Comprehensive final

A nurse is assisting with the admission of a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurses priority?

Initiate airborne precautions

The charge nurse is coordinating the evacuation of clients from the facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process?

Instruct clients who are able to ambulate to leave

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following findings should indicate to the nurse that the AAA is expanding?

Report of sudden severe back pain

A nurse is caring for a client who has a pseudomembranous colitis do to CDIff. Which of the following interventions is the nurses priority?

Performing hand hygiene before and after contact with the client

A nurse On the pediatric unit is assisting with the plan of care for a preschooler who will have a surgical procedure in the morning. The child has been crying despite his parents presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan because it offers which of the following benefits?

Allows the child to manipulate toy medical equipment

A nurse delegates newly Licensed nurse to provide one on one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching?

Ambulates the client's roommate while the client sleeps

A nurse in an urgent care center is reviewing laboratory results for several clients who have benefit stations of influenza. Which of the following clients should the nurse report to the provider in mediately?

An infant who is wbc count is 24,000

A nurse is observing a client who has schizophrenia and is in the day room when another client asks him if two items of clothing match. He replies a match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on. The nurse should identify these statements as which of the following speech alterations?

Associative looseness

A nurse is beginning her shift and reviewing the medication administration records for her clients. She notes a dosage of medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage

A nurse response to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first?

Check airway patency

A nurse is reinforcing teaching with a client who has hypothyroidism and is taking levothyroxine. the nurse should instruct the client to report which of the following manifestations to the provider?

Chest pain

A nurse is reinforcing teaching with an assistive personnel about dietary restrictions for a client who is taking phenelzine to treat depression. The APs selection of which of the following foods for the clients lunch indicates an understanding of the instructions?

Chicken salad

A nurse is caring for a client during Her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on the list of calcium sources for this client?

Collard greens

The healthcare facilities leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurse take first?

Collect the staff input about planning and implementing the change

A nurse is assisting with the admission of a client to the medical unit and ask him if he has advanced directives. The client states I have a document with me the name of someone who can make healthcare decisions for me I am not able to. Should identify that the client is referring to which of the following documents?

DPA

A nurse is collecting data from a client who has aids and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider?

Decreased hemoglobin

A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction. Which of the following manifestations should the nurse identify as indications Of a myocardial infarction?

Diaphoresis, dizziness, anxiety, impending doom, nausea, and vomiting

A nurse is contributing to the plan of care for a client who had a stroke and is to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend to take prior to initiating each feeding?

Elevate the head of the bed

A nurse is collecting data from a client who is taking varenicline for smoking cessation . Which of the following findings is nurses priority?

Erratic Behavior

A nurse is discussing the fire safety with newly hired nurses. Which of the following identify as the priority if a fire occurs in the health care facility?

Evacuate clients from the unit

A nurse is talking with a group of clients at a senior center about the risk factors for osteoporosis. Which of the following statements should the nurse include?

Extended periods of immobility increase your risk for osteoporosis

A nurse in the providers office is talking with an older adult client reports having trouble sleeping. Which of the following statements should the nurse identify as a possible causes for the patients sleeping difficulties?

I often have a cup of coffee with my dessert before going to bed

A nurse is caring for a client who takes more friend to treat chronic a fib and has early manifestations of Alzheimer's disease. The clients partner asked the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make?

It is likely that ginkgo biloba will interfere with the effectiveness of his other medications

A nurse is reinforcing teaching with the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the instructions?

It will help our child if we structure our daily routine

A nurse is talking with the parent of a four month old infant about growth and development. Which of the following statements indicates that the parent needs further instruction?

My baby loves to play with pillows in her crib

A nurse is assisting with the plan of care for a client who is post operative following a hip arthroplasty. In the clients medical record, the nurse notes a history of COPD. Which of the following oxygen delivery method should the nurse recommend to use this client?

Nasal cannula

A nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report to the provider as an indication of impending airway obstruction?

Nasal flaring

A nurse is reinforcing teaching with a client who has a new prescription for a Doxycycline. The nurse should reinforce to the client the need to monitor for which of the following adverse effects of this medication?

Photosensitivity

A nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the clients level of orientation?

Post a large calendar on the bulletin board

A nurse is assigned to care for several clients who are post operative. The nurse should identify the client taking which of the following medications is at risk for delayed wound healing?

Prednisone to treat persistent arthritis exacerbations

A nurse is collecting data from a client who has an acute visual disturbance and describes it as a curtain pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders?

Retinal detachment

A nurse is collecting data from a school age child who has celiac disease. Which of the following findings should the nurse expect?

Steatorrhea

A nurse is reinforcing teaching with a client who has a new prescription for sertraline. The client asked the nurse if we should continue to take St. John's wort for depression. Which of the following instructions should the nurse to give the client?

Stop taking the herbal supplement while taking the medication

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction?

Stop the infusion

Ours in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse can I vote in the upcoming presidential election? Which of the following responses should the nurse make?

We can work together to find out how you can get a mail in ballot

A nurse is reinforcing teaching with a client who is scheduled for LASIK surgery which of the following information should the nurse include?

Your procedure will only take 10 to 15 minutes per eye

A nurse is reinforcing teaching with the client who has come to the family planning clinic requesting an IUD. Which of the following information should the nurse reinforced with the client?

Your risk for ectopic pregnancy increases with an IUD

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization?

A 10 piece wooden puzzle

A nurse on the pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?

A Client in DKA and a blood glucose of 375

A nurse in a long-term care facility is caring for a group of clients. One of the clients as walking in the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first?

A companyto his room

A community health nurse is contributing to the plan of care for for high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for first?

A four day old newborn who has elevated Bilirubin level and requires photo therapy

A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma?

And irregularly shaped brown lesion with light blue areas on the neck

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?

Apply continuous pressure to the lower part of the child's nose

A nurse in a prenatal clinic is collecting data from several clients. which of the following client reports should the nurse identify as an expected physiologic adaptation to pregnancy?

Breast tenderness

A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client?

Build trust with the client by sitting quietly with him

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record to the clients bedside and perform which of the following verification procedures?

Compare the medical record number and name on the medication administration record with the clients identification band

A nurse is caring for a client who has a new diagnosis of acute systemic lupus erythematosus And is to begin medication therapy. Which of the following types of medications should the nurse expect to administer?

Corticosteroids

A nurse is reinforcing teaching with the parents of an infant who has a cleft palette. The parents asked the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months to prevent which of the following outcomes?

Difficulty with language acquisition

A nurse is caring for a client who has MRSA infection. A dietary assistant asks the nurse what precautions are necessary for entering the clients room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting

A nurse participating in the community health fair is providing information to a client who has a blood pressure of 150/90 during a blood pressure screening. Which of the following actions should the nurse take?

Give the client a written record of his blood pressure to bring to his provider

A nurse is reinforcing teaching with a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include?

Increase her caloric intake with meals

A nurse is collecting data from a client who has tuberculosis and a prescription for EthAmbutol. The nurse should inform the client that he is likely to develop which of the following alterations as an adverse effect of this medication?

Loss of red\green color discrimination

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize her femur fracture. Which of the following actions should the nurse recommend for the clients plan of care?

Offer the client a diet high in fluid and fiber

A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication?

Pulse ox of 85%

A newly licensed nurse in an urgent care center is caring for a client who has bruises that the nurse suspects are due to child abuse. Which of the following actions should the nurse take?

Report the suspected abuse to local authorities

A nurse is reinforcing teaching about self a ministration of NPH insulin with a client who has type two diabetes. Which of the following instructions should the nurse include?

Rotate injection sites within the same area

A charge nurse in a long-term care facility notes that several staff members are linked in completing an annual mandatory educational session about extremity restraint safely. Which of the following actions should the nurse plan take?

Send an email to each nonadherent employee that includes a link to upcoming educational sessions

A charge nurse in a skilled nursing facility notes several recent conflicts among staff on different shifts. Which of the following strategies should charge nurse plan to use to resolve these conflicts?

Set up a series of meetings for all staff members to discuss issues

A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include?

Sit with your back supported, keep your knees at hip level, and use an ergonomically designed computer keyboard

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make ?

Tell me what concerns you most about being hospitalized

A nurse is collecting data from a client who is receiving clozapine to treat schizophrenia. The nurse should identify that an increase in which of the following parameters is an early indication of agranulocytosis?

Temperature

A nurse is reinforcing teaching with the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include?

The tubes should stay in place until they fall out on their own

A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse why did this happen to me? Which of the following responses should the nurse make?

This must be so difficult for you

A nurse is assisting to prepare for the transfer of a client from the post anesthesia care unit following a sub total thyroidectomy. Which of the following equipment should the nurse have available at the patient's bedside?

Tracheostomy tray

A nurse is assisting with developing a plan of care for a client who has GERD. The nurses should suggest monitoring the client for which of the following complications?

Aspiration

A nurse is assisting with the admission of a client who has a urinary tract infection and a history of Myelomeningocele. After the admission history is complete, which of the following actions should the nurse recommend?

Attach a latex allergy alert identification band

A nurse in an urgent care center is collecting data from a group of clients who all have in odor Of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse?

A client who is difficult to arouse and is unable to respond to questions

A nurse is reinforcing discharge teaching with a client who had a TIA. The nurse should instruct the client to monitor which of the following parameters at home?

Blood pressure

A nurse on a pediatric mental health unit is caring for a school age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in the conversation?

Tell me about your favorite videogame

A nurse is caring for a client who has dehydration. Which of the following laboratory values should the nurse expect for this client?

Hematocrit 55%

A female client who has we currency Cystitis asked the nurse about preventing future episodes. Which of the following statements should the nurse provide for the reinforcement of teaching?

I prefer tub baths to showering

A nurse is reinforcing teaching with a client who has a spinal cord injury and will need to perform intermittent urinary self catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure?

I will perform intermittent self catheterization every 2 to 3 hours

A nurse is reinforcing teaching with the parent of a child who has type one diabetes how to manage the child's disorder during illness, such as cold. Which of the following statements by the parent indicates an understanding of the teaching?

I'll check his blood glucose more often

A nurse is caring for a client who is taking warfarin. Which of the following laboratory values should the nurse recognize as an effective response to the medication?

INR 3.0

A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further instruction is required?

If the patient seems confused, I will raise all four side rails so that he doesn't hurt himself

During a client care staff meeting, A charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing client information?

In the unit medication room

A nurse at a long-term care facility hears an AP talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions?

It's almost time for your appointment. Let me do your hair for you and brush your teeth

A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client?

Lateral

A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurses priority to collect?

Measure the clients weight daily

A nurse is reinforcing teaching with the Parent of a child who has a new prescription of iamotrigine For a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?

Rash

A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage the clients behavior?

Speak to the client with clear calm caring statements

A nurse is talking with a parent of a preschooler. The parent reports that her child grows upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent?

Use a stable relaxing routine such as a bath and bedtime story before bed

A nurse is preparing to administer 10 units of insulin glargine and four units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse take?

Use separate syringes for administering insulin glargine and NPH insulin

A nurse at a family planning clinic is preparing to give a presentation to clients about to use a diaphragm. Which of the following information should the nurse plan to include in the session?

Use spermicidal jelly whenever you use your diaphragm

A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for the client?

Walking with a staff member

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding?

Arm cast for a spiral fracture of the forearm

A nurse in an acute care clinic is talking with the client reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss nonpharmacological approaches that will relieve her pain. Which of the following interventions should the nurse suggest?

Apply warm compresses to sore joints

A nurse is reinforcing teaching with a client about how to use an albuterol MDI. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?

Hold the mouthpiece 1 to 2 inches in front of your mouth, tilt your head back slightly and open your mouth wide, depress the canister while taking a slow deep breath, and hold your breath for 10 seconds

A nurse is reviewing the laboratory report for a client who has CDK. The nurse finds the following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, and phosphate 4.8. Which of the following findings is the priority for the nurse to report to the provider?

Hyperkalemia

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make?

Maintain the head of the bed at 30°

A nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The clients neighbor, who speaks to the clients native language and the nurses, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter

A nurse is reinforcing teaching with the parent of a client who has severe reactive airway disease about Glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it Orally. Which of the following information should the nurse provide to the parent?

Oral glucocorticoids are more likely to slow linear growth in children

I nurse is assisting with the care of a client who had a precipitous delivery. The nurse should identify the collection which of the following data as a priority during the fourth stage of labor?

Palpating the clients fundus

A nurse is reinforcing discharge teaching with a client who has had a transient ischemic attack. Which of the following instructions should the nurse include?

Reduce dietary sodium

A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make?

The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common

A nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse recommend to include

The importance of colonoscopy screening starting at age 50 years old

Results of enzyme linked immunosorbent assay testing for an 18 month old infant who has pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors?

The infants mother is likely HIV positive

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia?

The client watches television in her bed during the day

A provider tells a client who reports practicing Hinduism that at 12 weeks gestation she needs more protein in her diet and suggest eating more meat. After the provider leaves examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?

Let's discuss other foods that are also high in protein that you could substitute for meat

A nurse is caring for a client who has chronic phantom limb pain following and above the knee amputation. Which of the following medication prescriptions should the nurse verify with the provider?

Meperidine