MAYBE EXIT ?
A nurse is providing postmortem care for a client. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps. A. Remove all equipment and tubes from the client's body. 2 B. Verify that the provider has certified the client's death. 1 C. Clean the client's body. 3 D. Determine the family's preferences about care of the body. 4 E. Apply identifying name tags onto the client. 5
-B -A -C -D -E
A nurse is caring for a client who has a depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make? A. Are you thinking of hurting yourself? B. Why would you think a thing like that? C. What would your family do without you? D. When you get better you will not feel this way.
A. Are you thinking of hurting yourself?
A nurse is reinforcing teaching with a client who is at 16 weeks of gestation and has a prescription for ferrous sulfate to treat iron-deficiency anemia. Which of the following recommendations should the nurse make to improve the absorption of the medication? A. Avoid drinking milk with the iron supplement B. Increase your dietary fiber intake C. Eliminate berries and citrus fruits from your diet. D. Take the iron supplement with green tea.
A. Avoid drinking milk with the iron supplement
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? A. Chadwick's sign. B. Chloasma. C. Hagar's sign. D. Ballottement.
A. Chadwick's sign
A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures? A. Changing a central venous catheter dressing for a client who is receiving IV therapy. B. Instilling an ophthalmic ointment for a client who has a corneal abrasion. C. Administering an IM injection to a client who has bacterial pneumonia. D. Inserting an NG tube for a client who needs continuous enteral feedings.
A. Changing a central venous catheter dressing for a client who is receiving IV therapy.
A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-month-old toddler. Which of the following instructions should the nurse provide? A. Clean the teeth with a small, soft-bristled toothbrush." B. Position the bristles of your child's toothbrush against the teeth at a 90-degree angle." C. Floss between your child's teeth before brushing." D. "Use a 5-inch strip of toothpaste on the toothbrush."
A. Clean the teeth with a small, soft-bristled toothbrush."
A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first? A. Determine the client's pattern for voiding. B. Offer toileting opportunities every 1 to 2 hr. C. Discourage intake of carbonated beverages D. Assist the client with relaxation techniques.
A. Determine the client's pattern for voiding.
A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take? A. Encourage the family to express their feelings of loss B. Ask the family not to touch the client's body C. Instruct the family to leave prior to cleaning the client's body D. Limit the amount of time the family spends in the client's room
A. Encourage the family to express their feelings of loss
A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching? A. Engage in low-impact aerobic exercises. B. Apply ice to the inflamed joint. C. Sleep on a soft mattress. D. Use fingers to push off from the bed or chair
A. Engage in low-impact aerobic exercises.
A nurse and assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions? A. Flex his hips while pulling the client. B. Place a small pillow under the client's head. C. Lower the client's bed to the lowest position. D. Stand next to the client's shoulders.
A. Flex his his while pulling the client
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? A. Gently stroke her abdomen during contractions. B. Help her to focus on an object in the room. C. Apply steady pressure with this tennis ball to her sacral area. D. Assist her to breathe in deeply at the beginning of each contraction.
A. Gently stroke her abdomen during contractions.
A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain. Which of the following conditions in the client's history should the nurse identify as a contraindication? A. Hepatitis C B. Diabetes mellitus C. Hypotension D. Cystitis
A. Hepatitis C
A nurse is collecting data from a client who reports difficulty sleeping at night. Which of the following client statements indicates an understanding of sleep promotion? A. I am going to bed at the same time every night." B. I am eating dinner later in the evening." C. I moved the television to my bedroom for background noise." D. I go to the 24-hour gym shortly before I go to bed.
A. I am going to bed at the same time every night."
A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching? A. I will need to remain upright for 1 hour after taking the medication. B. I should expect to have diarrhea while taking this medication. C. I can take antacids at the same time as this medication. D. I have to take this medication on an empty stomach.
A. I will need to remain upright for 1 hour after taking the medication.
A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take A. Keep the finger in a dependent position. B. Select the central tip of a finger. C. Wear sterile gloves. D. Test the first drop of blood that forms after the puncture.
A. Keep the finger in a dependent position.
A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make? A. Let's discuss how you feel when you leave your house." B. Have you tried leaving your house just once per day?" C. Tell me why you have developed an aversion to leaving your house. D. Have you thought about moving to a new neighborhood?"
A. Let's discuss how you feel when you leave your house."
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect? A. Memory loss that disrupts ADLs B. Pressured speech C. Catatonia D. Illusions
A. Memory loss that disrupts ADLs
A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first? A. Observe the client during and after meals. B. Instruct the client about effective coping strategies. C. Suggest that the client assist with meal planning. D. Refer the client to a support group for clients who have eating disorders.
A. Observe the client during and after meals.
A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include? A. Perform sponge baths until the baby's umbilical cord falls off." B. Apply talcum powder daily after bathing in order to prevent diaper rash." C. Ensure the bath water is at least 96 degrees Fahrenheit." D. Use an alkaline soap to bathe the baby."
A. Perform sponge baths until the baby's umbilical cord falls off."
A nurse is administering phacelias (?) to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? A. Reduced fat in the stools. B. Improved respiratory function C. Decreased sodium excretion D. Improved absorption of vitamins B and C
A. Reduced fat in the stools
A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? A. Secure the tubing with adhesive tape to the lower abdomen. B. Coil the tubing on the bed above the collection bag. C. Collect a sterile specimen from the urinary drainage bag D. Instruct the client to hold the drainage bag at waist height when ambulating
A. Secure the tubing with adhesive tape to the lower abdomen.
A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching? A. Somnolence B. Bradycardia C. Decreased blood pressure D. Decreased hemoglobin
A. Somnolence
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take? A. Support the client's decision to stop the treatment B. Tell the client she should discuss this decision with her family C. Ask the facility chaplain to visit the client. D. Discuss alternative treatment methods with the client.
A. Support the client's decision to stop the treatment
A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in potassium? A. Sweet potato B. Wheat bread C. Canned green beans D. Baked chicken breast
A. Sweet potato
A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take? A. Tell the APs to stop the conversation. B. Inform the client of the APs' actions. C. Document the event in the client's progress notes. D. submit an incident report to the risk manager.
A. Tell the APs to stop the conversation.
A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly? A. The restraints are secured with a quick-release knot. B. The nurse can insert three fingers under the secured restraint. C. The restraint's soft pad faces away from the client's skin. D. The restraints are attached to the side rails of the client's bed.
A. The restraints are secured with a quick-release knot.
A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? A. This must be very frightening for you. Let's talk more about it. B. Why do you feel the staff is the FBI?" C. The psychiatric staff is not the FBI. They are here to help you." D. What makes you think the staff is following you?
A. This must be very frightening for you. Let's talk more about it.
A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to assistive personnel? (Select all that apply.) A. Transfer a client who is receiving radiation therapy to radiology. B. Record urine output for a client who has a suprapubic catheter. C. Reinforce client teaching about walking with crutches. D. Plan care for a client who has dysphagia. E. Measure vital signs for a client who requires contact precautions.
A. Transfer a client who is receiving radiation therapy to radiology. B. Record urine output for a client who has a suprapubic catheter. E. Measure vital signs for a client who requires contact precautions.
A nurse is administering a client's morning oral medications. Which of the following actions should the nurse take? A. Verify the medication three times with the medication administration record. B. Document medication administration prior to administering medication. C. Identify the client by using one identifier before giving the medication. D. Administer time-critical medication 60 min before or after the scheduled time.
A. Verify the medication three times with the medication administration record.
A nurse is collecting data from a client. The nurse should identify which of the following manifestations is an indication of a candida infection A. Yellow patches in the mouth B. Hearing loss C. Night sweats D. Brittle nails
A. Yellow patches in the mouth
A nurse is reinforcing discharge teaching with a client who has a prescription for antibiotic therapy. The client reports experiencing diarrhea when taking antibiotics. Which of the following foods should the nurse recommend to lessen the occurrence of diarrhea? A. Yogurt B. Coffee C. Ice cream D. Apple juice
A. Yogurt
A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take? A. Write the information at an 8th-grade reading level. B. Present information from complex to simple C. Use a 12-point font size. D. Explain medical terminology using basic, one-syllable words.
A. write the information at an 8th grade reading level
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? A. Tinnitus B. Blurry vision C. Joint pain D. Constipation
B. Blurry vision
A nurse in an acute care facility is reviewing medication administration protocol with another nurse. Which of the following information should the nurse include in the review? A. Use one client identifier before administering medication. B. Check the clients' allergy bands with each medication administration. C. Document the administration of medications after all assigned clients have been medicated. D. Read medication labels twice before administration.
B. Check the clients' allergy bands with each medication administration.
A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication? A. Clear rhinorrhea B. Chemotherapy treatments C. Two diarrhea stools in the last day D. Medications for a cardiac anomaly
B. Chemotherapy treatments
A nurse is gathering data from a client who has severe anxiety. Which of the following findings should the nurse identify as an indication that the client is experiencing a crisis? A. Client reports intermittent depressed mood B. Client isolates themselves from their family and friends C. Client reports a decreased appetite D. The client expresses an inability to experience pleasure
B. Client isolates themselves from their family and friends
A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take? A. Remove the weights for 20 min for the client's report of severe pain. B. Compare bilateral pedal pulses. C. Position the knot of the rope at the top of the pulley. D. Apply 6.8 kg (15 lb) of weight for use in traction.
B. Compare bilateral pedal pulses
A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first? A. Encourage visits from family members. B. Determine the client's level of consciousness. C. Administer an anxiolytic medication. D. Keep lights on in the client's room.
B. Determine the client's level of consciousness.
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority? A. Ecchymosis on the inner left thigh B. Diminished pulses on the affected extremity C. One fingerbreadth of space between the cast and the skin D. The client reports muscle spasms in the left leg
B. Diminished pulses on the affected extremity
A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5° C (90.5° F). Which of the following data is the priority for the nurse to monitor? A. Pain sensation B. Heart rhythm C. Urinary output D. Muscle strength
B. Heart rhythm
A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client? A. Irregular menses B. Hypertension C. Vaginal yeast infection D. History of ectopic pregnancy
B. Hypertension
A nurse is reinforcing teaching with a client who has Crohn's disease. Which of the following statements by the client indicates an understanding of the teaching? A. I will experience severe constipation during an attack. B. I know that I will have episodes of remission. C. A surgical resection will cure this disease. D. A high-fiber diet will help keep my symptoms under control.
B. I know that I will have episodes of remission.
A nurse in an inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the client indicates an understanding of the procedure A. I might have occasional seizures for several days after the procedure. B. I might have short-term memory loss after the procedure. C. I will need to follow a full-liquid diet for 24 hours after the procedure. D. I will have a urinary catheter in place during the procedure.
B. I might have short-term memory loss after the procedure.
A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching? A .I will apply antibiotic ointment to my baby's penis." B. I will apply pressure with gauze if I see bleeding." C. I will wipe away yellow crusts that form around the incision." D. I will make sure that my baby's diaper is applied snugly."
B. I will apply pressure with gauze if I see bleeding."
A nurse is reinforcing discharge teaching with the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. I will notify my provider if my baby sleeps more than 10 hours per day." B. I will place my baby on his back for sleeping." C. I will change my baby's diaper every 4 hours." D. I will limit my baby's feedings, so he does not become overweight."
B. I will place my baby on his back for sleeping."
A nurse in a mental health facility is reinforcing teaching with a client about panic attacks. Which of the following statements by the client indicates an understanding of the instructions? A. I will expect each panic attack to last about 45 minutes. B. I will use abdominal breathing as the first sign of a panic attack. C. I will reduce physical activity to help avoid panic attacks. D. I will sit with others in the activity room until the panic attack subsides.
B. I will use abdominal breathing as the first sign of a panic attack.
A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident? A. Nursing care plan B. Incident report C. Controlled substance inventory record D. Provider's progress notes
B. Incident report
A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement A. Assign the client to a negative pressure airflow room. B. Initiate contact precautions for the client. C. Have visitors remain at least 0.91 m (3 feet) away from the client. D. Administer aspirin if the client develops a fever
B. Initiate contact precautions for the client.
A nurse is collecting data from a client who is 18 hr. postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect? A. Tolerates physical discomforts. B. Is eager to review the birth experience. C. Performs self-care independently. D. Begin reconnecting with their partner
B. Is eager to review the birth experience.
A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include? A. Provide a stimulating environment for the client. B. Limit the number of choices for the client. C. Use written signs to assist the client with locating the bathroom. D. Use confrontation to manage the client's behavior.
B. Limit the number of choices for the client.
A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend included in the plan? A. Keep the client's daily protein intake below 0.8 g/kg. B. Measure the client's abdominal girth daily. C. Position the client supine with legs elevated. D. Restrict the client's sodium intake to 3 g per day.
B. Measure the client's abdominal girth daily.
A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect? A. Constipation B. Muscle cramps C. Blurred vision D. Hypertension
B. Muscle cramps
A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider? A. Hypoglycemia B. Muscle pain C. Daytime drowsiness D. Palpitations
B. Muscle pain
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment? A. Hypotension B. New onset of hearing loss C. Slurred speech D. Hyperthermia
B. New onset of hearing loss
A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic clonic seizure. Which of the following actions should the nurse take? A. Restrain the child's upper extremities. B. Place a pillow under the child's head. C. Place a padded tongue blade in the child's mouth. D. Turn the child onto their back.
B. Place a pillow under the child's head.
A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take? A. Tape the tube to the child's cheek. B. Secure the tubing to the child's abdomen. C. Apply water-soluble lubricant to the site. D. Attach an extension tube to the site's opening prior to use.
B. Secure the tubing to the child's abdomen.
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? A. Supine B. Semi-Fowler's C. Left lateral D. Dorsal recumbent
B. Semi-Fowler's
A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds? A. Indicates decreased motility. B. Sounds are high-pitched. C. Sounds are soft and at a rate of 1/min. D. Can be a result of a paralytic ileus
B. Sounds are high-pitched.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first? A. Apply a warm compress B. Stop the infusion C. Elevate the arm D. Document the infiltration
B. Stop the infusion
A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness? A. The client wants to talk about the diagnosis with the nursing staff. B. The client has a decreased energy level. C. The client makes funeral arrangements. D. The client requests a second opinion.
B. The client has decreased energy level
A nurse determines that clients who receive zolpidem postoperatively have an increased fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings? A. The surgeon B. The risk manager C. The pharmacist D. The case manager
B. The risk manager
A nurse is caring for a client who asks why her newborn is receiving a phytonadione (vitamin K)injection. Which of the following statements should the nurse make? A. This medication prevents your baby from developing jaundice. B. This medication prevents your baby from developing bleeding problems. C. This medication enhances regulation of your baby's temperature." D. This medication enhances your baby's immune response.
B. This medication prevents your baby from developing bleeding problems.
A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching? A. You will feel pressure when I inflate the catheter balloon. B. You will need to urinate before the procedure." C. You will have a leg bag to collect the urine." D. You cannot drink fluids for 4 hours after the procedure."
B. You will need to urinate before the procedure."
A nurse is planning care for a client who is 6 hr postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care A. Apply warm, moist packs to the surgical site B. Use the continuous passive-motion machine intermittently. C. Massage the lower leg in smooth, long strokes. D. Place a pillow under the client's surgical knee.
B. use the continuous passive motion machine intermittently
A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place used sharp items in an empty cereal box for disposal." B. "I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water." C. "I will put soiled dressings in a tied plastic bag before placing them in the trash." D. "I will use animal-skin condoms when having sex."
C. "I will put soiled dressings in a tied plastic bag before placing them in the trash."
A nurse is receiving a change-of-shift report on four clients. Which of the following clients should the nurse plan to see first? A. A client who has cirrhosis and severe pruritus. B. A client who had a renal biopsy 3 hr ago and has pink-tinged urine. C. A client who has a femur fracture and reports numbness of the toes. D. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge.
C. A client who has a femur fracture and reports numbness of the toes.
A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information? A. A client's employer who is concerned about safety due to substance use B. A nurse from another unit after a client commits suicide C. A social worker who is assigned to an involuntarily committed school-age client D. A client's partner after the client reports intimate partner abuse.
C. A social worker who is assigned to an involuntarily committed school-age client
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect A. Acute hemolytic B. Circulatory overload C. Anaphylactic D. Febrile
C. Anaphylactic
A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider? A. Posterior fontanel closed B. Moves objects to mouth C. Anterior fontanel closed D. Plays with toes
C. Anterior fontanel closed
A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care? A. Place on bedrest. B. Administer diuretics. C. Apply support stockings. D. Limit fluid intake.
C. Apply support stockings.
A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching? A. Limit fluid intake to 750 mL per day B. Eat three large meals each day. C. Avoid exposing the neck to the cold. D. Cleanse the neck by rubbing with a washcloth.
C. Avoid exposing the neck to the cold.
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect? A. Believes that his brother's death will be reversible B. Alienates himself from his peers C. Believes his bad behavior is causing his brother's death D. Regresses to an earlier developmental level
C. Believes his bad behavior is causing his brother's death
A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use A. Remove the tape by pulling from the center of the dressing. B. Moisten the dressing before removal C. Clean the wound from the center to the outer edges. D. Wear sterile gloves to remove the dressing.
C. Clean the wound from the center to the outer edges.
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? A. The client does not appear to have any injuries resulting from the fall. B. An incident report has been completed and sent to risk management." C. Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom!" D. The client fell because the assistive personnel did not place non skid slippers on the client.``
C. Client stated, "I lost my balance and fell when I got out of bed to go to the bathroom!"
A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching? A. Use lemon glycerin swabs. B. Eat foods high in vitamin B12. C. Consume soft, bland foods. D. Rinse the mouth with an alcohol-based mouthwash.
C. Consume soft, bland foods.
A nurse begins to bathe a newly admitted client who reports that they have 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? A. Veracity B. Promoting trust C. Countertransference D. Boundary crossing
C. Countertransference
A nurse is supervising assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse? A. Turning the stockings inside out before applying them B. Asking the client to point their toes before applying the stockings. C. Ensuring that creases in the stockings are on the front of the client's legs. D. Applying the stockings before the client gets out of bed
C. Ensuring that creases in the stockings are on the front of the client's legs.
A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity? A. Fidelity involves making sure clients are able to make their own health care decisions. B. Fidelity involves treating every client with the same level of respect. C. Fidelity involves keeping promises made to clients. D. Fidelity involves ensuring that we do no harm to the client.
C. Fidelity involves keeping promises made to clients.
A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? A. Bounding pulse B. Clammy skin C. Fruity breath odor D. Elevated blood pressure
C. Fruity breath odor
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 indicates an understanding of the teaching? A. This medication will dilate my eyes. B. This medication will darken the color of my eyes. C. I should check my heart rate while taking this medication. D. I should take a zinc supplement while taking this medication.
C. I should check my heart rate while taking this medication.
A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective? A. Decreased BUN level B. Increased weight of 0.91 kg (2 lb.) C. Increased urinary output D. Decreased hemoglobin level
C. Increased urinary output
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? A. Members of a healthcare team can share a computer password. B. Unwanted printed health information can be discarded in a trash can. C. Information regarding client health can be e-mailed if encrypted. D. A client is restricted from accessing his own medical records
C. Information regarding client health can be e-mailed if encrypted.
A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take? A. Administer fluconazole to the preschooler. B. Request an x-ray of the preschooler's neck. C. Initiate droplet precautions. D. Monitor the preschooler's urine for protein.
C. Initiate droplet precautions.
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? A. Insert the tip of the rectal tube 15 cm (6 in). B. Administer a second enema if the first has poor results. C. Instruct the client to exhale while inserting the rectal tube. D. Administer the enema using cool tap water.
C. Instruct the client to exhale while inserting the rectal tube
A nurse is completing post mortem documentation for a client. Which of the following information should the nurse include in the documentation? A. Cause of the client's death. B. Last set of the client's vital signs. C. Location of the identification tag on the client's body. D. Copy of the client's advance directives.
C. Location of the identification tag on the client's body.
A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect? A. Bladder infection B. increased appetite C. Loss of taste D. Loose stools
C. Loss of taste
A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take? A. Increase the client's intake of oral fluids. B. Encourage the client to ambulate to loosen secretions. C. Maintain the client in high-Fowler's position. D. Instruct the client to cough every 4 hr.
C. Maintain the client in high-Fowler's position.
A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take? A. Remind the client about the specifics of the procedure. B. Ask the client to sign the consent form anyway. C. Notify the charge nurse about the situation. D. Explain to the client that the procedure will help treat his diagnosis.
C. Notify the charge nurse about the situation.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include? A. Medications taken prior to admission. B. Family medical history C. Physical assessment findings D. Medical health insurance claims
C. Physical assessment findings
A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures? A. Irrigation of a wound with antibiotic solution B. Insertion of a nasogastric tube C. Placement of a central venous catheter D. Administration of an iron injection using the Z-track technique
C. Placement of a central venous catheter
A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor? A. Blood urea nitrogen B. Triiodothyronine. C. Prothrombin time D. Arterial blood gasses
C. Prothrombin time
A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray? A. Shrimp salad B. Pulled-pork sandwich C. Roasted salmon D. Clam chowder
C. Roasted salmon
A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the healthcare team? A. Occupational therapist B. Physical therapist C. Social worker D. Primary care provider
C. Social worker
A nurse is observing assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure A. The AP positions the client-facing her B. The AP inserts the probe with a straight, forward morgen. C. The AP pulls the pinna up and back. D. The AP points the probe posteriorly.
C. The AP pulls the pinna up and back.
A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client? A. The names of the clients' nearest relatives. B. The diagnoses of the clients. C. The telephone numbers of the clients. D. The room numbers of the clients.
C. The telephone numbers of the clients.
A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching? A. Implement a sodium-restricted diet. B. Keep legs in a dependent position. C. Wrap the leg with an elastic bandage. D. Maintain bed rest for 48 hr.
C. Wrap the leg with an elastic bandage.
A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hr creatinine clearance test. Which of the following statements should the nurse include in the teaching? A. You can cleanse your perineal area with an antiseptic towel each time before you void. B. You should record your blood glucose level each time you void. C. You can begin collection of urine after discarding your first morning void. D. You should eat a protein-rich diet during the collection period.
C. You can begin collection of urine after discarding your first morning void.
A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching? A. We require informed consent for all routine treatments. B. A family member must witness your signature on the informed consent form. C. You can sign the informed consent form after the provider explains the pros and cons of the procedure. D. We can accept verbal consent unless the surgical procedure is an emergency.
C. You can sign the informed consent form after the provider explains the pros and cons of the procedure.
A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make? A. I'm sure that everything will be alright, regardless of your decision. B. If I were you, I would contact your spiritual director. C. You have a right to change your mind. D. Making this decision is wrong.
C. You have a right to change your mind.
A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use? A. Push the gown sleeves up to the elbows. B. Tie the gown with the gloves on. C. Apply the gown before the gloves. D. Tuck the glove cuffs under the gown sleeves.
C. apply the gown before the gloves
A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take? A. Cover the wound with a dry sterile dressing. B. Position the client in semi-Fowler's position. C. Instruct the client to lie supine with his knees flexed. D. Cover the wound with a transparent dressing.
C. instruct the client to lie supine with his knees flexed
A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching? A. 'Tilt your head forward while inhaling." B. "Exhale immediately after inhaling." C. "Take three quick breaths while depressing the canister." D. "Close your mouth around the mouthpiece."
D. "Close your mouth around the mouthpiece."
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? A. "An attorney will need to notarize this document for it to be valid." B. "My partner needs to be present when I sign this document. C. "I am not allowed to change my mind once I sign this document." D. "I should discuss this document with my family after I sign it."
D. "I should discuss this document with my family after I sign it."
A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should include which of the following is an acceptable weight gain for this client? A. 32 Ib. B. 24 Ib. C. 8 Ib. D. 16 Ib.
D. 16 Ib
A nurse is assisting with the plan of care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional conference? A. A client who has a torn rotator cuff. B. A client who has acute appendicitis C. A client who has a urinary tract infection. D. A client who has a spinal cord injury.
D. A client who has a spinal cord injury.
A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include? A. A nurse observes a client vomiting after receiving an oral pain medication. B. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. C. A nurse discovers that a client's family member has administered a PCA dose. D. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client
D. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client
A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia? A. Brief Psychiatric Rating Scale B. Mental Status Examination C. Patient Health Questionnaire - 9 D. Abnormal Involuntary Movement Scale
D. Abnormal Involuntary Movement Scale
A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take? A. Increase the rate of the client's feeding. B. Provide the client with a low-calorie formula. C. Switch the client to a formula containing less protein. D. Administer the client's formula at room temperature.
D. Administer the client's formula at room temperature.
A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take? A. Wipe from the outer to the inner canthus after administering the drops. B. Flush the eye with normal saline solution before administering the drops. C. Position the child side-lying on the bed before administering the drops. D. Apply pressure to the lacrimal punctum after administering the drops.
D. Apply pressure to the lacrimal punctum after administering the drops.
A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first? A. I know that the voices are real to you, but I do not hear them." B. Can you listen to me instead of the voices you are hearing?" C. Let's take a walk outside to see if the voices you are hearing will stop." D. Are the voices you are hearing telling you to hurt yourself or someone else?"
D. Are the voices you are hearing telling you to hurt yourself or someone else?"
A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take? A. Offer the child sips of clear fluids. B. Administer an oral antiepileptic medication. C. Place the child in a supine position. D. Check the child for oral injuries.
D. Check the child for oral injuries.
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take? A. Ensure at least three finger widths of space under tracheostomy ties. B. Prepare sterile supplies after removing the inner cannula. C. Cleanse the inner cannula with isopropyl alcohol. D. Clean the stoma using an inward to outward circular motion.
D. Clean the stoma using an inward to outward circular motion.
A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain? A. Urinary retention. B. Constipation. C. Difficulty swallowing. D. Clenched teeth.
D. Clenched teeth.
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take? A. Hold gentle, direct pressure on the protruding organ. B. Place the client's knees in an extended position C. Raise the head of the bed to a 45° angle. D. Cover the wound with sterile, saline-soaked gauze
D. Cover the wound with sterile, saline-soaked gauze
A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions? A. Identifying the client's perception of the changes in her physical appearance B. Providing the client with information on community resources that will strengthen her coping skills C. Encouraging the client to write about her feelings in a journal each day D. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds
D. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds
A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis? A. Elevated ammonia B. Decreased albumin C. Prolonged PT/INR D. Elevated lipase
D. Elevated lipase
A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching? A. Limit the client's social interactions. B. Assume responsibility for making the client's decisions. C. Maintain a verbal no-harm contract with the client. D. Encourage the client to be assertive.
D. Encourage the client to be assertive.
A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take? A. Observe the client's behavior every 2 hr. B. Keep the client's door shut when they are in the room. C. Limit the personal toiletries in the client's room to cologne. D. Ensure the client swallows each dose of medication.
D. Ensure the client swallows each dose of medication.
A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching? A. I will increase my fluid intake to 1,700 milliliters per day. B. I should do aerobic exercises once per day. C. I will consume low-protein, low-calorie foods. D. I should practice pursed lip breathing exercises.
D. I should practice pursed lip breathing exercises.
A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching? A. I can use synthetic blankets on my bed. B. I will increase the flow rate if I feel short of breath. C. I can use isopropyl alcohol to clean the nasal cannula when necessary. D. I will check my oxygen equipment at least once daily.
D. I will check my oxygen equipment at least once daily.
A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make? A. Let's discuss this when we have more time." B. I " wouldn't worry about this right now. Let's focus on your chemotherapy." C. I can't imagine how difficult it would be to lose my hair." D. I will get you information about some head-covering options."
D. I will get you information about some head-covering options."
A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching? A. I can remove my security band to give it to a family member." B. I will carry my baby to the nursery." C. I can take my baby to the lobby to visit family." D. I will have an identification band that matches the one my baby wears."
D. I will have an identification band that matches the one my baby wears."
A nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parent indicates an understanding of the teaching? A. I will attach the pacifier to my newborn's clothing with a string at bedtime. B. I will place my newborn's crib near a heat vent during cold weather. C. I will place my newborn face up on a pillow when sleeping. D. I will make sure that I can fit one finger between the mattress and the side of my newborn's crib.
D. I will make sure that I can fit one finger between the mattress and the side of my newborn's crib.
A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching? A. will no longer be able to eat nuts." B. will empty the pouch every 2 to 3 hours." C. I should expect my stool to be formed." D. I will notify my doctor if the stoma starts to look purple."
D. I will notify my doctor if the stoma starts to look purple."
A home health nurse is reinforcing teaching with a client who has diabetes mellitus. Which of the following statements should the nurse make to evaluate the client's use of a glucometer? A. Show me what blood glucose supplies you have available." B. Tell me how long you have been using this glucometer." C. Let me demonstrate to you how to use this machine correctly." D. I would like to observe you using your glucometer."
D. I would like to observe you using your glucometer."
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first? A. Complete an incident report. B. Notify the client's provider. C. Document the fall in the client's medical record. D. Measure the client's vital signs.
D. Measure the client's vital signs.
A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of the following statements by the partner indicates an understanding of the teaching? A. Playing music will increase my husband's alertness. B. I will discontinue music therapy when my husband is no longer responsive. C. My husband won't need medication for breakthrough pain while using music therapy. D. Music will distract my husband's awareness of the pain.
D. Music will distract my husband's awareness of the pain.
A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first? A. Open the side flap of the sterile kit, allowing it to lie flat on the work surface. B. Apply sterile gloves. C. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface. D. Open the outermost flap of the sterile kit away from the nurse's body.
D. Open the outermost flap of the sterile kit away from the nurse's body.
A nurse on a medical-surgical unit is assigning tasks to assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP? A. Measuring the depth of a stage 3 pressure injury. B. Demonstrating how to use an incentive spirometer C. Changing the appliance on a new colostomy D. Performing indwelling urinary catheter care.
D. Performing indwelling urinary catheter care.
A nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client? A. Offer the client a nutritious snack every 4 hr. B. Ensure that the provider has signed a prescription for restraints within 48 hr. C. Monitor the client's range of motion every 60 min. D. Plan to remove the restraints as soon as the client is calm.
D. Plan to remove the restraints as soon as the client is calm.
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect? A. Facial erythema B. Beefy, red tongue C. Peeling of the hands and feet D. Productive cough with thick mucus
D. Productive cough with thick mucus
A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse recommend included in the plan? A. Instruct the client to notify the provider if discomfort is felt during ECT. B. Schedule follow-up ECT treatments 1 month apart. C. Initiate NPO status 1 hr prior to ECT. D. Provide frequent reorientation after ECT.
D. Provide frequent reorientation after ECT.
A nurse is supervising assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene A. Locks the wheels on the client's bed B. Clears furniture from the path leading to the bathroom. C. Assists the client to the bathroom every 2 hr. D. Raises all four side rails on the client's bed.
D. Raises all four side rails on the client's bed
A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first? A. Call the supervisor to ask for another nurse. B. Document objective findings about the situation. C. Assign clients to the remaining staff. D. Remove the nurse from the client care area.
D. Remove the nurse from the client care area.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority? A. Elevated temperature B. Tachycardia C. Cramping D. Seizures
D. Seizures
A nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations? A. Swelling of the lips B. Nausea C. Hyperglycemia D. Shortness of breath
D. Shortness of breath
A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make? A. You should take the medication on an empty stomach to prevent a headache." B. You can discontinue the medication until the headache goes away." C. Swallow the tablet whole to minimize your headaches." D. The headaches should decrease as you get used to the medication."
D. The headaches should decrease as you get used to the medication."
A nurse is preparing to give a change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? A. Admission vital signs B. Steps required for dressing change C. preferred bath time D. Time of last pain medication
D. Time of last pain medication
A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family? A. To bury the client's body within 24 hr of their death. B. To prohibit medical personnel from touching the client's body. C. To stay with the client's body for 8 hr following their death . D. To cremate the client's body
D. To cremate the client's body
A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication? A. Tachycardia B. Lacrimation C. Hypertension D. Urinary retention
D. Urinary retention
A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan? A. Confront the client regarding inappropriate behavior. B. Maintain low-level lights in common areas. C. Give the client several meal options at lunchtime. D. Use symbols in the communal room signage
D. Use symbols in the communal room signage
A nurse is collecting data from a client who has pernicious anemia. The nurse should identify which of the following findings increases the client's risk for injury? A. Increased intake of green, leafy vegetables . B. Drinks 2,500 mL of fluid per day. C. Wears a face mask around others. D. Uses a firm-bristled toothbrush.
D. Uses a firm-bristled toothbrush.
A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take A. Remove personal protective equipment after leaving the client's room. B. Restrict the client's visitors. C. Ensure that the negative air pressure is active for the client's room. D. Wear a gown when assisting the client with personal hygiene.
D. Wear a gown when assisting the client with personal hygiene.
A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take? A. Gently massage the eyelid to facilitate absorption of the medication. B. Place an occlusive dressing on the affected eye to prevent the spread of infection. C. Instruct guardians to apply erythromycin ophthalmic ointment every morning for 14 days. D. Wipe any excess medication from the inner canthus outward.
D. Wipe any excess medication from the inner canthus outward.
A nurse is contributing to the plan of care for a client who was newly admitted and has tuberculosis. Which of the following actions should the nurse recommend including in the plan of care? A. Increase the client's daily intake of vitamin D. B. Place the client in a positive-pressure isolation room. C. Perform tuberculin skin testing. D. Initiate contact precautions.
D. initiate contact precaution
A nurse is monitoring a client's arterial pulses. The nurse should check for a dorsalis pedis pulse in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
The answer is D
