Exit
A nurse is reinforcing teaching with the family of the client who is terminally ill about the grief process, which of the following information should the nurse include in the teaching?
Anticipatory grieving prolongs the grief process
A nurse is collecting data from a client who uses a continuous positive airway pressure çpap machine at night for sleep apnea. the nurse should identify which of the following indicates proper use
there is one finger width between he straps and the face
A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. which of the following should the nurse include in the teaching?
Alert the staff if any of your identification bands are missing
A nurse is delegating client care assignments, which of the following tasks should the nurse assign to assistant personnel?
Apply an anti-embolic stocking for a client who is 2 days post-operative
A nurse is preparing a sterile field to perform a dressing change for a client's leg wound which of the following actions should the nurse take
place sterile objects at least 2.5 cm/1 inch from the edge of the sterile field
39. A nurse is reinforcing teaching with a group of AP about intimate partner violence the nurse should include that which of the following is a common characteristic of a predictor for intimate partner violence
possessiveness
A nurse is caring for a client who has anorexia nervosa and who has a behavioral management plan in place. which of the following findings should the nurse identify as an indication that the plan is effective
potassium 3.5/g dl
A nurse is assisting with parental examination of a client who is at 8 weeks of gestation the nurse notes that the client's vagina and uvula are purplish color. the nurse should document that this is the finding of which of the following
Chadwick's sign
A nurse in a clinic is reviewing the medical record of a toddler and notes that he previously had a severe allergic reaction to a gelatin, which of the following immunizations should the nurse identify as unsafe for this client to receive?
Measles Mumps and Rubella (MMR)
A nurse is checking for gastric residual volume on the client who is scheduled to receive an intermittent enteral feeding. The nurse finds that the client has a GRV greater than 250mLs on two consecutivemeasurements, which of the following actions should the nurse take?
Hold the feeding and recheck the GRV in one hour
nurse is reinforcing dietary teaching with a client whose pregnancy's BMI was 30.5 the nurse knows that the client understands the teaching when she states that she should expect to gain how many Ibs. during pregnancy
32
A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to assistive personnel?
Assist the client in range of motion exercises of hands
A nurse is reinforcing teaching with a client who has primary open angle glaucoma and a new prescription for timolol eye drops. which of the following statements by the client indicates an understanding of the teaching
I I should check my heart rate while taking this medication
A nurse begins to bathe a newly admitted client who reports that she has not had anything to eat that day, the nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?
Boundary crossing
A nurse is caring for a 3yr old child immediately following a clinic tonic seizure, which of the following actions should the nurse take?
Check the child for oral injuries
Anurse is assisting for the plan of care for the client who has burns to his lower extremities, which of the following actions should the nurse include. in the plan?
Clean the most contaminated wound first
A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding, the mother asks why is colostrum so important for my baby, which of the following responses should the nurse make?
Colostrum provides many important antibodies the newborn lacks
A home health nurse is collecting data from a client following a mild cardiac infarction MI which of the following statements by the client should the nurse address first
I am worried my body will never be the same as it was before
A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine, which of the following adverse effects should the nurse include on the teaching as indication of serotonin serum?
Diaphoresis
A nurse is caring for a client who is 2 days post-operative following a surgical creation of an ileostomy and is tolerating oral intake, which of the following actions should the nurse take?
Empty the ileostomy pouch every 2-3 hours
A nurse is caring for a client who is one day post-operative following a total hip arthroplasty and is receiving Heparin subcutaneously, which of the following adverse effects of the medication should the nurse report to the provider?
Epistaxis
A nurse is collecting data from a client who diabetic ketoaçidosis, which of the following findings should the nurse expect?
Fruity breath
A nurse is caring for a client who has advanced colorectal cancer and reports that her daughter insists on caring for her at home without assistance. The client states that she prefers help for home health care and hospice, which of the following responses should the nurse make?
I can be with you while you explain your feelings about your care to your daughter
A nurse is collecting data from an adolescent client who has experienced sexual abuse, which of the following statements by the client should the nurse recognize of the use of the defense mechanism of suppression?
I drink beer as often as I can, so I don't have to think about all of the times it happened
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension, which of the following statements by the client indicates an understanding of the teaching?
I should decrease my salt intake to 2g per day
A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablet, which of the following statement by the client indicates an understanding of the teaching?
I should expect pain relief in 1-3 minutes
A nurse is reinforcing teaching about how to collect fecal occult blood sample, which of the following statements by the client indicates an understanding of the teaching?
I should repeat the process three times
A male nurse is assigned to care for an older adult female client, the client tells the nurse that she wants a female nurse to care for her, which of the following statements should the nurse make?
I will ask to have you assigned to a female nurse
A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy which of the following statements by the client indicated an understanding of the teaching.
I will call the provider if I have increased flatulence after the examination
A nurse is reinforcing discharge teaching with a client who has a prescription for a home oxygen therapy, which of the following statements by client indicates an understanding of the teaching?
I will check my oxygen equipment at least once daily
A nurse is reinforcing dietary teaching with a client who has Cushing's syndrome which of the following statements indicates an understanding of the client
I will limit my sodium intake
A charge nurse in a long-term care facility is discussing ethical theories with a group of newly licensed nurses which of the following statements should the charge nurse identify that the newly licensed nurse understands utilitarianism?
I will respect the decision of a client who has a chronic illness and stops treatment
87. a nurse is reinforcing teaching about a low sodium diet with a client who has hypertension. which of the following indicates an understanding of the instructions?
I will use frozen vegetables instead of canned
A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravitation, which of the following client statements indicates and understanding of the nurse's instructions.
I will wait 1 hour before getting up in the morning before having breakfast
A nurse is reinforcing teaching with a client about footcare who has type2 diabetes which of the following statements indicates an understanding of the teaching
I will wear a clean pair of cotton socks each day
A nurse is reviewing the health history of a middle adult client who is receiving chemotherapy for leukemia, which of the following immunizations should the nurse recommend that the client receives?
Inactive Influenza
A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client, which of the following instructions should the nurse include in the teaching?
Instruct the client to inhale while inserting the rectal tube
A nurse is monitoring a client for hyperkalemia, which of the following findings should the nurse report to the provider?
Irregular heartbeat
A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?
Nonmaleficence
A nurse is caring for an adolescent client who has bulimia nervosa, which of the following actions should the nurse take?
Observe the client during and after meals
A nurse is collecting data from a client who has acute cholecystitis, which of the following findings should the nurse expect?
Pain in the right upper abdomen
18. A nurse is collecting data during a muscle skeletal examination of a client who has spinal colon deformity and reports back pain, which of the following images should the nurse identify as an indication of the client has kyphosis?
Person with higher lump on back
A nurse enters the room of a school aged child and finds him on the floor experiencing a tonic colonic seizure, which of the following actions should the nurse take?
Place a pillow under the client's head
A nurse is collecting data from an older adult client who has been taking furosemide for the past week, if the client has developed dehydration as an adverse effect of the medication, which of the following finding should the nurse expect?
Postural hypotension
A nurse is planning care for 4 clients, which of the following task should the nurse ask the charge nurse to reassign to the RN?
Provide discharge teaching about home IV medication therapy
A nurse is providing support to the family of a school aged child who has a new diagnosis of a terminal illness, which of the following actions should the nurse take?
Provide the family with time to talk openly
94. A nurse is contributing to the plan of care of a client who has HIV, which of the following interventions should the nurse recommend?
Remove all fruits and raw vegetables from client's diet
A nurse is reinforcing dietary teaching with a client who experienced a myocardial infarction. The nurse should instruct the client to limit which of the following in her diet?
Saturated fats
A nurse is administering an intermittent enteral feeding through the clients NG tube, during the installation the client reports abdominal cramping and nausea, which of the following actions should the nurse take?
Slow the rate of the formula instillation
A charge nurse is monitoring a group of assistant personnel regarding the use of gloves in contact isolation, which of the following actions by the AP should the charge nurse intervene?
Take gloves off inside when tasks are complete
A nurse is preparing to delegate care to assistive personnel. Which of the following information should the nurse verify prior to delegation?
The AP's job description
A nurse is providing change of shift report for a client which of the following should the nurse include in the report
The clients mother died 4 hours ago from breast cancer
A nurse is monitoring a client who has psychosis for adverse effects of clozapine. which of the following should the nurse identify as an indicationof agranulocytosis?
WBC 1000 mm
A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when taking antibiotics, which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea?
Yogurt
A nurse is reinforcing teaching with a client who is at 36 weeks of gestation and is about to undergo an amniocentesis, which of the following information should the nurse include in the instructions?
You will need to have an empty bladder for the test
A nurse is reviewing the medical records of 5 clients for which of the following events should the nurse write an incident report (select all that apply)
a client received the first dose of an antibiotic medication 1 hour before the collection of blood for a culture and sensitivity test, an approximate amount of urine was recorded after the urine leaked from the client's catheter bag, the client fell while ambulating to the bathroom alone
A nurse is collecting data from a group of clients who have major depressive disorder. the nurse should identify that which of the following clients is at the greatest risk for suicide
a client who exhibits an increase in energy
A nurse is receiving change of shift report on four clients, which of the following clients should the nurse see first
a client who had a hernia repair 4 hours ago and is reporting nausea
A nurse in a long-term care facility has just received change of shift report which of the following should the nurse attend to first?
a client who has a temperature of 38.4 101.1 and appears confused
A nurse is reinforcing teaching with a newly licensed nurse about strokes which of the following statements by the newly licensed nurse indicates an understanding of the teaching
a sudden severe headache is a warning sign of stroke
nurse is reinforcing discharge teaching with a client who is post-operative following cataract removal which of the following instructions should the nurse include in the teaching
avoid laying on the effected side
A nurse is collecting data from a client who has placenta preyia. Which of the following findings should the nurse expect?
bright red vaginal bleeding
A nurse is caring for a client who is terminally ill and is comatose the client has a living will that has a DNR order. The client's son requests removal of the DNR order which of the following actions should the nurse take.
place a hold on the order until review of the ethics committee
A nurse assisting with the development program of a group of older adults. which of the following action should the nurse take?
determine the literacy level of the participants
A nurse is caring for a client who is experiencing alcohol withdrawal the nurse should prepare to administer which of the following medications
diazepam
A nurse is contributing to the plan of care for a chest tube set to continue a suction to relieve a pneumothorax which of the following should the nurse include
ensure that the device is kept below the level of the clients chest
charge nurse is reviewing communications skills with a group of newly licensed nurses. which of the following should the nurse include as an example of assertive communication?
if you don't come in to cover an extra shift tomorrow we won't offer you overtime anymore
A nurse is contributing to the plan of care for a client who has chronic pancreatitis which of the following recommendations for the client's nutrition should the nurse take
increase the client's daily protein intake
A nurse is reinforcing teaching with a newly licensed nurse about client privacy which of the following information should the nurse include in the teaching
information about a client's health can be emailed if encrypted
A nurse is reinforcing with a patient about home safety for the parents of a 6-week-old infant which of the following instructions should the nurse include
keep one hand on your baby's abdomen if you turn away while he is on the changing table
A nurse is positioning a client in preparation for a lumbar puncture which of the following positions should the nurse place the client
lateral recumbent
A nurse is assisting with a community health course for family members of clients who half Alzheimer's disease. which of the following should the nurse include?
limit the number of choices for the client
A nurse is caring for a client who has moderate anxiety which of the following actions should the nurse take
maintain eye contact when talking with the client
A home health nurse is caring for a client who has Alzheimer's disease. the client's son is concerned about his mother becoming frustrated. which of the following interventions should the nurse include?
make a schedule for daily tasks
nurse is contributing to the plan of care for a client who has ascites due to chromosols, which of the following should the nurse recommend including in the plan?
measure the clients abdominal girth
57. A nurse is reinforcing teaching with a client who has hypothyroidism and a new prescription for levothyroxine the nurse should instruct the client to notify the provider for which of the following manifestations of thyroid toxicity?
nervousness
A nurse is reinforcing teaching with a parent of a child who has ADHD and is taking methylphenidate which of the following statements by the parents indicated the medication is effective
our child is able to complete his homework on time
A nurse is collecting data from a client who is 12 hours postoperative following an intestinal surgery. which of the following findings should the nurse report to the charge nurse prior to client ambulation.
oxygen saturation 90%
A nurse is participating in a performance improvement program which of the following actions should the nurse take to evaluate the effectiveness of the program
perform chart audits
A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. which of the following recommendations should the nurse make?
perform pelvic rocking exercises several times per day
A nurse is assisting in the care of an adult client who has COPD and is receiving albuterol treating with 20mg of progesterone twice daily. The clients asks why the nurse is checking his blood glucose level, which of the following responses should the nurse make?
prednisone can cause blood glucose levels to increase
A nurse is reinforcing food safety with a group of older adult clients. which of the following information should the nurse include?
refrigerate leftover foods within 3 hours
A nurse is reinforcing teaching about home safety precautions with the parent of a 3- month-old infant which of the following should the nurse include in the teaching
remove bibs when the infant is going to sleep
81. A nurse is preparing a health promotion program for high school students which of the following facts about cigarette smoking is likely to be most effective in changing the adolescents attitude towards smoking
smoking causes unattractive staining on the teeth and hands
65. A nurse is caring for a client who is receiving a continuous iv infusion. the nurse notes that the skin around the catheter site is edematous and cool which of the following actions should the nurse take first
stop the infusion
A nurse is reinforcing teaching with a client who has coronary artery disease and a new prescription for warfarin which of the following should the nurse include in the teaching
take the medication at the same time everyday
A nurse is caring for a client who is recently diagnosed with depression the clients partner asks when he will get better which of the following is the appropriate response by the nurse
tell me what you know about depression
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy the nurse should explain to the client that which of the following adverse reactions can occur following the procedure
temporary memory loss
nurse in a provider's office is collecting data from an 18-month-old toddler which of the following should the nurse identify as a potential indication of child mal- treatment?
the toddler is overly affectionate towards the nurse
A nurse is caring for a client who is to undergo a subtotal thyroidectomy which of the following items should the nurse place at the client's bedside
tracheostomy kit
70. A nurse is assisting with preparing a client who is to have a central venous catheter inserted for administration of TPN. which of the following should the nurse take?
verify the amount of TPN solution the client is receiving every 4 hours
A nurse is assisting with staff education about hand hygiene. which of the following should the nurse include in the teaching?
wash your hands with soap and water for 20 seconds
nurse is preparing to administer a medication to a client. to help verify a client's identity which of the following questions should the nurse ask the client.
what is your telephone number?
A nurse is talking to a client who refuses a blood transfusion for religious reasons. which of the following responses should the nurse make?
you have the right to change your mind
A nurse is reinforcing with a new mother on facility security measures, which of the following statements by the mother indicates an understanding of the teaching?
• I will have an identification band that matches the one my baby wears
A nurse is preparing to perform a 12 lead ECG for a client who reports palpitations, which of the following actions should the nurse take to insure an accurate capture of the client's heart rate and rhythm? SATA
• Position the electrodes on the client's chest and extremities • Tell the client to expect sensations similar to static electricity during the test • Explain to the client that movement can alter the test results
A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing acute mania, which of the following interventions should the nurse include in the plan of care?
• Provide the client with high calorie finger foods
A nurse is completing documentation in the medical record about a client who fell on the floor, which of the following statements should the nurse include in the documentation?
• The client stated "I lost my balance and fell when I got out of bed to the bathroom"
5. A nurse and a family practice office routinely review client's immunization status at their annual physical examination visit, for which of the following clients should the nurse recommend human papillaou virus immunization (HPV Virus)?
• a teenage boy
A nurse in a providers office is collecting data from a client who was just diagnosed with TB, which of the following actions should the nurse take first?
• contact those who live with the client
