Comprehensive Fundamentals

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 is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin

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 manifestations of influenza. Which of the following clients should the nurse report to the provider immediately?

An infant whose WBC count is 24,000/mm3

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 is caring for a client who has a platelet count of 50,000/mm3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take?

Apply pressure to the catheter removal site for 10 min.

A nurse is observing a client who has schizophrenia and is in the dayroom 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 caring for a client who has deep partial- and full-thickness burns and requires a topical antimicrobial drug. The nurse should reinforce with the client that the goal of this medication therapy is to reduce which of the following outcomes?

Bacterial growth

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 beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a 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 is collecting data from a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection?

Candidiasis

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum.

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port.

A nurse is caring for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen?

Collect the specimen upon arising in the morning.

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves to remove the old dressing.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's 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 is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac.

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express his thoughts about death and dying.

A nurse is reinforcing teaching with a client who is recovering from gallbladder surgery about how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?

Hold breath for 5 seconds after goal volume is reached.

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?

Hold the linens away from the body and clothing.

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

Measure the client's weight daily.

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

Meperidine

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

Obtain client information.

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 oximetry of 85%

A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take?

Raise the level of the bed.

A nurse in 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 this client's behavior?

Speak to the client with clear, calm, caring statements.

A nurse is reinforcing teaching with a client who is going to have an electroencephalogram (EEG) in the morning. Which of the following information should the nurse provide the client?

"Shampoo your hair before the procedure, and don't put any styling products on it afterward."

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 conversation?

"Tell me about your favorite video game."

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 at a family planning clinic is preparing to give a presentation to clients about how 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 community health nurse is contributing to the plan of care for four high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for first?

A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy

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

A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL

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?

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

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 nurse's priority?

Erratic behavior

A nurse in a substance use disorder program is interacting with a client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission?

"I have read that problems with substances can have a variety of predisposing factors."

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause for the client's sleeping difficulties?

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

A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following statements should the nurse provide further reinforcement of teaching?

"I prefer tub baths to showering."

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older."

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

"If the client seems confused, I'll raise all four side rails so that he doesn't hurt himself."

A nurse is caring for a client who takes warfarin to treat chronic atrial fibrillation and has early manifestations of Alzheimer's disease. The client's partner asks 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 at a long-term care facility hears an assistive personnel (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 is reinforcing teaching with a school-age child who has just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse reinforce with the child and his parents about care during the first 48 hr?

"Keep the cast above the level of your heart."

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 the most about being hospitalized."

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 instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands."

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 observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

"Using a cuff that is too small will result in an inaccurately high reading."

A nurse is assisting with the admission of a child who has a urinary tract infection (UTI) 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 is drawing blood for laboratory testing from a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene.

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 (AP) about dietary restrictions for a client who is taking phenelzine to treat depression. The AP's selection of which of the following foods for the client's lunch indicates an understanding of the instructions?

Chicken salad

A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water.

A health care facility's leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurses take first?

Collect the staff's input about planning and implementing the change.

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

Compare the medical record number and name on the MAR with the client's identification band.

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR?

Confirm unresponsiveness.

A nurse is reviewing the medical record of a client who is requesting a prescription for sildenafil citrate. Which of the following data in the client's record should the nurse identify as a contraindication for the use of this medication?

Current use of nitroglycerine to treat heart failure

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe.

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound?

Excessive wax in the ear canal

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking.

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

Offering the client a diet high in fluid and fiber

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line.

A nurse is contributing to the plan of care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restraints within 24 hr.

A nurse is collecting data from a client who has an abdominal aortic aneurysm (AAA). 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 is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand.

A nurse is reinforcing teaching with a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?

The side hip between the iliac crest and anterior iliac spine

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client's.

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc

A newly licensed nurse in an urgent care center is caring for a child 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 preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the client's decision.

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

Obtain the services of an interpreter.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for the tracheostomy care

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart or sour foods first.

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

Palpating the client's fundus.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

Perform hand hygiene.

A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is the nurse's priority?

Performing hand hygiene before and after contact with the client

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is reinforcing teaching with a client who has a new prescription for 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 is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45° angle to the bed.

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 client's level of orientation?

Post a large calendar on the bulletin board.

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent exudate

A nurse is reinforcing teaching with the parents of a child who has a new prescription of lamotrigine 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 is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty?

Reading the newspaper

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)?

Record urinary output after emptying the indwelling urinary catheter.

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

Reduce dietary sodium.

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain.

A nurse is reinforcing teaching with a client about how to use an albuterol metered dose inhaler. 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?

The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from his mouth, tilt his head back slightly, and then open his mouth. Next, he should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway. After holding his breath for 10 seconds, the client should resume his usual breathing pattern.

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation.

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 this client?

Walking with a staff member

A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wipes the labia minora in an anteroposterior direction.

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 story time, before bed."

A nurse 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 collecting data from a client who has an onsent of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain?"

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth?"

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse make?

"You don't have to give up pasta; just adjust the amount you eat."

A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask?

"Does anyone smoke around or in the same house as your child?"

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make?

"Donate autologous blood before the surgery."

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 is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?

"I am going to listen to your abdomen."

A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery."

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 1 diabetes mellitus how to manage the child's disorder during illness, such as colds. Which of the following statements by the parent indicates an understanding of the teaching?

"I'll check his blood glucose more often."

A provider tells a client who reports practicing Hinduism that, at 12-weeks of gestation, she needs more protein in her diet and suggests eating more meat. After the provider leaves the 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 collecting data from a 66-year-old client during a routine physical examination at her first clinic visit and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I had any immunizations." Which of the following responses should the nurse make?

"Let's go ahead with giving you this immunization."

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 minutes after eating a meal."

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections."

A nurse is reinforcing teaching with a client who is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include?

"Your procedure will only take 10 or 15 minutes for each eye."

A nurse is reinforcing teaching with a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following information should the nurse reinforce with the client?

"Your risk for ectopic pregnancy increases with an IUD."

A nurse is reinforcing discharge teaching with a client who has a new prescription for metoprolol. Which of the following instructions should the nurse include?

- "Do not stop taking this medication abruptly." - "Count your radial pulse daily." - "Change positions slowly."

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

- Nausea and vomiting .- Diaphoresis and dizzines - Anxiety and feelings of doom

A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse in an urgent care center is collecting data from a group of clients who all have an 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 assisting with the plan of care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse recommend to use for this client?

A nasal cannula

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

Absent bowel sounds with distention

A nurse in a long-term care facility is caring for a group of clients. One of the clients is 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?

Accompany the client back to his room.

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

Administer analgesics to the child on a routine schedule throughout the day and night.

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

Applying warm compresses to sore joints

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 is assisting with developing a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should suggest monitoring the client for which of the following complications?

Aspiration

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?

Attempt to increase the clients' self-motivation.

A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die," and is now pacing in an increasingly agitated and angry manner. Which of the following actions is the nurse's priority?

Attempt to reduce environmental stimuli.

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

Blood pressure

A nurse is assisting with the care of a client who has Addison's disease and comes to the emergency department reporting nausea, vomiting, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse should expect that the provider will prescribe which of the following medications?

Hydrocortisone

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?

Collapse the device of air after emptying.

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 a list of calcium sources for this client?

Collard greens

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.

A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?

Data collection for the client

A nurse is caring for a client who is taking acarbose to treat type 2 diabetes mellitus. For which of the following adverse effects of this medication should the nurse monitor?

Diarrhea

A nurse is reinforcing teaching with the parents of an infant who has a cleft palate. The parents ask 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 is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 min.

A nurse is assisting with the admission of a client to the medical unit and asks him if he has advance directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

Durable power of attorney document

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the client's head of bed 45° before the feeding.

A nurse is reviewing the laboratory data of a client who reports manifestations that suggest systemic lupus erythematosus (SLE). The nurse should expect an increase in which of the following parameters for a client who has SLE?

Erythrocyte sedimentation rate (ESR)

A nurse is discussing fire safety with newly hired nurses. The nurse should identify which of the following actions as the priority if a fire occurs in the healthcare facility?

Evacuate clients from the unit.

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses.

A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take?

Explain that it is against policy to share access codes and refer the resident to his supervisor.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client.

A nurse is assisting to teach a group of unit nurses about a client who has a surgical wound that is healing by secondary intention. Which of the following information should the nurse include in the teaching?

Granulation tissue fills the wound during healing.

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.

A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority for the nurse to report to the provider?

Hyperkalemia

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 caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using two identifiers.

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1in).

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 clients' information?

In the unit medication room.

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability of the toddler to cry or speak

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

Initiate airborne precautions.

A charge nurse is coordinating the evacuation of clients from a 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 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 receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher.

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

Locks the brakes on the bed and the wheelchair before moving the client.

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 insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?

Lower abdomen

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 degrees.

A nurse on a medical-surgical unit is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes these values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

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 the parent of a child 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 the parent?

Oral glucocorticoids are more likely to slow linear growth in children.

A nurse is assigned to care for several clients who are postoperative. 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 performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

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 assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?

Screening groups of older adults in nursing care facilities for early influenza manifestations.

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

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

Send an e-mail 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 the charge nurse plan to use to resolve these conflicts?

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

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 this client's behavior?

Speak to the client with clear, calm, caring statements.

A nurse within 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 this client's behavior?

Speak to the client with clear, calm, caring statements.

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions.

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 about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop reinforcing the teaching and check with the surgeon about

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

A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch

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 collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2° C (102.6° F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?

Temporal

A nurse is collecting data for an adult client. Identify the correct sequence of steps used for data collection of the abdomen.

The appropriate sequence for the nurse to perform the abdominal data collection is to inspect, auscultate, percuss, and then palpate. This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other data collection for an adult client is inspection, palpation, percussion, and auscultation.

A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hr ago. The nurse finds 10 mm of induration with slight redness. Which of the following conclusions should the nurse make?

The client has had an exposure to tuberculosis.

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 client's insomnia?

The client watches television in her bed during the day.

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 (ELISA) 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 infant's mother is likely HIV positive.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?

The nurse washes with her hands held higher than her elbows.

A nurse is assisting to prepare for the transfer of a client from the postanesthesia care unit (PACU) following a subtotal thyroidectomy. Which of the following equipment should the nurse have available at the client's bedside?

Tracheostomy tray

A nurse is reinforcing teaching with a client about treatment options for profound sensorineural hearing loss. The nurse should include which of the following information about the function of cochlear implants?

Transmits impulses directly to auditory nerve endings nerve endings

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?

Turn the stocking inside out up to the heel before applying.

A nurse is preparing to administer 10 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take?

Use separate syringes for administering insulin glargine and NPH insulin.

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level.

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

Corticosteroids

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

Give the client a written record of his BP to bring to his provider

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

Hct 55%

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?

"Let's set up a meeting time with the doctor to discuss your options for home care."

A nurse is talking with the parent of a 4-month-old infant about growth and development. Which of the following statements indicates that the parent needs further instructions?

"My baby loves to play with the pillows in her crib."

A nurse is reinforcing teaching about self-administration of NPH insulin with a client who has type 2 diabetes mellitus. Which of the following instructions should the nurse include?

Rotate injection sites within the same area.