PN Comprehensive Online Practice 2023 B

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client whose urinary output was 100 mL for the past 12 hr

A nurse is collecting data from a newly admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

Irritability An infant who has hypovolemia will experience irritability due to decreased perfusion. The nurse should report this finding to the provider.

A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV. Which of the following information should the nurse include in the teaching?

"Your HIV status will be shared with members of your health care team."

A nurse is assisting with a discussion about STIs with a group of adolescents at a health fair. Which of the following statements should the nurse make?

"An infection with gonorrhea can result in infertility."

A nurse is caring for a client who is recovering from a motor-vehicle crash. The client's employer calls to ask if the client's injuries will prevent them from returning to work. Which of the following responses should the nurse make?

"I cannot give you this information. You will need to speak with your employee."

A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, "I am very upset and I want to be alone for a little while." Which of the following responses should the nurse make?

"I see that you are feeling overwhelmed. I will come back when you are ready." This response by the nurse is therapeutic and uses the communication technique of sharing observations. This response meets the requirements of a trusting nurse-client relationship. It respects the client's right to privacy and allows them to have control over their personal space while encouraging the expression of feelings.

A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I should apply sterile saline to lubricate the suction catheter."

A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which of the following statements made by the client indicates an understanding of the teaching?

"I should wear a soft scarf around my neck when I am outside."

A nurse is reinforcing teaching with a newborn's parents about umbilical cord care. Which of the following statements by a parent indicates an understanding of the instructions?

"I will give our baby sponge baths until the cord falls off."

A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will secure the car seat in the car by using the seatbelt."

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

"I will use condoms in addition to birth control pills to decrease my risk of becoming pregnant."

A nurse is reinforcing teaching with a client about taking warfarin to treat atrial fibrillation. Which of the following statements by the client indicates an understanding of the teaching?

"If I forget to take a dose, I can take it later on the same day."

A nurse in an inpatient mental health facility is caring for a newly admitted client who has alcohol use disorder. During a therapy session, the client asks about Alcoholics Anonymous (AA). Which of the following responses should the nurse make?

"What is your current understanding about the purpose of AA?"

A nurse is assisting with performing a nonstress test for a client who is at 39 weeks of gestation. Which of the following instructions should the nurse reinforce with the client?

"You should depress the button on the handheld marker when you feel your baby move." The nurse should instruct the client to depress the button on the handheld marker when they feel fetal movement. The nurse will note the mark on the fetal monitor tracing and the provider can review it. This test monitors fetal well-being

A nurse is reinforcing teaching with a client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the nurse should instruct the client to take after washing their hands.

1. Expose the glans of the penis 2. Cleanse the penis using an antiseptic swab 3. Begin urination 4. pass the cup into the urine stream 5. Move the cup out the urine stream 6. Replace the foreskin

A nurse is caring for a client who has a prescription for famotidine 160 mg PO every 6 hr. Available is famotidine oral suspension 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20 mL 160/40X5= 20mL

A nurse is assisting with the care of a school-age child immediately following surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider?

250 mL of sanguineous drainage over the last 3 hr

A nurse is assisting with the development of an in-service for newly licensed nurses about seclusion. In which of the following situations should the nurse identify the need to request a prescription for seclusion?

A client attempts to hit another client during group therapy. The nurse should request a prescription for seclusion for a client who is at risk for harming themselves or others, or who exhibits violent behavior.

A nurse is caring for a client who is experiencing acetaminophen toxicity. Which of the following medications should the nurse plan to administer to the client?

Acetylcysteine Acetaminophen toxicity can result in liver damage or death and requires treatment with acetylcysteine as an antidote. The nurse should plan to mix the medication with water or juice and administer an oral dose every 4 hr for up to 72 hr.

A nurse is reinforcing teaching about self-administration of enoxaparin. Which of the following instructions should the nurse include?

Administer by subcutaneous injection.

A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?

As soon as the client awakens in the morning Sputum from the base of the lungs provides the best specimen for collection. The AP should obtain the specimen early in the morning because overnight fluid accumulates in the base of the lungs while the client is sleeping.

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy via nasal cannula. Which of the following instructions should the nurse include?

Apply a water-based lubricant around the nostrils to prevent irritation." The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy.

A nurse is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include?

Apply capsaicin cream four times daily.

A nurse is reinforcing teaching with a client who has a new prosthesis for an above-the-knee amputation of the right leg. Which of the following instructions should the nurse include?

Apply the prosthesis immediately upon waking each day.

A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

Applying the stockings before the client gets out of bed

A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

Avoid foods with a high sugar content.

A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?

Avoid lying on the affected side.

A nurse is assisting in the care of an adolescent. Select the 4 findings that require follow-up. Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.

Capillary refill Pedal Pulse Skin Temperature Pain

A nurse is talking with a client who says the provider agreed to initiate a do-not-resuscitate (DNR) prescription. After leaving the client's room, which of the following actions should the nurse take first?

Check for documentation that the provider spoke with the client about the DNR. The first action the nurse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decision and that documentation meets legal requirements.

A nurse in a long-term care facility is reviewing standard precaution guidelines with an assistive personnel (AP). The nurse should instruct the AP to use which of the following to clean up a blood spill?

Chlorine bleach solution

A nurse is reviewing the medical history of a client who is scheduled for a colonoscopy to establish a diagnosis of diverticulitis. Which of the following findings should the nurse identify as increasing the client's risk for developing diverticular disease?

Chronic constipation Diverticular disease is a disorder in which pouches or sac-like projections occur in the bowel mucosa through weakened areas of the muscular layer of the intestines. The nurse should identify chronic constipation as a risk factor for diverticular disease.

A nurse is documenting client care in the medical record. Which of the following entries should the nurse make?

Client remains NPO until x-ray procedure is complete.

The nurse is continuing to care for the adolescent. Complete the following sentence by using the lists of options. Adolescent still reports pain as 10 on a scale of 0 to 10 following administration of pain medication. Right foot is cool and pale. Unable to palpate pedal pulse. Adolescent reports tingling and numbness in right foot. The client is at greatest risk for developing ___________ as evidenced by the client's _________________

Compartment Syndrome Pain level

A nurse is assisting with an in-service about hepatitis A for a group of staff nurses. The nurse should include that hepatitis A is transmitted through which of the following methods?

Consumption of contaminated food

The nurse is continuing to care for the adolescent. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent. Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.

Contraindicated- Elevate the right leg above the heart. applying ice to the affected extremity Anticipated prepare the adolescent for surgery remove the splint

A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use?

Coronary artery disease Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension.

A home health nurse is caring for a client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

Determine the client's mobility status. The first action the nurse should take when using the nursing process is to determine the client's mobility status. The nurse should begin collecting data about the client's ability to move freely within their environment while preventing injury. The nurse should begin by placing the client in the position providing the most support, then moving in increments to positions requiring less support and higher levels of tolerance.

A nurse is collecting data from a client who reports recent methamphetamine use. Which of the following manifestations should the nurse expect?

Dilated Pupils

A nurse manager is preparing to complete a performance analysis for a group of assistive personnel (AP). The manager asks a staff nurse for feedback on each AP's abilities. Which of the following actions should the staff nurse take?

Discuss how each AP's actions measure against the job description. To provide objective information, the staff nurse should compare the behavior of each AP to the facility job description. The nurse can provide specific information about how each AP either meets the standard or demonstrates a need for improvement.

A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which of the following instructions should the nurse include in the teaching?

Drink high-protein and high-calorie nutritional supplements.

A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. Which of the following information should the nurse include?

Eat a bedtime snack.

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply. Adolescent brought to the emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as a 10 on a scale of 0 to 10 and is unable to bear weight.

Elevate the adolescent's affected limb to chest level monitor neurovascular status every hour. remove the indwelling urinary catheter when no longer indicated.

A nurse is preparing to administer purified protein derivative (PPD) to a client who has suspected tuberculosis. Which of the following actions should the nurse plan to take?

Ensure the injection produces a wheal on the skin. The nurse should ensure that the injection of the PPD produces a wheal, or bleb, on the skin. This indicates the medication has been injected into the dermis of the skin.

A nurse is collecting data from a client who has a hip fracture. Which of the following findings should the nurse expect?

External Rotation

The nurse is collecting data from the adolescent 4 hr following the fasciotomy. Click to highlight the findings below that indicate an improvement in the adolescent's condition.

Extremity pulse +3 Capillary refill 2 seconds Right extremity is warm to the touch Adolescent reports no numbness or tingling Adolescent reports pain as 2 on a scale of 0 to 10.

A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increased fatigue. Upon auscultation, the nurse hears high-pitched popping sounds. The nurse should report which of the following to the provider after hearing this sound?

Fine crackles Fine crackles are high-pitched popping sounds often caused by pulmonary edema, which can be a complication of heart failure.

A nurse is preparing to administer a dose of digoxin to a client who is receiving continuous tube feedings. Which of the following actions should the nurse take?

Flush the feeding tube with water before and after administering the medication. To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administration.

A nurse is caring for a client who is receiving continuous feedings via a gastrostomy tube. Which of the following actions should the nurse plan to take?

Flush the tube with 50 mL of water if it becomes clogged. MY ANSWER

A nurse is caring for a client who is refusing a prescribed medication. Which of the following actions should the nurse take first?

Identify the client's concerns about receiving the medication.

A nurse is reinforcing teaching with a client about how to replace their two-piece ostomy pouching system. The client tells the nurse that removing the skin barrier is painful. Which of the following strategies should the nurse suggest?

Hold the skin taut while removing the barrier.

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

Hypervigilance Common manifestations of PTSD include recurrent recollections of the precipitating trauma, hypervigilance, irritability, insomnia, and difficulty concentrating.

A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which of the following client statements should the nurse use as an example of rationalization?

I didn't get a good grade because my teacher does not like me.

A nurse is reinforcing teaching with a client who has acute diverticulitis. Which of the following statements by the client indicates an understanding of the instructions?

I will receive the nutrients I need through my IV fluid."

A nurse is reinforcing discharge teaching with the parents of a school-age child who has severe hemophilia A. Which of the following statements by the parents indicates an understanding of the teaching?

I will soak my child's toothbrush in warm water to soften it before my child uses it.

A nurse is reviewing the medical record of a client who is receiving warfarin and has atrial fibrillation. Which of the following laboratory values should the nurse report to the provider?

INR 5 A client receiving warfarin to prevent clot formation related to atrial fibrillation should have an INR of 2 to 3. An INR of 5 or greater indicates that the client is at risk for bleeding. Therefore, the nurse should notify the provider about this laboratory value

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

Instruct the client to avoid the Valsalva maneuver

A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

Lack of change in pupil size when the client looks from a far to a near object

A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Lack of sleep The greatest risk for this client is exhaustion or death from lack of sleep; therefore, this is the priority finding. The nurse should encourage frequent periods of rest for the client throughout the day

A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

Maintain a sequential compression device.

A nurse is preparing to administer medications to a client who is NPO and is receiving enteral feedings through an NG tube. Which of the following prescriptions should the nurse clarify with the provider?

Metoprolol ER 50 mg per NG tube BID

A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?

Moist mucous membranes The condition of mucous membranes is an indicator of hydration status. Moist mucous membranes indicate adequate hydration and a positive response to IV fluid therapy

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Obtaining a client's vital signs prior to discharge Obtaining vital signs does not require use of the nursing process and is within the range of function for an AP. Therefore, the nurse should delegate this task to the AP.

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse plan to take?

Monitor the client's intake and output The nurse should ensure that intake and output measurements are accurately obtained to monitor for fluid overload.

A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following information?

Motor response

A nurse is contributing to the plan of care for a client who has a prescription for range-of-motion exercises of the shoulder. Which of the following exercises should the nurse recommend to promote shoulder hyperextension?

Move the arm behind the body with the elbow straight. Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow straight.

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

Muscle weakness The nurse should expect a client who has hypokalemia to have bilateral muscle weakness. Other manifestations of hypokalemia include hyporeflexia, muscle stiffness, cramping, and paralysis.

A nurse is collecting data from a 5-year-old child at a well-child visit. The parent reports that the child is having frequent nightmares. Which of the following statements by the parent indicates to the nurse that the child is experiencing sleep terrors rather than nightmares?

My child goes back to sleep right away.

A nurse is using an interpreter to reinforce discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Observe the client's facial expressions during communication.

A nurse is making assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

Perform postmortem care for a client who died 1 hr ago.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place an abduction wedge between the client's legs when in bed.

A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?

Place the client in a lateral position. Late decelerations occur due to utero-placental insufficiency. The nurse should assist the client into a lateral position to improve uterine perfusion and oxygen transfer to the fetus.

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. For which of the following results should the nurse notify the provider?

Platelet count 95,000/mm3 The nurse should recognize that this platelet count is below the expected reference range for a client who is pregnant and might be indicative of HELLP syndrome. Other manifestations of HELLP syndrome include malaise and epigastric pain. The nurse should immediately notify the provider of this result.

A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?

Poor lighting in the learning setting

A nurse notices an assistive personnel (AP) taking a nap in the break room during meal time. The nurse also notes that the AP is drowsy while performing routine tasks. Which of the following actions should the nurse take?

Report the observations about the AP to the unit's nurse manager

A nurse is receiving change-of-shift report for a group of clients. The nurse should plan to implement which of the following time-management strategies?

Prepare a priority list of client needs for the shift.

A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

Report the situation to the provider who obtained the informed consent.

A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which of the following client findings indicates a therapeutic effect of this medication?

Reports a decrease in the number of stools Pancrelipase is administered as replacement therapy for a deficiency in pancreatic enzymes, which results in steatorrhea, or fatty stools. The nurse should monitor for improved nutrition and a decrease in the number of bowel movements, which would indicate a therapeutic response to the medication.

A nurse is caring for a newborn who is 1 hr old. The client who gave birth received fentanyl 30 min before delivery. For which of the following adverse effects should the nurse monitor the newborn?

Respiratory Depression

A nurse is preparing to perform venipuncture to obtain a blood sample from a client. Which of the following actions should the nurse take?

Select a site in the antecubital fossa.

A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?

Separate the child's used washcloth from those of others.

A nurse is assisting with the care of an adolescent in the emergency department (ED). Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Skin findings Temperature WBC Casual blood glucose potassium

A nurse is caring for a client who adheres to a kosher diet. Which of the following food selections should the nurse expect to see on the client's meal tray?

Spaghetti noodles with red sauce

A nurse is reinforcing teaching with a client who has a prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include in the teaching?

Take up to three tablets during a single angina episode.

A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the nurse take?

Tell the client they should not experience any discomfort. The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort.

A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

The AP reports client information to the oncoming AP in the hallway.

The nurse is continuing to care for the adolescent. The nurse is assisting with preparing the adolescent for a fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery?

The adolescent's parents have concerns regarding the surgery

A nurse is caring for a client who is in the final stages of cancer. Which of the following client situations should the nurse identify as an ethical dilemma?

The client asks the nurse to help them die peacefully in their sleep.

A nurse is caring for a client who is in an inpatient mental health facility and has dependent personality disorder. Which of the following client behaviors should the nurse expect?

The client calls their partner to ask what they should wear each day.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and has a new prescription for a regular diet. For which of the following findings should the nurse notify the provider?

The client has absent bowel sounds. Absence of bowel sounds can indicate absence of peristalsis, which is a manifestation of an ileus. The nurse should report this finding to the provider for reconsideration of the diet prescription.

A nurse is caring for a client who has asthma and has been taking montelukast for 1 month. Which of the following findings should indicate to the nurse that the client is complying with this medication regimen?

The client takes the medication once daily at bedtime.

A nurse is caring for a client who has a phobia of elevators. Which of the following should the nurse recognize as an indication that systematic desensitization has been effective for the client?

The client remains relaxed when thinking of the phobia. The purpose of desensitization therapy is to teach the client to use relaxation techniques to overcome the anxiety caused by the phobia. The nurse should recognize the client's lack of anxiety when thinking about the phobia as a positive response to the therapy.

A nurse in a pediatric clinic is collecting data from a toddler. Which of the following findings should the nurse identify as a possible indication of physical neglect?

The toddler is inadequately dressed for the weather.

A nurse is reinforcing teaching about food selection with a client who has a moderate burn injury. Which of the following foods should the nurse recommend as being high in vitamin C?

Tomatoes The nurse should recommend tomatoes, which are a food source that is high in vitamin C.

A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

open sterile packages.

A nurse is reinforcing discharge teaching with a client who has undergone vein ligation and stripping to treat varicose veins. Which of the following instructions should the nurse include in the teaching?

Walk for 1 to 2 hr each day The nurse should instruct the client to walk for at least 1 to 2 hr per day after surgery to promote venous return.

A nurse is assisting with the plan of care for a client who has bipolar disorder and is in the manic phase. Which of the following activities should the nurse recommend for the client?

Walking outside with a staff member

A nurse is reinforcing preoperative teaching with a client who will receive morphine through a PCA pump after surgery. Which of the following information should the nurse include?

You should increase your fluid intake while receiving this medication through the PCA pump.

A nurse is reinforcing teaching with a client who has hypothyroidism and a prescription for levothyroxine. Which of the following instructions should the nurse include in the teaching?

You will need to take the medication for the rest of your life.

A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements should the nurse make?

Your oncologist might prescribe a cold cap to wear during treatment to reduce hair loss."

A nurse is supervising an assistive personnel (AP) who is preparing to remove personal protective equipment (PPE) after providing direct care to a client who requires airborne and contact precautions. The nurse should recognize that the AP understands the procedure when which of the following PPE is removed first?

gloves