Exodus

A charge nurse is participating on a performance improvement committee to implement changes to reduce the number of the client falls in the facility When implementing changes Which of the following actions should the nurse take first

Allow staff to provide feedback about the changes

49. A nurse is providing care to a client who reports there is no one at home to help him after his outpatient surgery . Which of the following actions should the nurse take ?

Assist with a referral to a home health care agency

113. A nurse is collecting data from client who has a long leg cast on his left leg . Which of the following findings is the priority ?

Diminished pulses on the affected extremity

A nurse is reinforcing teaching with a client about how to collect a 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

33.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 help ensure an accurate of the client's heart rate and rhythm

position the electrodes on the client's chest and extremities Explain to the client that movement can Alter the test results

A nurse in a clinic is reviewing the medical record of a toddler and notes that he has previously had a severe allergic reaction to gelatin . Which of the following immunizations should the nurse identify as unsafe for this client to receive

Measles , mumps , and rubella

A nurse is reinforcing teaching about a low sodium diet with a client who has hypertension Which of the following statements by the client indicates an understanding of the instructions

" I will use frozen vegetables rather rather than canned

A nurse is reinforcing dietary teaching with a client whose 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

- 16lb

A nurse is caring for a client who is 2 days postoperative following the surgical creation of an ileostomy and is tolerating oral intake Which of the following actions should the nurse take ?

- Apply sterile dressing to the stoma

A nurse is collecting data from an older adult client who has been taking furosemide for the past week If the client has developed medication which of the following findings should the nurse expect

- Postural hypotension

A nurse collecting data from an older adult client who has hypertension and is taking amlodipine . The nurse should identify which of the following manifestations as an adverse effect of the medication

-Dizziness

142.A community health nurse is assisting in the development of a brochure about hypertension Which of the following actions should the nurse take ?

-Explain medical terminology using basic one- syllable words

A nurse is reviewing the health history of middle adult client who is receiving chemotherapy for leukemia. Which the following immunizations should the nurs recommend that the receive

-Inactivated influenza immunization

A nurse is caring for a client who is 12 hr postpartum and has deep vein thrombosis of the left leg The client is anticoagulant therapy Which of the following actions should the nurse ?

-Initiate bed rest .

A nurse is contributing to a plan of care for a client who has ascites due to cirrhosis Which of the following interventions should the nurse recommend to include in the plan of care

-Measure the client's abdominal girth

131.A nurse is providing a change of shift report for a client . Which of the following should the nurse include in the report

-The clients received the prescribed antibiotic every 8 hours

133.A nurse is implementing a bladder training program for client who had a stroke Which of the following interventions should the nurse take

-check for residual urine after voiding

132.A nurse is participating in an interprofessional care conference for a client who has alcohol use disorder . The nurse should collaborate with the dietitian to Promote which of the following dietary changes

. -Increases daily intake of thiamin- rich food

A nurse is reviewing the medical records of five clients For which of the following events should the nurse write an incident report

A client fell when ambulating to the bathroom alone A client received the first dose of antibiotic 1 hour before the collection of blood for culture and sensitivity A client received an 0900 daily medication at 1000

A charge nurse asks a staff nurse to recommend a client for discharge in response t mass casualty disaster Which the following clients should the staff nurse recommend

A client is 3 days post operative following knee arthroscopy and requires rehabilitation.

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 energy

106. A nurse is receiving change of shift reports from four clients Which of the following clients should the nurse see first

A client who has cirrhosis and hematemesis

A nurse is reinforcing teaching with 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 a warning sign of stroke

.A nurse is assisting with the plan of care for a client who has burns to his lower extremities Which of the following actions should the nurse include in the plan ?

Apply dressing with sterile gloves

A nurse at a provider's office is caring for a client who is in the third trimester of pregnancy Which of the following findings should the nurse report to the provider ?

Blurred vision

A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider wave

Blurry vision

A nurse is collecting data from a client who has placenta previa . Which of the following findings should the nurse expect

Bright red vaginal bleeding

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation . The nurse notes that the client's vagina and vulva are a purplish color . The nurse should document this finding as which of the following

Chadwick's sign

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. the following responses should the nurse make ?

Colostrum provides many important antibodies that the newborn lacks

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease Which of the following instructions should the nurse include in the teaching ?

Decrease sodium intake

A nurse is assisting with the development of an education program for a group of adult clients. Which should the nurse fo first

Determine the literacy level of participants

14. 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 in the teaching as an indication of serotonin syndrome

Diaphoresis

A nurse is reinforcing teaching with a client who has a new prescription for metformin . Which of the following should the nurse include as an adverse effect of this medication

Diarrhea

A nurse is reinforcing teaching with a client who has a new prescription for spironolactone.Which of the following foods should the nurse instruct the client to avoid

Dried apricots

A nurse is caring for a client who has moderate anxiety Which of the following actions should the nurse take

Encourage the client to rest as much as possible

A nurse is caring for a client who is 12 hr postpartum has had an episiotomy and reports perineal pain Which of the following actions should the nurse take

Encourage the client to use the sitz bath twice daily for 20 min

48.A nurse is caring for a client who is 1 day postoperative 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 caring for four clients Which of the following situations requires a signed consent form

Giving a Haemophilus influenza B vaccine to an infant

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine - rich foods The nurse should monitor the client for which of the following findings as an adverse effect of this medication

Hypertension

A nurse is checking for gastric residual volume GRV ) on a client who is scheduled to receive an intermittent enteral feeding The nurse finds that the client has a GRV greater than 250ml on two consecutive measurements Which of the following actions should the nurse take ?

Hold the feeding and recheck the GRV in 1 hr

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 as an indication that a newly licensed nurse understands utilitarianism

I will consider what is going to benefit the most people when making decisions

143.A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy Which of the following by the client indicates an understanding of the teaching

I will drink clear liquid the day before examination

A nurse is reinforcing teaching with a client who is at 12 week gestation and has hyperemesis gravidarum Which of the following client statements indicates an understanding of the nurse's instruction ?

I will eat or drink something every or hours throughout the day

A nurse is reinforcing dietary teaching with a client who has cushing's syndrome Which of the following statements by the client indicates an understanding of the teaching

I will limit my sodium intake

A nurse is reinforcing teaching about hoine infection prevention with a client who HIV positive . Which of the following statements by the client indicates an understandin of the teaching

I will put soiled dressings in a tied plastic bag before placing them in the trash

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

Identify data collection methods

61. A nurse contributing to the plan of care for client who has chronic pancreatitis Which of the following recommendations for the client's nutrition should the nurse make

Increase the client's daily protein

19.A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering hypotonic enemas to a client Which of the following instructions should the nurse include in the teaching

Instruct the client to exhale while inserting the rectal tube

73. A nurse is reinforcing teaching about food safety with a group of adult clients Which of the following information should the nurse include

Keep refrigerator temperature at 4.4 C degrees ( 40F )

A nurse is preparing to test a client's plantar babinski reflex . Which of the following instructions should the nurse give to prepare the client for this task

Lie down and I will stroke the bottom of your foot

A nurse is administering pancreatic enzymes to a child who has cystic fibrosis Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment

Reduced fat in the stools

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 2.5cm ( 1 in ) from the edge of the sterile field

56. A nurse is extremities Which of the following collecting data from a client who has heart failure and edema of the lower actions should the nurse take to monitor for pitting edema ?

Press firmly with the fingertip on edematous areas

A nurse is collecting data from an adolescent who has experienced sexual abuse Which ofthe following statements by the client should the nurse recognize as the use of the defense mechanism of suppression

Sometimes get angry about but know that just creates other problems

in bed using a draw sheet The nurse 77. A nurse and an assistive personnel are repositioning a patient who is immobile up should instruct the AP to take which of the following actions

Stand next to the client's shoulders

A nurse is reinforcing teaching with a client who has coronary artery disease and a new prescription for warfarin Which of the following information should the nurse include in the teaching

Take the medication the same time every day .

26. A nurse is caring for client who is to undergo subtotal thyroidectomy Which of he following items should the nurse place at the client's bedside

Tracheostomy kit

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 he takes antibiotics Which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea

Yogurt

20. A nurse is reinforcing discharge teaching with a client who has angina and a new prescription for sublingual nitroglycerin Which of the following information should the nurse include in the teaching ?

You will feel a tingling sensation in your mouth when taking a nitroglycerin tablet

43. A nurse is performing a heel stick on a newborn to obtain blood for glucose monitoring Which of the following actions should the nurse take ?

apply a warm cloth to the heel 10 min prior to the procedure

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

arms pick heavy items . -perform pelvic rocking exercises several times per day . -sit

A nurse is reinforcing discharge teaching with a client following a gastrectomy which the following foods should the nurse instruct the client to avoid to prevent dumping -yndrome

ice cream

A nurse is reinforcing with a client who has hypothyroidism and a new prescription for levothyroxine The nurse should instruct the client to notify the provider of which of the following manifestations ?

nervousness

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy The nurse should place the client in which of the following positions

semi fowler's

A nurse is reinforcing teaching j'with a client about measures to reduce the manifestations of irritable bowel syndrome . Which of the following statements should the nurse make ?

you can take peppermint oil to soothe your discomfort