doors

place the locks at the tops of exterior doors

A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for this client? Wheat crackers canned barley soup potato pancakes white flour tortillas

potato pancakes

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take? a. Monitor blood pressure every two hours b. attach an inline filter to the IV tubing c. protect the IV bag from exposure to light d. keep calcium gluconate at the clients bedside

protect the IV bag from exposure to light

A nurse is caring for a client who is receiving radiation therapy and it's experiencing anorexia. Which of the following actions should the nurse take? a. Encouraged the client to drink low protein supplements b. tell the client to drink two glasses of water with meals c. serve the clients largest meal in the evening d. provide the client with cold foods rather than hot foods

provide the client with cold foods rather than hot foods

80. A nurse is reviewing the medical history of a client who asks about the use of warfarin. The nurse should identify which of the following findings as a contraindication for the administration of this medication? a. Recent myocardial infarction b. recent eye surgery c. breast cancer d. thrombophlebitis

recent eye surgery

97. A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precaution should the nurse take? a. Place a mask on the client prior to transport b. wear a face shield prior to entering the clients room c. use an alcohol based rub following client care d. remove the protected gown while in the client's room

remove the protected gown while in the client's room

A nurse is caring for a client who is postoperative following a liver biopsy. Which of the following positions should the nurse place the client immediately following the procedure? a. Prone b. Trendelenburg c. hi fowlers d. right lateral

right lateral

A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestation should the nurse expect? a. Suspicious of others b. self-centered behavior c. violates others rights d. callousness

self-centered behavior

A nurse is providing this church instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider? a. Weight gain b. dry mouth c. sedation d. shuffling gait

shuffling gait

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department period which of the following should the nurse include when the teaching about interacting with the client who is aggravated, pacing, and speaking loudly? A. Use a face shield with a mask when providing care for the client B. tell the client you seem to be very upset C. engage the panic alarm D. initiate seclusion protocol

tell the client you seem to be very upset

A nurse is assessing the fontanelles of an 8 month old infant which of the following findings should the nurse recognize as an expected finding? a. Both fontanelles are the same size b. both fontanelles show molding c. the posterior fontanelle is open d. the anterior fontanelle is open

the anterior fontanelle is open

A nurse is caring for a client who states he recently purchase lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client has a history of alcohol use disorder b. the client has a history of asthma c. the client takes vitamin C daily d. the client takes furosemide twice daily

the client has a history of asthma

A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation for the tidaling? a. There is a loop of tubing below the drainage system b. the system is working properly c. the tubing is partially obstructed by clots d. the lung has re expanded

the system is working properly

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism? a. I'm so glad I've retired because the work was making me sick and depressed b. since I retired I have entered many gardening competitions c. there were layoffs on my company so I journaled about what I accomplished during my career d. I had to retire because my boss didn't like me

there were layoffs on my company so I journaled about what I accomplished during my career

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage? a. Take pancrealipase b. complete oral hygiene c. eat a meal d. using an albuterol inhaler

using an albuterol inhaler

A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications? a. Ranitidine b. vitamin B12 c. vitamin K d. metoclopramide

vitamin B12

And the nurse is working with a client who has an anxiety disorder and is in orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. let me show you simple relaxation exercise to manage stress c. we should establish our rules in the initial session d. let's talk about how you can change your response to stress

we should establish our rules in the initial session

A nurse in a family health clinic is caring for a client who requires information regarding the correct use of condoms. Which of the following statements should the nurse make? a. Use of a petroleum based lubricant with a condom increases the condoms effectiveness b. condoms are equally effective for birth control with or without the use of vaginal spermicides c. when using implanted contraceptive methods condoms should also be used to protect against STD's d. ensure that the condom fits snugly over the tip of the penis

when using implanted contraceptive methods condoms should also be used to protect against STD's