exit

A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she

Develops edema of the ankles

A nurse is preparing a client for the insertion of an NG tube. Which of the ff. actions should the nurse take?

Determine if the client has a deviated septum

A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the following?

From onset of symptoms until 24 hours of antibiotic therapy

A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client?

Hypotension

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?

"Advance directives include a living will"

A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparartion classes. Which of the following responses by the nurse supports the partner's involvement during labor?

"Breathing with your partner will help her to relax during contractions"

A nurse in a clinic is obtaining a health history from a client scheduled to un- dergo a cardiac catheterization in 2 days. Which of the ff. questions is the most im- portant for the nurse to ask?

"Do you know if you're allergic to iodine?"

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

"Gently stroke her abdomen during contractions"

A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states,

"I guess I have to take some of the blame because of the way my friends and I dress"

A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?

"I should discuss this document with my family after I sign it"

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider?

"I try not to look at the scales on my body"

A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will document in the medical record the support nurse who assists with planning care for my clients"

A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child?

"I will encourage my child to wear a bicycle helmet whenever bike riding"

A nurse is reinforcing teaching with a new mother on facility security measure. Which of the following statements by the mother indicates that the teaching was effective?

"I will have an identification band that matches the one my baby wears"

A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching?

"I will instruct the client to sit when putting on a pair of pants"

A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the ff. statements by the client demonstrates understanding of the teaching?

"I will rinse my mouth after taking this medication"

A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching?

"I will walk barefoot to prevent slipping" "I will check my smoke alarms once a month"

A nurse working in a provider's office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is cor- rect?

"When all the blisters are scabbed over"

A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching?

"You should increase fluid intake to relieve dysuria"

A client's daughter calls the nurse requesting information about her mother's condition. The client's chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse?

"You will need to contact your mother directly about her condition"

A Client with emphysema asks the nurse why he has difficulty exhaling. Which of the following statements by the nurse is appropriate?

"Your windpipe is inflamed and constricted"

A nurse is preparing to administer haloperidol (Haldol) 4 mg IM start to a client. Available is haloperidol for injection mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)

0.8 mL

A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer?

1.5 mL

A nurse is preparing the administer NPH (Novolin N) insulin to a client who has diabetes mellitus before breakfast at 0700. At which of the ff. times should the nurse plan to check the client for hypoglycemia?

1100

A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy?

16 lb

A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client?

4 tablets

A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first?

A client who has COPD and dementia and was agitated during the night shift

A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge?

A client who has a sodium level of 140 mEq/L after one episode of diarrhea

A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?

Appears greenish-brown in color

A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse evaluates that the client understands the teaching when she states she will gain

A..?

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

Administer liquid supplements

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Administer the medication to the toddler each evening

A nurse is working on a mental health unit is reviewing policies for client seclusion. For which of the following is seclusion appropriate?

Aggressive behavior

A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

Allow the client to choose treatment times

A nurse is reinforcing teaching with a client who has a new prosthesis for an above the knee amputation of the right leg. Which of the ff. instructions should the nurse reinforce to the client?

Apply the prosthesis immediately upon waking each day

An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?

Ask the AP to discuss the issue in a private area

A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?

Ask the client to flex the hips and knees

A nurse enters client's room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse first?

Assist the client to a nearby waiting room

A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply)

Assist the client to empty her bladder

A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck. Which of the following should the nurse include?

Avoid exposing the neck to the cold

A nurse is caring for a child who has terminated cancer. Which of the following responses by the child's school-age brother should the nurse expect?

Believes his bad behavior is causing his brother's death

A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting, and fever with chills. Which of the following diagnostics tests should the nurse expect to be prescribed?

Cerebrospinal fluid analysis

A nurse is caring for a client who had a bronchoscopy and just arrived to the medical surgical unit. Which of the following actions should the nurse perform first?

Check for a gag reflex

A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identity

Chromosomal abnormalities

A nurse is caring for a client who has a fractured radius and has a short arm cast applied yesterday. Which of the ff. findings should the nurse report to the provider?

Client report of decreased sensation in the finger

A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Complete post mortem care for a client who has died

A nurse is preparing to empty a postoperative client's closed-wound drainage system. Which of the following actions should the nurse plan to take?

Compress the container before replacing the drainage plug

A charge nurse in a long-term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first?

Confront the AP about suspected impairment

A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that the "felt something pop" when he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nurse take first?

Cover the wound with sterile saline-soaked gauze

A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship?

Defining responsibilities

A nurse is caring a client who has asthma and has a prescription for theophylline (theochron) 200mg PO BID. Which of the following should the nurse include in the teaching?

Discontinue drinking caffeinated beverages

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure?

Disorientation

A nurse caring for the mother of a newborn finds the client crying in her room. The client tells th nurse, "I don't think I can handle caring for a baby." Which of the following nursing interventions is appropriate?

Encourage the client to share her feelings

A nurse is contributing to the plan of care for a client who is on suicide pre- cautions. Which of the ff. interventions is appropriate for the nurse to recommend?

Encourage the client to sign a no-harm contract

A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend?

Encourage the client to take frequent walks during the day

A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching?

Engage in low-impact aerobic exercises

A nurse is interviewing clients as part of a skin cancer screening program. Which of the following statement made by a client indicates that he may have a premalignant lesion?

I have this flat, scaly area with red edge on neck

An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?

I will plan to avoid grapefruit juice while taking this medication

A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements is appropriate for the nurse to make?

If you'd like to wear a wig, you should select it before hair loss occurs

A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan?

Increase counter traction every 24 hours. Inspect the ropes, knots, and pulleys every 8 hours.

A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Inform the adolescent that he might experience a headache

A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client's understanding of the teaching when the client states, "I will

Install gates at the top and bottom of the stairs

A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?

Instruct the client to remain as still as possible during the recording

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?

Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride

A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client?

Irritability

A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use?

Leave space between the tip of the penis and the end of the condom catheter

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal?

Lorazepam

A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client's medications prior to contacting the provider. Which of the following medication is the likely cause of the increased sedation?

Lorazepam (Ativan)

A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate?

Lower left

A nurse is caring for a client who is 12hr postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first?

Massage the fundus. Obtain the client's vital signs.

A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls?

Medication record

A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate?

Monitor the client's skin integrity on a regular schedule

A nurse is caring for client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching?

Nicotinic acid (niacin)

A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first?

Observe the client during and after meals

A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

Observe the movements of the client's chest wall

A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam. Which of the following should indicate to the nurse the child is not current with the minimum required immunization?

One MMR vaccine

A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

Oral Suction Equipment

A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit?

Orthostatic hypotension

A nurse is caring for a client who just had blood drawn for an arterial blood gas analysis. Which of the ff. values should the nurse expect if the client is in respi- ratory acidosis?

PaCO2 51 mm Hg

A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B?

Performing oral hygiene

A nurse is preparing a sterile field to peform a dressing change. 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

A nurse is caring for a client who reports 12 liquid stools in the past 8hr. Which of the following findings indicates that the client is experience dehydration?

Potassium level 2.5 mg/L

A nurse is supervising an assitive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take?

Reinforce safe meal setup techniques

A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first?

Remove the tracheostomy inner cannula

A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possi- ble latex allergy?

Rhinorrhea

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include in the meal tray?

Roasted Salmon

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Skin rash with fever

While a nurse is assisting a client to ambulate, the client reports lightheadedness and begins to fall. Which of the following nursing actions demonstrates a correct understanding by the nurse about ergonomic principles?

Spread feet apart and extend one leg for the client to slide down while lowering the client to the floor

A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

Suction for 30 seconds

A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene?

Tells a client he will lose his phone privileges if he does not take his medication

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client who is at risk for a deep thrombosis. Which of the following actions the AP is applying the stockings correctly?

The AP applies the stockings before getting the client out of bed

A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching?

The infant is lying in the crib with a stuffed animal

A client is requesting information from a nurse regarding the appointment of a health care proxy. Which of the following responses by the nurse is appropriate?

The person you appoint will make health care decision for you if you cannot do so yourself

A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report?

Time of last pain medication

A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?

Urine output 12 mL/hr

A nurse is using contact precautions while caring for a toddler. Which of the following actions should the nurse take?

Use a designated stethoscope for the toddler

A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

Use a moisture barrier on the client's skin

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client's identity?

Verify the client's identity using a photograph

A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching?

Wash the bed linens in hot water. Clean the child's toys with 1:10 bleach solution.

A nurse is caring for a client who is recieving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8.Which of the following actions should the nurse take?

Withhold the ordered dose of the medication