CP20

A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?

Swollen lips

A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrelipase. Which of the following should the nurse include in the teaching?

Take with meals.

A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action?

Notify the facility

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene?

Offers oral fluids to the client

A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

Ototoxicity

A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?

Place the client in a low-Fowler's position.

A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include?

Place the infusion pump cord against the baseboards.

A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?

Place the newborn 45 cm (18 in) from the light source.

A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment?

Pulse oximeter

A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take?

Discard opened cans of formula after 24 hr.

A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis?

Sputum culture

A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include?

Eat a dry carbohydrate before getting out of bed.

A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include?

Educating the client how to cover nose and mouth with tissues when coughing

A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?

Egg whites

A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?

Fever

A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include?

Gently massage the skin under the straps once per day.

A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?

HBA1C

A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?

Hyperemesis

A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?

Infuse 0.9% sodium chloride V.

A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating?

Justice

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Measure the amount of gastric drainage every 2 hr.

A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

Monitor for abdominal ascites.

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

Monitoring the insertion site for infection

A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider?

No bowel movement for 3 days

A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

The client pockets food on one side of his mouth.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins.

A nurse is providing dietary teaching for a client who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching?

Avoid foods that have high levels of oxalates.

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?

Blood pressure 94/68 mm Hg

A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication?

Burning

A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching?

Change clothes after working in the field.

A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome?

Change in mental status

A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?

Check the FHR.

A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report?

Client found lying on the floor near the bedside table.

A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?

Clopidogrel

A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?

Consistent contractions last 80 seconds.

A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

Decreased reflexes

A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

Determine the client's pain level.

A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take?

Dim the lights in the room prior to the examination.

A client who has a diagnosis of com acenta is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take?

Prepare the client for a cesarean section.

A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

Pulse 54/min

A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.)

Repeats the words of others when speaking Speaks in word salad Has a blunt affect Experiences delusions

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

Rephrase sentences the client does not understand.

A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

Report the incident to Adult Protective Services.

A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take?

Report to the nurse manager.

A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take?

Require the cient wear a dosimeter badge.

A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take?

Review deep breathing and coughing exercises.

A nurse is caring for a client following insertion of a subclavian prescription to initiate an IV infusion of Ringer's lactate at 150 ml per hr. Prior to starting the infusion, which of the following actions should the nontunneled percutaneous central venous catheter (CVC). The provider writes a nurse take?

Review the chest x-ray report.

A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?

Schedule routine care tasks during hours when the client is awake.

A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe?

Sertraline

A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications?

Shellfish allergy

A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation?

Sucralfate 1 g PO 1 hr ac

A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

Elevated pulmonary artery pressure

A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections (UTIS). Which of the following information should the nurse plan to include in the teaching about UTI prevention?

Empty the bladder before and after intercourse.

A nurse performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take prevent a pressure injury?

Encourage client fluid intake of 2,500 ml daily.

A nurse is reviewing the medical record of a client who has new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity?

Furosemide

A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Generalized edema

A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect?

Head compression

A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories?

Healthy weight

A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?

Hospice care encourages the family to coordinate health care services.

A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of following findings should the nurse expect?

Hyperreflexia

A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine?

Hypertension

A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect?

Hypotension

A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?

Identify the reason for the client's refusal.

A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

Improve joint functioning.

At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?

Indigestion

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?

Inform the client of available community resources.

A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation?

Iron

A nurse is creating a plan care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

Monitor the client for 1 hr after meals.

A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions should the nurse take?

Occlude the IV tubing above the injection port.

A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first?

Open the client's windows.

A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following?

Opioid intoxication

A nurse is planning care for a client who has a gambling disorder. Which of following instructions should the nurse provide to the client?

Participate in a 12-step program.

A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?

Pedal pulses 2+

nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

Pertussis

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

Use a designated stethoscope when caring for the toddler.

A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is

asymmetric, with variegated coloring.

A nurse is evaluating the allergy profile of a client who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan?

lodine

A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include?

relieved by position change

A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching?

series of four hepatitis vaccines is recommended to prevent viral hepatitis.

A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication this medication?

Нерatitis C

A nurse is providing grief counseling for the parents of a school-age child whose sibling recently died. Which of the following statements should the nurse make?

"Bring the child to the funeral service before visitors arrive."

A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?

"Do you have a plan to end your life?"

A nurse is caring for client who has schizophrenia. Which of the following findings is the nurse's priority?

The client reports hearing voices.

A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

The client takes aspirin daily.

A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding?

The infant closes their eyes.

A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

The infusion pump for administering contimuous feeding is turned off.

A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

The nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The provider's prescription should include the

A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex?

Avocados

A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?

"This technique decreases the risk of subcutaneous infiltration."

A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include?

"Try to have your baby empty your breasts with each feeding."

A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern?

A brainstorming session with nurses

A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel?

A client who had a stroke 2 days ago and needs help toileting

A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include?

A client who has a history of MRSA can still transmit the infection,

A nurse is performing change-of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first?

A client who has gastroenteritis and is lethargic and confused

A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?

A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding

A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the following clients should the nurse see first?

A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days

A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective?

"I will use my cell phone on the ear opposite of my pacemaker."

A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,

"My stoma will drain liquid fluid continuously."

A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience muscle weakness."

A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?

A dient who has a traumatic arm amputation

A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following?

The tubing may be kinked.

A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

Troponin I 1.8 ng/mL

A nurse is caring for a client who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI?

Urine output of 250 mL/hr

A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate?

Use aseptic technique and drop the medication into the conjunctival sac.

A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder?

Uses others for personal gain

A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Viewing the newborn's actions to be uncooperative

A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

Wear an N95 respirator.

A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective?

Weight loss

A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Withhold digoxin.

A nurse is teaching a newly licensed nurse about informed consent. Which of the following statements should the nurse include in the teaching? (Select all that apply.)

witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave client who signs an informed consent form should understand the treatment plan." "A client who signs an informed consent form should be competent." "The nurse should disclose the purpose of the treatment before the client signs the consent form."

the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of

Abdominal rigidity

A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching?

Administer the medication with a glass of orange juice.

A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?

Allow the infant to suck on a pacifier during feedings.

A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant?

An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo

A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan?

Compare blood pressure in both arms every 2 hr.

A community health nurse is teaching a group of restaurant workers about hepatitis A. Which of the following statements should the nurse make?

"Hepatitis A can be spread by fecal-oral contact."

A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?

"I am thankful there are no serious complications from this type of surgery."

A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

"Please stop this discussion."

A nurse in a mental health clinic is observing clients the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic?

"You're curious why I am interested in you and not the others?"

A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

0900

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

1 cm of water present in the water seal

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer pain medication to the client.

A nurse from the State Health Department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention?

Lyme disease

A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care?

Maintain the head at a midline position.

A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings Indicates fluid overload?

Bounding pulses

A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder (OCD). Which of the following is appropriate for the nurse to include in the plan of care?

Teach the client to meditate about obsessive thoughts.

A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview?

Lean in slightly when speaking to the client.