NCLEX RN 4
A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching? A) "I will have my husband wear a condom during intercourse." B) "I will check my temperature every 4 hours." C) "I will wipe from front to back after bowel movements." D) "I will notify my doctor if my baby moves fewer than 4 times in the 2 hours following each meal."
A) "I will have my husband wear a condom during intercourse."
A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? A) Check on the client B) Unlock the crash cart C) Begin cardiopulmonary resuscitation D) Announce a code
A) Check on the client
A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching? A) Cue the client by providing picture cards that portray common needs. B) Increase the volume of the voice when speaking to the client. C) Encourage the client to limit hand gestures when communicating. D) Vary the use of phrases and terminology in discussions.
A) Cue the client by providing picture cards that portray common needs.
A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting? SELECT ALL THAT APPLY A) Dietician B) Physical therapist C) Hospice nurse D) Social worker E) Respiratory therapist
A) Dietician B) Physical therapist D) Social worker
A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first? A) Evaluate level of consciousness. B) Place the client on bed rest. C) Encourage increased fluid intake. D) Initiate continuous ECG monitoring.
A) Evaluate level of consciousness.
A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following? A) Facial edema B) Urinary frequency C) Acid indigestion D) Breast leakage
A) Facial edema
A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster? A) Immediate B) Delayed C) Minimal D) Expectant
A) Immediate
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene? A) Including in a client's nurses' note that an incident report was completed after a medication error B) Drawing horizontal lines through blank spaces left in the nurses' notes followed by a signature C) Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet D) Documenting the provider was contacted to clarify a questionable prescription
A) Including in a client's nurses' note that an incident report was completed after a medication error
A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first? A) Initiate a bladder training schedule. B) Administer solifenacin (Vesicare). C) Insert an indwelling urinary catheter. D) Perform intermittent catheterization.
A) Initiate a bladder training schedule.
A nurse in a provider's office is orientating a newly licensed nurse on how to position a client for a vaginal examination. The nurse include in the teaching to place a client in which following position? A) Lithotomy B) Dorsal recumbent C) Prone D) Lateral recumbent
A) Lithotomy
A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? A) Loss of color discrimination B) Nausea and vomiting C) Red-orange discoloration to body fluids D) Edema of feet and hands
A) Loss of color discrimination
A nurses caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor? A) Maternal respirations B) Fetal heart rate C) Maternal deep-tendon reflexes D) Maternal urinary output
A) Maternal respirations
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? A) Obtain an ECG B) Administer oral C) Encourage potassium-rich foods D) Monitor I & O
A) Obtain an ECG
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? A) Place the infant in a supine position when sleeping B) place the infant on a firm mattress when sleeping C) avoid covering the infant with loose bedding while sleeping D) avoid leaving stuffed animals in the crib with the sleeping infant
A) Place the infant in a supine position when sleeping
A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A) Promoting oxygenation B) Management of pain C) Maintaining hydration D) Preventing infection
A) Promoting oxygenation
A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion? A) Reduced bleeding time B) Decreased plasma globulins C) Improved activity tolerance D) Increased immune functioning
A) Reduced bleeding time
A nurse is caring for a client who has a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication? A) Speech pathologist B) Occupational therapist C) Social worker D) Respiratory therapist
A) Speech pathologist
A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone the teaching? A) States that pain is an 8 on a scale of 0 to 10 B) States that her partner should be given the information C) Expresses concern about the exercises causing pain when performed after surgery D) Expresses uncertainty about the benefits of the exercises
A) States that pain is an 8 on a scale of 0 to 10
A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first? A) Take an ABG specimen to the laboratory. B) Transport a client to the radiology department for an x-ray. C) Obtain a clean catch urine sample from a newly admitted client. D) Pass fresh water to clients.
A) Take an ABG specimen to the laboratory.
A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching? A) "I will only be on this medication 4 to 6 months because it can lead to physical dependence." B) "I can have 1 to 2 alcoholic beverages each week." C) "I will need to stop taking Xanax two weeks before I can begin taking this medication." D) "I can have 6 to 8 ounces of grapefruit juice each day."
B) "I can have 1 to 2 alcoholic beverages each week."
A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first? A) A client 48 hr following abdominal surgery with redness and swelling at the edges of the incision B) A client following knee replacement surgery complaining of pain and warmth in the calf C) A client admitted with cholecystitis who reports frequent nausea and vomiting D) A client admitted with a GI bleed receiving packed RBCs for hemoglobin of 7.8 gm/dL
B) A client following knee replacement surgery complaining of pain and warmth in the calf
A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which type of ethical principles? A) Justice B) Autonomy C) Veracity D) Fidelity
B) Autonomy
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit? A) Obtain an arterial pH level B) Check the HR and BP C) Insert an indwelling catheter D) Collect a serum BUN and creatinine
B) Check the HR and BP
A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? A) Administer an anticoagulant B) Check the leg for warmth and Edema C) Apply elastic stockings D) Promote bed rest & extremity elevation
B) Check the leg for warmth and Edema
A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action? A) Inform the nurse manager. B) Determine the client's condition. C) Notify the provider. D) Complete an incident report.
B) Determine the client's condition.
A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? A) Provide assistance w/ ambulation when indicated B) Determine the mobility status of each patient C) Maintain the side rails of each be in the raised position D) Plan a fall prevention program for clients at risk
B) Determine the mobility status of each patient
A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider? A) Lithium carbonate 0.8 mmol/L B) Digoxin 3.0 ng/mL C) Peak serum gentamicin 6 mcg/mL D) Magnesium sulfate 4 mEq/L
B) Digoxin 3.0 ng/mL
A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis? A) Increased appetite B) Elevated temperature C) Bradycardia D) Drowsiness
B) Elevated temperature
A nurses caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? A) Promote adequate intake of calcium. B) Evaluate neurovascular status. C) Elevate the extremity above the heart. D) Apply ice intermittently for the first 24 hr.
B) Evaluate neurovascular status.
A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile? A) Prospective audit B) Outcome audit C) Process audit D) Structure audit
B) Outcome audit
Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? A) Bathe a client who is scheduled for physical therapy at 9 a.m. B) Perform fingersticks for glucose levels on clients who have diabetes mellitus. C) Stock procedure rooms. D) Distribute clean linens.
B) Perform fingersticks for glucose levels on clients who have diabetes mellitus.
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A) Place O2 at 2 L per nasal canula on the client B) Place the client in the orthopneic position C) Perform chest percussion D) perform nasotracheal suction
B) Place the client in the orthopneic position
A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention? A) Cholesterol 220 mg/dL B) Platelets 95,000 mm^3 C) BUN 20 mg/dL D) Potassium 3.5 mEq/L
B) Platelets 95,000 mm^3
A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? A) Blood glucose 150 mg/dL B) Potassium 2.5 mEq/L C) Total protein 5.2 g/dL D) Urine specific gravity 1.040
B) Potassium 2.5 mEq/L
A nurses caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is a priority concern of the nurse? A) Enhancing self-esteem B) Preventing injury C) Encouraging problem solving D) Promoting usefulness
B) Preventing injury
A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching? A) Place proper lights and reflectors on the bicycle. B) Use a properly-fitted bicycle helmet. C) Wear light-colored clothing at night. D) Use hand signals when turning.
B) Use a properly-fitted bicycle helmet.
A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching? A) "It is necessary to have written consent for invasive procedures." B) "Implied consent is appropriate for some aspects of nursing care." C) "It is the responsibility of the provider to obtain express consent." D) "Informed consent should be obtained separately for each surgical procedure."
C) "It is the responsibility of the provider to obtain express consent."
A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who is stable angina. Which of the following statements by the client indicates teaching has been effective? A) "I should leave the patch on for 16 to 20 hours each day." B) "I will apply a new patch in the same location each day." C) "The patch should be effective within an hour of being applied." D) "The medication is not absorbed as well when placed on the abdomen."
C) "The patch should be effective within an hour of being applied."
A nurse working the 7 PM to 7 AM shift on the pediatric unit has received report on four post operative clients. Which of the following requires immediate intervention? A) An adolescent who is postoperative following an appendectomy and has refused to ambulate for the past 8 hr B) A school-age child who is postoperative following a herniorrhaphy with an infiltrated peripheral IV that has been clamped C) A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing D) An infant who is postoperative following a cleft palate repair with a heart rate of 146/min and a respiratory rate of 28/min
C) A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing
A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality? A) Placement of computer systems in restricted areas B) Installation of firewall software on each computer C) Ability of staff to access electronic health records of clients throughout the facility D) Occurrence of an automatic log-off after a period of inactivity
C) Ability of staff to access electronic health records of clients throughout the facility
A nurse is caring for a client who is 48 hr post operative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A) Absent bowel sounds B) Serum BUN level 22 mg/dL C) Absent dorsalis pedis pulses D) Serum creatinine level of 1.3 mg/dL
C) Absent dorsalis pedis pulses
A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of a 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first? A) Administer an analgesic. B) Assist the client to shift positions. C) Check pedal pulse. D) Distract the client with music therapy.
C) Check pedal pulse.
A nurse caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? A) Establishing a sense of achievement B) Contributing to society C) Creating meaningful social relationships D) Enhancing self- confidence
C) Creating meaningful social relationships
A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screening should the nurse recommend to the client? A) Mammogram every year to detect breast cancer B) Colonoscopy every 10 years to detect colon cancer C) Dermatologist evaluation every 3 years to detect skin cancer D) Complete eye examination every year to detect eye disorders
C) Dermatologist evaluation every 3 years to detect skin cancer
A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take? A) Administer epinephrine (Adrenaline). B) Elevate the lower extremities. C) Determine respiratory status. D) Apply oxygen via non-rebreather mask.
C) Determine respiratory status.
A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention? A) Painful swallowing B) Hoarse voice C) Difficulty breathing D) Blood-tinged sputum
C) Difficulty breathing
A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice? A) Assign a security guard to stay at the client's door. B) Request a prescription from the provider for soft restraints. C) Discuss the risks associated with leaving with the client. D) Remove the telephone from the client's room.
C) Discuss the risks associated with leaving with the client.
A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects? A) Tachycardia B) Sternal retractions C) Hypoglycemia D) Hypothermia
C) Hypoglycemia
A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? A) Homelessness B) Lack of family support C) Hypoxic D) Under nourished
C) Hypoxic
A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern? A) Facial abrasions B) Penetrating head wound C) Incomplete amputation of the foot D) Tibia fracture requiring open reduction
C) Incomplete amputation of the foot
A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include? A) Medications will eliminate HIV in most clients. B) Adolescents are at a lower risk for developing HIV. C) Initial HIV symptoms are often similar to the flu. D) Using condoms ensures the prevention of HIV during sexual intercourse.
C) Initial HIV symptoms are often similar to the flu.
A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)? A) Pupil dilation B) Ataxia C) Lethargy D) Bradycardia
C) Lethargy
A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurse's priority action? A) Providing pain control B) Preventing hemorrhage C) Maintaining a patent airway D) Ensuring adequate fluid intake
C) Maintaining a patent airway
A nurse is caring for toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse? A) Administer nebulized epinephrine (racemic epinephrine). B) Ensure adequate hydration. C) Obtain an oxygen saturation level. D) Encourage parents to comfort the client.
C) Obtain an oxygen saturation level.
A nurse is caring for a client who was admitted to the unit three hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern? A) Urinary output of 75 mL over the past 3 hr B) 8-point elevation in the pre-surgery diastolic blood pressure C) Oxygen saturation of 90% on oxygen at 2 L per nasal cannula D) Core body temperature of 36.2° C (97.2° F)
C) Oxygen saturation of 90% on oxygen at 2 L per nasal cannula
A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule? A) Use a filter needle to administer the promethazine. B) Expel air bubbles back into the ampule. C) Set the ampule on a flat surface to withdraw the promethazine. D) Break the ampule toward the body.
C) Set the ampule on a flat surface to withdraw the promethazine.
A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions? A) Prone with head of the bed flat B) Dorsal recumbent with head of the bed elevated to 15° C) Supine with head of the bed elevated to 30° D) Side-lying with head of the bed elevated to 45°.
C) Supine with head of the bed elevated to 30°
A nurse is collecting data on four clients. Which of the following findings is the most urgent? A) Bladder distension and urgency B) Pedal edema C) Warmth and pain in the calf D) Hypoactive bowel sounds
C) Warmth and pain in the calf
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A) A client who has peripheral vascular disease and reports numbness in the toes B) client who has depression & is easily distracted C) A client who has Alzheimer's disease and is unable to complete ADLS D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop
D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop
A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A) A client who has COPD with an oxygen saturation of 90% B) A client who has diabetes mellitus with a HbA1C of 9% C) A client who has heart failure with 2+ pitting edema of the lower extremities D) A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant
D) A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant
A nurse in a providers office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern? A) A client who is 26 weeks of gestation and reporting leukorrhea B) A client who is 10 weeks of gestation and reporting urinary frequency C) A client who is 37 weeks of gestation and reporting perineal discomfort D) A client who is 34 weeks of gestation and reporting abdominal tenderness
D) A client who is 34 weeks of gestation and reporting abdominal tenderness
A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? A) A client who is has a history of HF B) A client who has type 1 DM C) A client who is reporting pain associated w/ osteoarthritis of the knees D) A client who is having a nosebleed associated w/ hypertension
D) A client who is having a nosebleed associated w/ hypertension
A nurses caring for a group of pediatric clients. Which of the following clients requires immediate intervention? A) A client who has cystic fibrosis and has a paroxysmal cough B) A client who is prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79% C) A client who has celiac disease and abdominal distention D) A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting
D) A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting
A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client? A) Acupuncture is loosely regulated by the federal government. B) Acupuncture has been discredited by scientific research. C) Acupuncture is thought to be effective only as a placebo. D) Acupuncture has been proven to reduce pain and increase function.
D) Acupuncture has been proven to reduce pain and increase function.
A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin? A) Provide a toy doctor's kit to play with. B) Keep all syringes and needles out of sight until needed. C) Use an approach that is firm but direct. D) Allow the child to manipulate the medical equipment.
D) Allow the child to manipulate the medical equipment.
A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign? A) A preschooler with a hip spica cast who is being discharged today B) An infant scheduled for a surgical repair of a ventricular septal defect tomorrow C) A toddler with a fractured femur who has been in Bryant's traction for 5 days D) An adolescent who is 2 days postoperative following an appendectomy
D) An adolescent who is 2 days postoperative following an appendectomy
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? A) Initiate oxygen therapy B) Encourage an increase in oral fluids C) Provide room humidification D) Assist client to cough effectively
D) Assist client to cough effectively
A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor? A) Diplopia B) Loss of bladder control C) Paresthesias D) Decreased respiratory effort
D) Decreased respiratory effort
A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective? A) Self-reporting the ability to perform the procedure B) Answering appropriately when questioned orally C) Responding accurately on a written examination D) Demonstrating independent performance of the procedure
D) Demonstrating independent performance of the procedure
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? A) Malaise B) Anorexia C) Headache D) Diarrhea
D) Diarrhea
A nurses caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? A) Administer an anti-anxiety medication. B) Take the client to a place of seclusion. C) Obtain an order for soft wrist restraints. D) Engage the client in physical activity.
D) Engage the client in physical activity.
A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication? A) Hyperkalemia B) Severe diarrhea C) Atelectasis D) Excessive vomiting
D) Excessive vomiting
A nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? A) Administer medications w/ meals when possible B) Ensure client understanding of medication's effects C) Determine the client's ability to self-administer meds D) Have the client position the head w/ chin down while swallowing
D) Have the client position the head w/ chin down while swallowing
A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client? A) Raising her voice level when speaking to the client B) Asking the client open-ended questions C) Clarifying client statements with the family as needed D) Having the client use eye blinks to indicate yes or no
D) Having the client use eye blinks to indicate yes or no
A nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? A) Ensure all 4 side rails are up. B) Administer a prescribed sedative. C) Place the client in soft wrist restraints D) Move the client to a room near the nurses' station
D) Move the client to a room near the nurses' station
A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal? A) Support the client's relationship with his caregivers. B) Encourage the client to express his feelings. C) Determine who is responsible for the abuse. D) Protect the client from further abuse.
D) Protect the client from further abuse.
A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first? A) Notify the provider. B) Obtain a chest x-ray. C) Flush the catheter. D) Stop the infusion.
D) Stop the infusion.
A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate? A) "I know this must be difficult, but your mother will calm down soon." B) "Let's discuss some strategies you can use when this happens again." C) "Individuals near death are ready to let go toward the end." D) "Have you determined why she is crying and saying she is ready to die?"
B) "Let's discuss some strategies you can use when this happens again."
A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unity where her family will be unable to stay with her all the time. Which of the following responses is appropriate? A) "I know this must be frightening, but you are going to be fine." B) "Let's talk for a minute about your concerns." C) "You were transferred because it is in your best interest." D) "Why do you feel a family member should be with you?"
B) "Let's talk for a minute about your concerns."
