Finished Line comprehensive C
A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic?
"Can you talk about what was happening with your partner at home?"
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?
"Have your child drink a small glass of water after swallowing the medication."
A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching?
"I should change the stoma pouch every day"
A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?
"I think the baby should be sleeping through the night by now.
A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?
"I will avoid food and beverages that contain caffeine"
A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?
"I will let the client know that I am available as the interpreter."
A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I will need to increase my insulin doses later in my pregnancy"
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?
"This type of seizure can be mistaken for daydreaming"
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
"What are the voices telling you?"
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?
"What high school did you graduate from"
A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching?
"You should not have this procedure if you are allergic to iodine."
A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?
"You should push the button before physical activity to allow maximum pain control"
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
"Your desire to be an organ donor must be documented in writing"
A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA)
- Explain the procedure - Expected outcome of the procedure - Potential complications - Possible alternative treatments
A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA)
- Let's talk about your mom's cancer and how things will progress from here. - Tell me how you are feeling about your mom dying. - You sound like you have questions about your mom dying. Let's talk about it.
A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA)
- Wear a lead apron when providing care - Limit visitors to 30 mins
A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps)
1. Transport the client to another area of the nursing unit 2. Activate the facility's fire alarm system 3. Close all nearby windows and doors 4. Use the unit's fire extinguisher to attempt to put out the fire
A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero)
1.7 mL per dose
A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider ?
3+ deep tendon reflexes -preeclampsia
A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 90.7 (200 lb). The nurse should identify the weight of the following total percentage?
7.5%
A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first?
8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing - bleeding
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A client who has a hip fracture and a new onset of tachypnea
A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia
A client who has fractured left tibia and pallor in the affected extremity
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
A client who has preeclampsia and reports a persistent headache
A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge?
A client who is 1 day postoperative following a vertebroplasty
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN?
A client who is postoperative following a bowel resection with an NGT set to continuous suction
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
A client who is receiving heparin for deep vein thrombosis.
A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care?
A client who received a Mantoux test 48 hours ago and has induration
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who was just given a glass of orange juice for a low blood glucose level
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?
A history of gastroesophageal reflux disease
A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider?
A two day old newborn who has a respiratory rate of 70 (30 - 60 is normal)
A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
Administer analgesics on a scheduled basis for the first 24 hr
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take?
Administer calcium gluconate IV Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV.
A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?
Administer enalapril 2.5 mg PO twice daily
A nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?
Administering potassium via IV bolus
A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture?
Apply an orthotic to the clients foot
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?
Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP?
Applying a condom catheter for a client who has a spinal cord injury
A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ?
Autonomy Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client's own best interest
A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching?
Avoid hot tub while wearing the patch
A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?
Below the knee amputation
A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication?
Blood pressure
A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except?
Bounding pulse
A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ?
Check the mouth for smooth and smoky breath - airway obstruction via foreign body
A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department?
Chlamydia
A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?
Clamp the catheter distal to the injection port
A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?
Clarify the source of the referral
A charge nurse is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the charge nurse include in the teaching?
Client might feel guilt over some aspect of their loss
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure?
Compare the client's current weight with preprocedure weight.
A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
Compare the current infusion with the prescription in the client's medication record.
A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?
Consume food high in bran fiber
A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ?
Continue the monitor the fetal heart rate (Not a problem- absent or late are a problem)
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
Contractions
A nurse is assessing a client's respirations which of the following actions should the nurse take?
Count respirations for 1 minute if the rhythm is irregular
A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?
Disorganized speech
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?
Document the client's condition every 15 minutes
A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include.
Document the client's conditions every 15 minutes
A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take?
Don sterile gloves prior to the procedure.
A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication.
Dumping syndrome
A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority?
Dysphagia
A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching ?
Eat 1g/kg of protein per day
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
Eat a light snack before bedtime
A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect?
Elevated temperature
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
Encourage the client to take frequent rest periods
A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority?
Erythema 5 cm (2in) above the IV site
A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?
Establish a toileting schedule for the client
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include ?
Excessive sweating
A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take?
Explain the risks of leaving
A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?
Give the dose over 60 min
A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control?
HbA1c 6.5%
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?
HbA1c level less than 7%
A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?
Heightened perceptual field
A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ?
Hematuria - urinalysis will show red blood cells and protein, also reddish brown col colored urine
A nurse is caring for a client who has end stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
Hypertension
A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?
Hypertension
A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ?
Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow
A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity?
Hyporeflexia
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
I can resume activities, such as sewing.
A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching?
I can use my ultrasound picture as a focal point during contractions
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
I can visit my nephew who has chickenpox 5 days after the sores have crusted."
A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching?
I should urinate before the test
A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
I will change my baby's diaper at least every 4 hours
A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching?
I will determine which muscles to contract by stopping and starting my stream of urine
A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching?
I will remove bananas from my diet
A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?
Identify environmental hazards in the home
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
Increase in frequency of swallowing (may indicate bleeding)
A nurse is administering an analgesic to a client who has a chest tube . The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first ?
Inform the provider of the time of the last does of pain medication
A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first?
Inform the provider of the time of the last dose of pain medication.
A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?
Iniang IV 1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing
A nurse is caring for a child who has sickle cell anemia and experiencing vaso- constrictive crisis. Which of the following actions should the nurse include in the plan of care?
Initiate IV fluid replacement
A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ?
Initiate seizure precautions
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?
Instruct the client on the use of esophageal speech (I think)
A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?
Instruct the client to empty her bladder prior to the procedure.
A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching?
Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry
A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform?
Kick a ball forward
A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?
Left ventricular failure
A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information?
Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ?
A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor?
Liver function test
A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification?
Lorazepam 0.5 mg PO one tablet daily
A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?
Maintain NPO status for client(ABC)
A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia?
Maternal hypoglycemia
A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?
Measure the client's urine output every hour. - monitor for toxicity.
A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client's medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive?
Migraines with aura
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
Minimize noise in the newborn environment
A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?
Monitor the child's cardiac status
A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take?
Monitor the dorsalis pedis pulse every 15 minutes (because circulation)
A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings?
Murmur at the mitral area
A nurse is obtaining a nutritional health history on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation?
New prescription for an iron supplement
A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take?
Offer high-calorie, high protein snacks to the client
A client who is pregnant voice her concern that her 3y/o son will feel left out once the newborn arrives. Which of the following statements by the nurse is appropriate?
Offer your son a gift when the baby receives one
A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations?
Orthostatic hypotension
A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take?
Palpate the client's fundus
A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness?
Participate in community drills and mock events
A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel?
Perform chest compressions during cardiac resuscitation
A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP?
Perform post mortem care
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
Perform the procedure twice a day
A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?
Peripheral neuropathy
A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client's lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take?
Place a cardiac monitor on the client
A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?
Place the cap from the solution sterile side up on clean surface
A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention?
Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client's abdomen
A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?
Platelets 100,000/mm3 (150,000-300,00 risk for bleeding)
A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take?
Please a warm moist compress on the site
A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?
Positioning both hands on the grips with his elbows slightly flexed
A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider?
Potassium 3.2 mEq/L
A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery?
Potassium 5.2 mEq/L
A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client?
Potato pancakes
A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement?
Pour water from a squeeze bottle over the client's perineal area.
A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?
Prealbumin 10 mcg/dl (normal: 16-40)
A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect?
Preoccupied with aging
A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?
Previous violent behavior Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse?
Privately interview the client about her condition.
A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider?
Protruding Hemorrhoids
A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?
Provide anticipatory guidance classes to parents through public schools
A nurse is obtaining a medical history from a client who has new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin?
Renal insufficiency
A client's partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take?
Report the information to the charge nurse
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information?
Request a female translator interpreter through the facility
A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take?
Request non gas forming foods from the dietary department
A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider?
ST segment elevations (Remember this could possibly lead to infarctions)
A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client?
Scratchy, high pitched sound upon chest auscultation
The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
Seductive Behavior
A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure?
Sensation of skin warmth
A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?
Serum glucose level- increased
A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?
Serum potassium- diuretic that retains potassium= hyperkalemic risk
A nurse is obtaining a client's medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution?
Severe renal impairment. (Stage IV Kidney Disease)
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider?
Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported
A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider?
Sunken fontanels and dry mucous membranes
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
Swelling of the face
A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client?
Tape stockinet over monitoring device and cords
A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? Primary - before it happens Secondary - screening Tertiary - already happened
Teach parenting skills to families at risk for abuse
A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?
Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic)
A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make?
Tell me the standing weight of the client in room 102 before breakfast
A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first?
Test the client for Trousseau's sign
A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider?
The client coughs after swallowing
A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?
The client exhibits impulsive behavior
A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder?
The client exhibits impulsive behavior - spending money giving away money or possessions
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings is a potential contraindication for using lavender?
The client has a history of asthma
A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?
The client is showing evidence of phenytoin toxicity
A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report ?
The estimated blood loss was 250 milliliters
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
The estimated blood loss was 250 milliliters.
A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?
This test should be performed after you baby is 24 hours old
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (SATA)
Tremors Diaphoresis Inability to concentrate
A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?
Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls
A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects?
Urinary retention
A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take?
Use a syringe to allow the medications to Flow by gravity
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
Use an albuterol inhaler
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching?
Use modeling to help the clients improve their interpersonal skills
A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?
Use of tobacco decreases the level of athletic ability
A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?
Uses the tpn IV tubing to administer the clients next dose of antibiotic
A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ?
Vitamin b12 level
A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ?
WBC count 2,900 /mm3 (Agrunlocytosis - 4,800-15,000 normal range)
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
We can review some information to help you select a safe alternative practitioner
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
We should establish our roles in the initial session.
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
Weak femoral pulses
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?
Wear gloves to apply the patch to the client's skin
A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?
Whole grain bread
A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?
You have the right to decide who receives information
A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?
You may breastfeed unless your nipples are cracked or bleeding.
a home health nurse is caring for an adult client who reports, "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take?
initiate a consultation with a speech→ language pathologist; swallow eval
