NURSE CASSIE

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

"Advance directives include a living will"

Which of the following statements by the client indicates an understanding of the teaching?

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

A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching?

"I should take this medication in the morning and at night.

A nurse is discussing a living will with a client. Which of the following statements by the client indicates an understanding of this document?

"It communicates my wishes for end-of-life care."

A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment for bladder cancer. Which of the following instructions should the nurse include in the teaching?

- cleanse the skin around the stoma with a mild soap and warm water

A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods?

-make sure room is lite

Administer the medication to the toddler each evening

.

Maintainance for hearing aid?A. Wipe with soft clothB. Clean with alcoholC. Change battery every year

A. Wipe with soft cloth

A client is collecting nutritional data from a group of adult clients. Which of the following clientsshould the nurse recommend an interprofessional conference with a dietitian?

BMI of 32

A nurse is caring for a client who is one day post-operative following a total hip arthroplasty and is receiving Heparin subcutaneously, which of the following adverse effects of the medication should the nurse report to the provider?

Epistaxis

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

Hypotension

A nurse is verifying informed consent for a client who is postoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

I am thankful I am done having children

A nurse is Reinforcing teaching about hand hygiene to a newly licensed nurse. Which of these following information should the nurse nclude in her teaching?

Interlace the fingers while rubbing hands together

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 to include in the plan?

Measure the client's abdominal girth daily

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

Oral suction equipment

A nurse is collecting data from a client who has cholecystitis. Which of these following findings should the nurseexpect?

Pain in the right upper abdomen

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Remind the client of the day and time often

A nurse is assisting with the care of a client who is at 37 weeks of gestationand is undergoing a nonstress test. Which of the following actions shouldthe nurse take?

Remind the client to press the button when she feels fetal movement

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

Skin rash with fever

A nurse is administering an intermittent enteral feeding through the clients NG tube, during the installation the client reports abdominal cramping and nausea, which of the following actions should the nurse take?

Slow the rate of the formula instillation

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Soiled dressings should be placed in a biohazard trash receptacle

A nurse is assisting with the care of a client who is receiving chemotherapy and radiation foradvanced breast cancer. The client states, "I'm

Tell me more about what you are thinking"

A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of this medication. Which of the following responses should the nurse make?

This medication will decrease the risk of hemorrhage in your newborn

A nurse is feeding a client who had a stroke resulting in left-sided weakness. Which of the following actions should the nurse take?

ask the client to tilt his head forward while swallowing

A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse disinfect the client's overhead table following a blood spill?

bleach

A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse use to disinfect the clients overbed table following a blood spill...?

bleach

AP

complete post mortum care for a client who had died

Chest pain

complicated grief

Identifiers after checking the id band what's next identifiersA. Home PhoneB. Medical Record NumberC. MAR

home phone

A nurse is reinforcing teaching with a parent of a child who has ADHD and is taking methylphenidate which of the following statements by the parents indicated the medication is effective

our child is able to complete his homework on time

pitting edema( check)

press firmly on affected extremity

A nurse is caring for a client who is to undergo a subtotal thyroidectomy which of the following items should the nurse place at the client's bedside

tracheostomy kit

A nurse is talking to a client who refuses a blood transfusion for religious reasons. which of the following responses should the nurse make?

you have the right to change your mind

A nurse is reinforcing teaching with the parents of a child who has a new diagnosis of Wilms tumor. Which of the following interventions should the nurse include in the teaching?

"You should not palpate your child's abdomen prior to surgery.

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

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

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

Administer the medication to the toddler each evening

A nurse is caring for four clients. Which of the following situations require a signed consent form?

Administering an iron injection Z-track method

A patient in traction reports severe pain from a muscle spasm. What is the nurse's priority action?a. Assess the patient's body alignmentb. Give the patient a PRN pain medicationc. Notify the health care providerd. Remove some of the weights

Assess the patient's body alignment

A nurse is caring for a client who has a follow up visit for bipolar disorder and a new prescriptionfor Lithium Therapy. Which of the following indicates Lithium Toxicity?

Dysrhythmias

A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching?

Encourage the client to be assertive

A nurse is reinforcing teaching with the support person of a client who is in the firststage of labor. Which of the following instructions should the nurse include regardingeffleurage?

Gently stroke her abdomen during contractions

A nurse enters the room of a school-age child and finds him on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the child's head

A nurse enters the room of a school aged child and finds him on the floor experiencing a tonic colonic seizure, which of the following actions should the nurse take?

Place a pillow under the client's head

A nurse is preparing a sterile field to perform a dressing change for a client's leg wound, which of the following actions should the nurse take?

Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field

A nurse preparing a sterile field to perform a dressing change for a client's leg wound. Which of the following actions should the nurse take?

Place sterile objects at least 2.5 cm from the edge of the sterile field.

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

Position the car seat at 90 degree angle

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

Suctions for 30 seconds

A nurse is caring for a client who reports frequent headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse include?

The headaches should decrease as you get used to the medication

A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?

Tilt the client's head forward during meals

A nurse is assisting with a community health course for family members of clients who half Alzheimer's disease. which of the following should the nurse include?

limit the number of choices for the client

Patient speaks in different languageA. Have the patient's partner translate B. Print picture

print picture

Haloperidol

tardive dyskinesia

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

time of last pain medication

A nurse is assisting with staff education about hand hygiene. which of the following should the nurse include in the teaching?

wash your hands with soap and water for 20 seconds

What signs that indicates effectiveness of levothyroxine?

weigh loss

A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

"Move clients to a room above ground with few windows.

A nurse is collecting nutritional data from a group of adult clients. For which of the following clients should the nurse recommend an interprofessional care conference with a dietician?

A client who has a body mass index of 32

A nurse is receiving change of shift report on four clients. Which of the following clients should the nurse plan to see first?

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 social worker who is assigned to an involuntary committed school-age client

44. Which of the following foods is a patient to avoid for 2 days before collecting a stool sample for guaiac testing?A) MilkB) Red meatC) RiceD) GrapefruitE) Cereal

B) Red meat

The middle aged adult reports fatigue, insomnia, and difficulty focusing on tasks. The clienthas three teenagers in the home and is the primary caregiver for the client's elderly mother withsignificant health problems. The nurse knows that one of the difficulties in this situation is what?

Being a member of sandwich generation

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

Complete post mortem care for a client who has died

A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medication?

Decreased kidney function

A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse recommend considering when administering medication?

Decreased kidney function

A nurse is caring for a client who is receiving intermittent enteral tube feedings and has diarrhea. Which of the following actions should the nurse take?

Deliver a smaller amount of formula more frequently

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement?

Determine the client's ability to use the call light

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

Explain medical terminology using basic, one-syllable words

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Measure the duration of the seizure

A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel?

Naproxen

The nurse works with the client taking phenytoin for seizure prevention. Which instruction isthe most essential for the nurse to reinforce regarding this medication?

Notify the health care provider immediately if a skin rash develops

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

Observe the movements of the client's chest wall

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing acute mania, which of the following interventions should the nurse include in the plan of care?

Provide the client with high calorie finger foods

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

Reduced fat in the stools

A charge nurse in the long-term care facility notices the smell of alcohol from one of the nurse'sbreath. Which oc the following actions should the nurse take first?

Remove the nurse from the client care area

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an .understanding of the teaching?

Soiled dressings should be placed in biohazard trash receptacle

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

Suction for 30 seconds

The nurse cares for the client who just underwent through an abdominal surgery. To increasethe client's comfort level, it is most important for the nurse to place the client in which position?

Supine with knees flexed

A nurse is reinforcing teaching about passive range of motion exercises with the family of a client who had a stroke. Which of the following instructions should the nurse include in the teaching?

Support the extremity above and below each joint during the exercises

A nurse is assisting with the admission of a client who states, "The last time I was in the hospital, the nurses took forever to answer my call light." Which of the following is an appropriate response by the nurse?

That must have been a difficult experience for you."

A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

The psychiatric staff is not FBI. They are here to help you.

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

Time of last pain medication

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

Urine output 12 mL/hr

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

Use a moisture barrier on the client's skin

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following instructions should the nurse include in the teaching?

You might experience swollen gums while taking this medication

Hinduism

dont touch the body after death

A nurse is reinforcing teaching with a parent of a preschooler who has atopic dermatitis. Which of the following instructions should the nurse include in the teachings?

dress the child in soft cotton clothing

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

explain medical terminology using basic one syllable words

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include

grapes

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 90.5 degree F. Which of the following data is the priority for the nurse to monitor?

heart rhythm

A nurse is caring for a client who has schizophrenia. Which of the following behaviors of the client should the nurse identify as a negative symptom of schizophrenia?

initiates speech rarely

A nurse is participating in a performance improvement program which of the following actions should the nurse take to evaluate the effectiveness of the program?

perform chart audits

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. which of the following recommendations should the nurse make?

perform pelvic rocking exercises several times per day

A nurse is reinforcing teaching about home safety precautions with the parent of a 3-month-old infant which of the following should the nurse include in the teaching

remove bibs when the infant is going to sleep

A charge nurse is observing a newly licensed nurse perform suction on a tracheostomy. Which ofthe following should the charge nurse intervene?

suctioning for 30 seconds

A nurse is caring for a client who is recently diagnosed with depression the clients partner asks when he will get better which of the following is the appropriate response by the nurse

tell me what you know about depression

A nurse is collecting data from a client who uses a continuous positive airway pressure cpap machine at night for sleep apnea. the nurse should identify which of the following indicates proper use

there is one finger width between he straps and the face

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?

"I lost my balance and fell when I got out of bed to the bathroom"

A nurse is talking with the partner of a client who recently died, which of the following statements should the nurse make?

"Tell me what I can do for you at this time.

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

1.5ml

A charge nurse at Emergency Department recommends that a client should be discharged inresponse to mass casualty disaster. Which of the following clients should the nurse recommend?

A client who is 3 days post-op of knee arthroplasty and requires knee rehabilitation

A nurse and a family practice office routinely review client's immunization status at their annual physical examination visit, for which of the following clients should the nurse recommend human papillaou virus immunization (HPV Virus)?

A teenage boy

A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching? A. Use three pronged grounded plugs. B. Cover extension cords with a rug. C. Check the tingling sensations around the cord to ensure the electricity is working. D. Remove the plug from the socket by pulling the cord.

A. Use three pronged grounded plugs.

A nurse is receiving info about advance directives w/ a newly admitted client. Which of the following statements by the client indicates an understanding of the information?

Advance directives include a living will

A nurse is caring for a client who is taking multiple medications about the possible interactions. Which of the following members of the interdisciplinary team should the nurse make a referral to?

Advance practice nurse

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

Advanced practice nurse

A nurse is RT with the family of a client who is terminally ill about the grief process. WOTFinformation should the nurse include in the teaching?

Anger towards the health care staff is expected

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding, the mother asks why is colostrum so important for my baby, which of the following responses should the nurse make?

Colostrum provides many important antibodies the newborn lacks

A nurse is collecting data from a client who has UTI and is taking ciproflaxin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?

Discontinue the medication. I will ask your provider for another antibiotic.

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

Disorientation

A nurse is assisting with the physical examination on a 7-year-old child. Which of these following options should thenurse take?

Explain the purpose of the equipment used

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

I am thankful I am done having children

A nurse is caring for a client who has advanced colorectal cancer and reports that her daughter insists on caring for her at home without assistance. The client states that she prefers help for home health care and hospice, which of the following responses should the nurse make?

I can be with you while you explain your feelings about your care to your daughter

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and has a prescription for timolol eye drops. Which of the following statements by the client indicates an understanding of the teaching?

I should check my heart rate while taking this medication

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

I try not to look at the scales on my body

A nurse is reinforcing with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

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

A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?

I will mix the medication with water

A nurse is reinforcing teaching with a client who has a new rx for transdermal nitroglycerin patches. Which of the following statements by the client indicates an understanding of the teaching?

I will place the patch on a hairless area of skin

A charge nurse in a long-term care facility is discussing ethical theories with a group of newly licensed nurses which of the following statements should the charge nurse identify that the newly licensed nurse understands utilitarianism?

I will respect the decision of a client who has a chronic illness and stops treatment

A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program?

Identify data collection methods

A nurse is reviewing the health history of a middle adult client who is receiving chemotherapy for leukemia, which of the following immunizations should the nurse recommend that the client receives?

Inactive Influenza

A nurse is caring for a client who is 2 days postoperative. The client 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 error?

Incident report

A nurse is caring for a client who recently gave birth to her first child. The newborn iscrying and the client states, "I can't seem to do anything right. What should I do?. Whichof the following responses should the nurse make?

Let me show you how to swaddle and cuddle him, then you try.

The nurse instructs the AP to complete a bath for the client. The AP claims that they do nothave enough time. What action should the nurse take?

Risk manager/Supervisor

A nurse is caring for a client who delivered by C-section 1 day ago. The client requests nonpharmacological interventions to manage pain when changing position. Which of the followingresponses should the nurse make?

Use breathing techniques when changing positions

A nurse is preparing to administer spironolactone and lisinopril to a client who reports anxiety,dyspnea, and weakness of the leg. Which of the following actions should the nurse take first?

Withhold the prescribed medication

A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when he takes antibiotics. Which of the following food choices should the nurse recommend to lessen the occurance of diarrhea?

Yogurt

A nurse is reinforcing teaching with a client who has a prescription for antibiotic therapy. The client tells the nurse that he always experiences diarrhea when taking antibiotics, which of the following food choices should the nurse recommend to lessen the occurrence of diarrhea?

Yogurt

A nurse is caring for a client who is receiving enteral nutrition. Which of the following findings indicates a need to decrease the rate of the enteral feeding?

diarrhea

When should the nurse perform sputum collection

in the morning

Palliative care purpose

quality of life and comfort

A charge nurse is discussing about confidentiality of a client; about sharing the client's medicalrecord. Which of the following people should the nurse identify as an appropriate person to shareclient's information with?

social worker