pn study review
1. A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the clients respirations? a. Place the client in a supine position b. Observe the movements of the client chest wall c. Inform the client when beginning to observe his respirations d. Count the client respiration for 15 seconds
b
1. A nurse is preparing to give 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. Steps required for dressing change b. Time of last pain medication c. Preferred bath time d. Admission vital signs
b
1. a nurse in a provider office is reinforcing teaching about skin care with a clien who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? a. I will limit my time in the tanning bed to 15min b. I will dry my skin by patting it with a towel c. I will cleanse my skin using an antibacterial soap d. I will use an astringent on my face
b
1. nurse on a medical surgical unit is assisting with the admission of a client who has advanced lung cancer. which of the following actions regarding advance directives should the nurse take? a. Tell the client that a family member should serve as a health care surrogate b. Contact the facility risk manager to verify if the client has a living will c. Ensure that an attorney has reviewed the client advanced directive d. Document client decision about end of life care in the medical record.
b
1. 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 clients history should the nurse identify as a contraindication? a. Hypotension b. Diabetes mellitus c. Hepatitis C d. Cystitis
c
1. 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. Eat three large meals each day b. Avoid exposing the neck to the cold c. Limit fluid intake to 750 ml per day-/31ml-hr d. Cleanse the neck by rubbing with a washcloth
c or d
1. A nurse is positioning a client in preparation for a lumbar puncture. In which of the following position should the nurse place the client? a. Semi-fowler b. Prone c. Lithotomy d. Lateral recumbent
d
1. A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning . which of the following actions should the nurse take? a. Replace the IV pump tubing b. Plug the IV pump cord into a different outlet c. Clear the setting and reset the IV pump d. Discontinue use and tag the IV pump
d
1. A nurse is reinforcing teaching with a client about collecting a stool specimen to check for occult blood. Which of the following statements by the client indicates an understanding of the client teaching? a. Eating pasteurized dairy products will affect my test results b. Having urine mixed in with the stool will not affect the result c. I should collect a specimen once each week for 4 weeks d. I should avoid eating red meat for 3 days before my test
d
1. A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statement indicates an understanding of the teaching? a. I will apply the patch in the same place every day b. I will remove the patch if I develop a headache c. I will replace the patch every 12 hr d. I will place the patch on a hairless area of skin
d
1. 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 darken the color of my eye b. I should take a zinc supplement while taking this medication c. This medication will dilate my eyes d. I should check my heart rate while taking this medication
d
1. A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instruction should the nurse include in the teaching? a. Eat foods high in vitamin B 12 b. Rinse the mouth with an alcohol based mouthwash c. Use lemon glycerin swabs d. Consume soft, bland foods.
d
1. A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum . which of the following client statements indicates an understanding of the nurses instructions? a. I will wait 1 hour after getting up in the morning to have breakfast b. I will try to eat balanced meal instead of only foods that appeal to my taste c. I will eat a low protein snack 30 min before going to bed each night d. I will eat or drink something every 2-3 hours throughout the day
d
1. A nurse is reinforcing teaching with a client who is postoperative following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? a. Consume high fiber food at each meal b. Ambulate for 15 min after each meal c. Include one serving of protein with each meal d. Drink at least 240 ml (8oz) of liquid with each meal
d
1. A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include? a. Pu a small cushion under the newborn head for support b. Keep the airbag on if the car seat is in the front seat c. Position the care seat at a 90 angle/ is at 45 d. Place the should harness at the level of the infants shouders.
d
1. 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? a. Federal legislation dictates the legal guidelines for advance directive b. Advance directives include instructions for resolving financial matters after my death c. My medical record should not include my advance directives d. Advance directives include living will
d
1. A nurse is reviewing laboratory data from a client who has diabetes mellitus. Which of the following laboratory test is the most accurate indicator of long term disease management? a. Urine ketones b. Fasting blood glucose c. Glucose tolerance test d. Glycosylated hemoglobin
d
1. A nurse is reviewing laboratory values for a client who is 34 weeks of gestation. Which of the following finding should the nurse report to the provider? a. Hgb 13.2 b. BUN 15 c. Fasting blood glucose 72 d. Urine protein 3+
d
1. A nurse overhears tow assistive personnel discussing a client medical history in the hallway. Which of the following actions should the nurse take first? a. Participate in an in-service about client confidentiality b. Speak to the staff members in private about client confidentiality c. Report the incident to the charge nurse d. Tell the staff members to stop their discussion
d
1. A nurse working in a clinic is reinforcing teaching with a clien who has hepatitis A. which of the following client statements indicates an understanding of the teaching? a. I can continue to prepare meals for my family b. I know that this virus is transmitted by contact with my blood c. I will wash my hands using an alcohol based cleanser d. I will use different hand towels than other in my home
d
1. A nurse is caring for a client who has admitted for observation following a head injury. Which of the following finding by the nurse indicates the client is experiencing increased intracranial pressure? a. Irritability b. Decrease blood pressure c. Pin- point pupils d. Pallor
a
1. 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. Instruct the client to hold the drainage bag at waist height when ambulating c. Coil the tubing on the bed above the collection bag d. Collect a sterile specimen from the urinary drainage bag.
a
1. A nurse is caring for a client who has been admitted to the mental health unit while reinforcing teaching about the client prescribed medications, the nurse communicates truthfully about adverse effect of the medication. Which of the following ethical concepts is the nurse exhibiting? a. Veracity b. Justice c. Beneficence d. Autonomy
a
1. A nurse is caring for a client who has major depressive disorder and is taking an antidepressant . the nurse should identify which of the following finding as the priority to report to the provider? a. The client has sudden increase in energy b. The client is withdrawn and uncommunicative c. The client report a change in sleeping pattern d. The client neglects personal hygiene
a
1. A nurse is caring for a client who is on isolation precaution. Which of the following pieces of personal protective equipment should the nurse remove first? a. Gloves b. Mask c. Gown d. Eyewear
a
1. 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. Cover the wound with sterile , saline soaked gauze b. Hold gentle direct pressure on the protruding organ c. Place the client knee in an extended position d. Raise the head of the bed to a 45 angle fowler
a
1. A nurse is caring for a client who recently gave birth to her first child . the newborn is crying and the client state, " I can't seem to do anything right. What should I do?" which of the following responses should the nurse make? a. Let me show you how to swaddle and cuddle him, then you try. b. I 'll take him back to the nurse , so you can get some rest c. If I turn him on his side, maybe he'll go back to sleep d. Babies need to cry soon after they are born to develop their lung
a
1. A nurse is collecting a health history from the guardian of a 4 year old child. Which of the following statements by the guardian is the priority for the nurse to address? a. I have a difficult time getting my child to eat green vegetable b. My child still wets the bed at least two times per week c. I have noticed that my child is withdrawn since we switched day care provider d. My child continually asks me the same questions
a
1. A nurse is collecting data from a 6 months old infant during a well child visit. Which of the following finding should the nurse report to the provider? a. Temperature b. Gross motor skill c. Weight d. Feeding habits
a
1. A nurse is collecting data from a clien who is 12hrs postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation? a. Oxygen saturation 90% b. Apical pulse rate 88/ min c. Oral temperature 37. 6 C. d. Respiratory rate 20/ min
a
1. A nurse is collecting data from a client who has diabetes mellitus and a blood glucose of 40mg/dl. Which of the following finding should the nurse expect? a. Clammy skin b. Increase thirst c. Fruity breath d. Deep respiration
a
1. A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect? a. Saturation of perineal pad in 15min b. Client report of uterine cramping c. Boggy fundus 3 fingerbreadths above the umbilicus d. Client report of burning with urination
a
1. A nurse is collecting data from a client whose partner died 1 year ago. Which of the following findings indicates that the client is experiencing complicated grief? a. The client develops chest pain each time he talks about his partner b. The client keeps a framed picture of his partner on the wall c. The client attends a grief support group twice each month d. The client report he has no interest in dating
a
1. A nurse is reinforcing teaching about ADLs with a client who has multiple sclerosis. Which of the following client statement should indicates to the nurse an understanding of the teaching? a. I will take rest period throughout the day b. I will eliminated vitamin D from my diet c. I will decrease my fiber intake d. I will take tube baths rather than shower
a
1. A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching? a. I should decrease my salt intake to 2 grams per day b. I will set my blood pressure goal at 130 over 84 c. I should exercised for 15 minutes two times per week d. I can have two glasses of wine with dinner
a
1. A nurse is reinforcing teaching about newborn care with a new guardian . which of the following statements by the guardian indicates an understanding of the teaching? a. I will wash my baby face with a warm, wet washcloth without soap b. I will was my baby head using a moist towelette c. I will give my baby a bathe every day d. I will bathe my baby under a faucet of running water.
a
1. A nurse is reinforcing teaching about passive range of motion exercises with the family of a client who has had a stroke . which of the following instruction should the nurse include in the teaching? a. Support the extremity above and below each joint during the exercises b. Repeat each exercise movement 10 times c. Move each joint just past the point of resistance. d. Position the bed at mid thigh level
a
1. A nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicates an understanding of the teaching? a. I will know my blood pressure is too high if I get a reading of 140/90 or higher b. I will make sure my hand is about 6 inches below my heart when I use the device c. I will check my blood pressure at a different time each day d. I will loosely wrap the blood pressure cuff around my upper arm.
a
1. A nurse is reinforcing teaching with a client who has a new prescription for propranolol. The nurse should include which of the following as a potential adverse effect of this medication? a. Decreased heart rate b. White patches on the tongue c. Increase urinary output d. Sudden weight loss
a
1. A nurse is reinforcing teaching with a client who is about to start using an albuterol metered dose inhaler. Which of the following instruction should the nurse include in the teaching? a. Close your mouth around the mouthpiece b. Exhale immediately after inhaling c. Take three quick breaths while depressing the canister d. Tilt you head forward while inhaling
a
1. A nurse is reinforcing teaching with the guardian of a 2month old infant about immunization. Which of the following statements by a guardian indicates an understanding of the teaching? a. My baby will receive the rotavirus immunization orally b. I should not feed my baby anything for 2hrs prior to an immunization c. My baby will receive three doses of the meningococcal immunization before kindergarten d. I should expect my baby to have a high fever for 24hr after an immunization.
a
1. A nurse is reviewing the home medications of a client who recently had transient ischemic attack and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over the counter medication interacts adversely with clopidogrel? a. Naproxen b. Vitamin D3, c. Docusate sodium d. Ranitidine
a
1. A nurse is reviewing the medical record of a client who has COPD. Which of the following laboratory finding indicates a need to request a dietary referral for the client? a. Prealbumin 13 mg/dl b. Total calcium 10 mg/ dl c. Sodium 138 mEq/ L d. Potassium 3.5 mEq/L
a
1. 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. Placement of a central venous catheter b. Insertion of a nasogastric tube c. Administration of an iron injection using Z track technique d. Irrigation of a wound with antibiotic solution
a
1. A nurse is supervising an assistive personnel who is providing client care. The nurse should identify that which of the following actions by the AP demonstrate effective use of supplies? a. Wear clean gloves when performing oral hygiene b. Disposes of contaminated sheets in a linen bag c. Empties the sharps container when it is full d. Wears an N95 mask when bathing a client who has clostridium difficile
a
1. A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following finding requires intervention by the nurse? a. An assistive personnel is encouraging intake of oral fluids b. Bencodiazepine are administered every 4hrs c. Supplemental oxygen is in use d. A family remains at the client bedside 24hrs each day.
a
1. A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first? a. Debrief staff members about the conflict b. Request security ppersonnel restrains the client c. Place the client in seclusion d. states expectations for the clients behavior
a
1. a nurse is reinforcing teaching with a client who has cystocele. Which of the following statement by the client indicates an understanding of the teaching? a. I will practice perineal exercises to decrease urinary leakage b. I will experience less urinary incontinence if I use artificial sweeteners c. I should use a perineal spray to reduce odor from urinary leakage d. I will decrease my fluid intake to reduce incontinence
a
1. A nurse is assisting with the care of a group of clients. Which of following actions should the nurse take to manage her time effectively? Multiply answereds a. Complete activities with one client before moving to another client b. Delegate collection of vitals signs to the assistive personnel on the team c. Keep track of how long it takes to complete certain tasks d. Plan a time at the end of the shift to document nursing interventions e. Make a priority to do list at the beginning of the shift
a,b,c,e
1. A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? Multiple answered a. a client fell when ambulating to the bathroom alone b. a client received an 0900 daily medication at 1000 c. a client received the first dose of an antibiotic 1hr before the collection of blood for culture and sensitivity testing. d. A client who has an infection refuse the evening meal e. An approximate amount of urine was recorded after the urine leaked from the client catheter bag
a,b,c,e
1. A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a clients medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information? a. A client employer who is concerned about safety due to substance use b. A social worker who is assigned to an involuntarily committed school age client c. A nurse from another unit after a client commit suicide d. A client partner after the client reports intimate partner abuse
b
1. A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statement by the newly licensed nurse indicates an understanding of the teaching? a. Following a blood spill, I should use a bleach solution with a ratio of 1: 20 b. Soiled dressing should be placed in a biohazard trash receptacle c. Droplet precaution requires that I wear a gown and gloves when providing client care d. For a client who has clostridium difficule, I will cleanse my hand with an alcohol based rub
b
1. A community health nurse is assisting with the development of a pamphlet regarding chocking hazards for toddlers. Which of the following foods should the nurse include? a. Potatoes, b. Grapes c. Corn d. Oranges
b
1. A nurse at a provider office is caring for a client who is in the third trimester of pregnancy. Which of the following finding should the nurse report to the provider? a. Shortness of breath when climbing stairs b. Blurred vision c. Leukorrhea d. Period numbness of the finger
b
1. 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 finding? a. The case manager b. The risk manager c. The pharmacist d. The surgeon
b
1. 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 restrains to the client? a. Offer the client a nutritious snack every 4hrs b. Plan to remove the restrains as soon as the client is calm c. Ensure that the provider has signed a prescription for restraints within 48 hrs d. Monitor the client range of motion every 60min
b
1. A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Beside obtaining an X-ray, which of the following methods should the nurse use to verify the placement ? a. Add food coloring to the formula b. Measure the gastric residual c. Test the pH of the gastric aspirate d. Inject air and listen for bubbling.
b
1. A nurse is assisting with a the admission of a client who states, the last time I was in this hospital, the nurses took forever to answer my call light."which of the following is an appropriate response by the nurse? a. It will not happen this time because we have more staff b. That must have been a difficult experience for you c. Lets discuss what brought you to the hospital this time d. I am sure no one meant to ignore you.
b
1. A nurse is assisting with monitoring a client who is receiving a unit of packet RBC. Which of the following finding inidicates the client is experiencing a transfusion reaction? a. Apical pulse rate 58/min b. Temperature 38.8 / 101. 8 c. Blood pressure 158-92 d. Straw colored urine
b
1. A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume excess? a. Urine output of 360 ml/12hr b. Distended neck veins c. Decreased bowel sounds d. Blood pressure of 100/74 mm HG
b
1. A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan? a. Perform dressing changes every other day b. Apply dressing with sterile glove c. Cleanse the most contaminated wound first d. Use hydrogen peroxide for wound cleaning
b
1. 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 clients plan of care? a. Limit fluid intake b. Apply support stocking c. Administer diuretics d. Place on bedrest.
b
1. A nurse is assisting with the planning of an in service about updates in wound care for nursing staff. Which f of the following sources should the nurse identify as providing the best evidence base information? a. An entry on a nursing blog addressing wound healing b. Information from a wound care product vendor c. First hand experience with wound care products d. A peer reviewed journal article
b
1. A nurse is caring for a an older adult client who has acute delirium. Which of the following actions should the nurse take first? a. Determine the client level of consciousness b. Keep lights on in the clients room c. Administer an anxiolytic medication d. Encourage visit from family members.
b
1. A nurse is caring for a client who has a prescription for acetaminophen 300mg with codeine 30mg, 1 tablet every 3-4 hours PRN for pain. The nurse inadvertently administer 2 tablets to the client. In which of the following locations should the nurse document this client care incident? a. Controlled substance inventory record b. Incident report c. Nursing care plan d. Providers progress notes
b
1. A nurse is caring for a client who has femur fracture with the leg in Buck traction. Which of fhe following actions should the nurse take? a. Apply 6.8 (15lbs) of weight for use in traction b. Compare bilateral pedal pulse c. Remove the weight for 20 min for the client report of severe pain d. Position the knot of the rope at the top of the pulley
b
1. 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. Lets talk more about it b. The psychiatric staff is not FBI. They are her to help you. c. Why do you feel the staff is the FBI? d. What makes you think the staff is following you?
b
1. A nurse is caring for a client who has prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next? a. Place the cap over the needle b. Inject 15 units of air into the regular insulin vial c. Withdraw 10 units of NPH insulin d. Verify the dosage with another nurse steps: Inject 10 units of air into the bottle of NPH insulin Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle
b
1. A nurse is caring for a client who has recently died. Which of the following actions should the nurse take? a. Remove the client denture b. Place a pillow under the client head c. Place the client in high fowler position d. Remove the absorbent pads from underneath the client
b
1. A nurse is caring for a client who has toxoplasmosis and asks about the cause of the client infection. Which of the following responses should the nurse make? a. Eating shellfish b. Handling cat feces c. Touching body fluids d. Drinking contaminated water
b
1. A nurse is caring for a client who is unable to perform ADL and wear dentures. Which of the following actions should the nurse take when providing denture care? a. Place a towel in the sink when cleaning the denture b. Use a circular motion to cleanse the biting surface of the dentures c. Store the dentures in a dry denture cup on the bedside table after cleaning d. Remove the lower dentures before the upper dentures.
b
1. A nurse is caring for a client who suddenly develop chest pain and dyspnea. Which of the following actions should the nurse take first? a. Place the client on bedrest b. Elevate the head of the client bed c. Obtain the client ABG level d. Prepare the client for a ventilation perfusion scan.
b
1. A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following finding should the nurse expect? a. Elevated blood pressure b. Fruity breath odor c. Clammy skin d. Bounding pulse
b
1. A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider? a. Fatigue when ambulating 152 m (500 ft) b. Productive cough with pink, frothy sputum c. Weight loss of 1kg (2.2lb) in the past 24hrs d. Pale, clammy skin
b
1. A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following finding should the nurse report to the provider? a. Urine output of 300 ml over 8hrs b. Occasional small clots in the urine or bright red apperance c. Frequent urge to urinate d. Dark red urine
b
1. A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect? a. Blunted affectd b. Slurred speech c. Grandiose thinking d. Hypersomnia
b
1. A nurse is collecting data from the caregiver of a client who has Alzheimers disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend? a. Allow the client to nap for at least 1hr during the day b. Encourage the client to take frequent walks during the day c. Put a simple lock on the clients bedroom door d. Give the client a barbiturate medication at bedtime.
b
1. A nurse is completing post-mortem documentation for a client . which of the following information should the nurse include in the documentation? a. Copy of the client advance directives b. Location of the identification tag on the clients body c. Last set of the client vitals signs d. Cause of the client death
b
1. A nurse is contacting an occupational therapist for a client who had a stroke with right side weakness and has difficulty eating. Which of the following roles should the nurse expect the occupational therapies to perform? a. Use heat, massage , and water to treat a client strength and movement b. Provide and adjust devices to assist the client with daily living activities c. Assists in finding an economic living arrangement for the client d. Promote health by ensuring the client nutritional needs are met.
b
1. A nurse is monitoring a group of assistive personnel regarding the use of gloves in contact isolation. For which of the following actions by an AP should the charge nurse intervene? a. Pulls gloves off inside out when task are completed b. Removes gloves last after other personal proctective equipment c. Changes gloves between tasks for the same client d. Washes hands after removing gloves
b
1. A nurse is participatin in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team? a. A client tells the nurse he prefers a snack before bedtime b. The client is unable to grasp eating utensil c. The client request to perform ADLs later in the day d. The client requires reinforcement of teaching about the purpose of his medications.
b
1. A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use? a. Apply intermittent suction for 30 second b. Wait 1 min between suctioning attempts c. Apply suction while inserting the catheter d. Insert the catheter 10 cm ( 4in)
b
1. A nurse is preparing to complete a sterile dressing change for a client wound. Which of the following actins should the nurse take first? a. Apply sterile gloves. 4. b. Open the outermost flap of the sterile kit away from the nurse body 1. c. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface 3. d. Open the side flap of the sterile kit, allowing it to lie flat on the work surface. 2.
b
1. A nurse is preparing to delegate client care to an assistive personnel (AP) . which of the following information should the nurse verify prior to delegation? a. The client age b. The AP years of experience c. The AP job description d. The client length of facility stay
b
1. A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report? a. The client mother died 4 year ago from breast cancer b. The client received the prescribed antibiotic every 8 hours c. The client partner visited earlier today for 2hrs d. The client report pain is reduced when he is positioned on his side.
b
1. A nurse is reinforcing teaching about common discomforts during the first trimester with a client who is at 10 weeks of gestation. Which of the following examples should the nurse include? a. Swelling of the face b. Leukorrhea the rest are complications c. Burning during urination d. Diarrhea
b
1. A nurse is reinforcing teaching with a client who is at 16 weeks of gestation and has 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. Increase your dietary fiber intake b. Avoid drinking milk with the iron supplement c. Take the iron supplement with green tea d. Eliminate berries and citrus fruits from your diet
b
1. A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective? a. Our child has lost some weight since his last appointment b. Our child is able to complete his homework on time c. Our child has increase his daily caloric intake d. Our child has a better grasp of reality
b
1. A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching? a. The staff will watch me closely for 1hr after each meal b. The staff will weight me every night before I go to bed c. I should gain half of a pound per wk to meet my treatment goal d. The treatment goal is to be within 60 percent of my ideal body weight.
b
1. A nuse is caring for a 3 years old child immediately following a tonic clonic seizure. Which of the following actions should the nurse take? a. Administer an oral antiepileptic medication b. Check the child for oral injuries c. Place the child in a supine position d. Offer the child sips of clear fluid.
b
1. a nurse is caring for a clien who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective? a. Hg 10 g/dl b. Potassium 3.5 mEq/L c. BMI 14.5 d. Sodium mEq/L
b
1. A nurse is caring for a client who is taking warfarin and has an INR of 5.5. the nurse should expect which of the following instructions from the provider? a. Change the medication to heparin IV. b. Obtain an aPTT level 30-40sec, INR- 0.8-1.2 c. Reduce the dosage of the medication d. Administer protamine sulfate
b or c
1. A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse role in obtaining informed consent. Which of the following statement by the newly licensed nurse indicates an understanding of the teaching? a. I will provide the client with an explanation of the procedure before I sign the consent form b. It is my responsibility to obtain informed consent from the client prior to the procedure c. When I sign the consent form. I am stating that the client appears to be competent to give consent d. I will sign the consent form to indicate that the client has received written material explaining the procedure
c
1. 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 upper extremities b. place a padded tongue blade in the child mouth c. place a pillow under the child head d. turn the child on to their back.
c
1. A nurse in a provider office is caring for a group of client who have communicable diseases. Which of the following infections should the nurse report to the state health department? a. Human papillomavirus b. Impetigo contagiosa c. Neisseria gonorrhoeae d. Sarcoptes scabies
c
1. A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following request should the nurse anticipate from the client family? a. To bury the client body within 24hrs of their death b. To stay with the client body for 8hr following their death c. To cremate the client body d. To prohibit medical personnel from touching the clients body
c
1. A nurse is assisting with a prenatal examination of a client who is at 8 wks 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. Ballottenment b. Hegar sign c. Chadwick sign d. Chloasma
c
1. A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make? a. You should talk to your counselor about the voices b. Tell me what medication you are taking c. Let talk about what the voices are saying to you d. I m sure the voices will go away soon.
c
1. A nurse is assisting with the care of a client who is 6hr postoperative following a right total knee arthroplasy. Which of the following actions should the nurse take? a. Maintain the head of the client bed in high fowlers position b. Check the client pedal pulses every hour c. Remove the client dressing when it becomes saturated d. Place an abductor wedger under the client right knee.
c
1. A nurse is assisting with the development of an education program for a group of older adults. Which of the following actions should the nurse take first? a. Create handout for participants b. Determine the literacy level of participants c. Schedule a time to implement the program d. Establish learning outcomes
c
1. A nurse is caring for a client who has dehydration due to diarrhea. Which of the following finding should the nurse report to the provider? a. Urine specific gravity 1.020 b. BUN 18mg/dl c. Urine output 12ml/ml d. Serum creatine 1.0 mg/dl
c
1. A nurse is caring for a client who has terminal cancer. which of the following actions should the nurse take to promote the client autonomy? a. Be honest with the client about the prognosis b. Administer pain medication on a routine schedule c. Allow the client to choose treatment times d. Provide privacy during client care procedures
c
1. A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client . which of following action should the nurse take? a. Contact the provider within 48hrs to obtain a prescription for the restrains b. Fasten the restrains ties to the bed side rails c. Check that one finger will fit between the client wrist and the restrains d. Remove the restraints from the client every 2hrs
c
1. A nurse is caring for a group of client. Which of the following clients should the nurse recognize is experiencing fluid volume excess? a. A client who is 1 day postoperative and has Hgb level of 16g/dl b. A client who has COPD and an oxygen saturation of 92% c. A client who has heart failure and has had orthopnea for 2 days d. A client who has a urinary tract infection with bladder distention two fingerbreadths below the umbilicus
c
1. A nurse is collecting data from a 9 years old child during a well child visit. Which of the following findings should the nurse expect? a. Demonstrates self centered thinking b. Displays emotional detachment from parents c. Expresses conflict over independence and control d. Grasps concept of cause and effect
c
1. A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and report feeling dizzy has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take? a. Check the client temperature b. Instruct the client to take a brisk walk c. Position the client on their left side d. Provide the client with a glass of orange juice
c
1. A nurse is collecting data from a client who is 8hrs postoperative following an appendectomy which of the following manifestations is the best indication that the client needs a PRN analgesic? a. The client reports pain as 7 on a scale of 0-10 b. The client grimaces when changing position c. The client heart rate has increase to 110/min d. The client demonstrate a decreased attention span.
c
1. A nurse is collecting data from a client who is at 20 weeks of gestation and has been taking ferrous sulfate. For which of the following findings should the nurse monitor as a common adverse effect of iron supplementation and report to the provider? a. Dry mouth b. Tinnitus c. Constipation d. Hematuria
c
1. A nurse is collecting data from a client who is in renal failure . the nurse should identify that which of the following finding is a manifestation of hyperkalemia? a. Hyperactive reflexes b. Trousseaus sign c. Irregular heart rate d. Dry mucous membranes
c
1. 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 finding an as indication of proper CPAP use? a. The mask is secure over the client mouth and the client nose is uncovered b. There is one finger width between the strap on the mask and the client face c. The therapeutic dose of albuterol is being inhaled. d. The mask fits loosely so air can escape from underneath
c
1. A nurse is contributing to the plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. The client reports hearing voices. Which of the following interventions should the nurse plan to take? a. Provide extended periods of alone time for the client b. Discourage the client from discussing the hallucination c. Reinforce that although the voices are real to the client, the nurse does not heart them d. Ensure that the client avoids other forms of auditory stimulation, such as music or television
c
1. A nurse is contributing to the plan of care for a client who is experiencing panic level anxiety and reports visual hallucinations. Which of the following actions should the nurse recommend including in the plan of care? a. Provide the client with a restricted calories meal b. Encourange the client to participate in a game in the day room c. Instruct the client to spend quiet time alone in their room d. Use a low pitched voice when speaking to the client
c
1. A nurse is preparing to apply a thigh length sequential compression device for a client who is postoperative. Which of the following actions should the nurse take? a. Wrap the sleeve loosely around the client lower leg b. Position the client prone to apply the device c. Measure the circumference of the client upper leg d. Turn on the mechanical unit prior to applying the sleeve
c
1. 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 isopropyl alcohol to clean the nasal cannula when necessary b. I will increase the flow rate if I feel short of breath c. I will check my oxygen equipment at least once daily d. I can use synthetic blankets on my bed.
c
1. A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching? a. Assume responsibility for making the client decision b. Limit the client social interaction c. Encourage the client to be assertive d. Maintain a verbal no- harm contract with the client.
c
1. A nurse is reinforcing teaching about palliative care to a cline who has cancer. which of the following statements should the nurse make? a. It is for client who are given 6months or less to live b. It includes restriction of nutritional support c. It enhances quality of life by promoting comfort d. It is for client who have a terminal illness
c
1. A nurse is reinforcing teaching about preventing dental caries with the parent of a 12 months old toddler. Which of the following instructions should the nurse provide? a. Floss between your child teeth before brutching b. Position the bristle of your child toothbrush against the tee at a 90 degree angle c. Clean the teeth with a small, soft britled toothbrush d. Use a 5-inch strip of toothpaste on the toothbrush.
c
1. A nurse is reinforcing teaching licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription? a. Heparin 5000 U subcutaneous every 8hr b. Doxazosin .5 mg PO PRN bedtime c. Lorazepam 0.5 mg PO PPR at bed time d. MGSO4 10g PO daily
c
1. 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 can take antacids at the same time as this medication b. I have to take this medication on an empty stomach c. I should expect to have diarrhea while taking this medication
c
1. 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 can take antacids at the same time as this medication b. I have to take this medication on an empty stomach c. I should expect to have diarrhea while taking this medication 1. 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 can take antacids at the same time as this medication b. I have to take this medication on an empty stomach c. I should expect to have diarrhea while taking this medication
c
1. A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin. Which of the following information should the nurse include in the teaching? a. Take an antacid if the medication causes gastrointestinal upset b. Expect to experience diarrhea while taking this medication c. This medication can increase your risk for sunburn d. Restrict your daily fluid intake while taking this medication
c
1. 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? a. I can prevent constipation if I drink more milk while taking this medication b. I will report black stool to my doctor c. I will mix the medication with a full glass of water d. I can prevent nausea if I take the medication on an empty stomach
c
1. A nurse is reinforcing teaching with a client who is schedule to have a colonoscopy in 1week. Which of the following client statements indicates an understanding of the teaching? a. This procedures will take place while im under general anesthesia b. I'll have my friend drive me home after the procedure c. I will follow a full liquid diet the day before the procedure d. I can expect rectal bleeding for a week after the procedure
c
1. 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 take my baby to the lobby to visit family b. I will carry my baby to the nursery c. I will have an identification band that matches the one on my baby wears d. I can remove my security band to give it to a family member
c
1. A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching a. Use a needleless syringe to instill feeding b. Provide thin liquid to help the client swallow c. Place oral suction equipment next to the client bedside d. Give the client a straw to use for drinking
c
1. A nurse is reinforcing teaching with a parent of a 4 - months old infant during a home visit. Which of the following statements by the parents indicates an understanding of the teaching? a. I will lay my baby head on a pillow while he is in the crib b. I will leave my baby bib on while he is sleeping c. I will use a cool mist vaporizer in my baby room d. I will leave the plastic covering on the crib mattress.
c
1. A nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parents indicates an understanding of the teaching? a. I will place my newborn face up on a pillow when sleeping b. I will place my newborn crib near a heat vent during cold weather c. I will make sure that I can fit one finger between the mattress and the side of my newborn crib d. I will attach the pacifier to my newborn clotting with a string at bedtime
c
1. A nurse is reinforcing teaching with a parent of a preschooler about immunization. Which of the following statements by the parents indicates an understanding of the teaching? a. I can make several office visits so my child does not get so many immunization b. It is recommended that my child receive his firs flu immunization at the age of 6 c. I understand that immunizations will be withheld if my child has lactose intolerance d. My child will need to start the human papillomavirus serie when he enters kindergardens
c
1. 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. Assist her to brethe in deeply at the beginning of each contraction b. Apply steady pressure with this tennis ball to her sacral area c. Gently stroke her abdomen during contractions d. Help her to focus on an object in the room
c
1. A nurse is reviewing client confidentiality with a group of newly licensed nurse . which of the following situations should the nurse include as an example of a breach in confidentiality? a. A nurse discusses a clients postoperative complications during shift report b. A facility risk manager include information from a client medical record in a written report c. A nurse tells the chaplain that a client has a new diagnosis of cancer d. A social worker reads a client chart as follow up to a requested consultation
c
1. A nurse is reviewing the guidelines for documenting client care. Which of the following actions should the nurse plan to take? a. Document giving a dose of pain medication just prior to administration b. Document information telephoned in by a nurse who left the unit for the day c. Limit documentation to subjective information d. Avoid quoting client comments when documenting.
c
1. A nurse is using a glucometer to measure a client capillary blood glucose level. Which of the following actions should the nurse take? a. Select the central tip of a finger b. Wear sterile gloves c. Keep the finger in a dependent position d. Test the first drop of blood that forms after the puncture
c
1. A nurse on a medical surgical unit is preparing to assist with the admission of client who were injured in a tornado. Which of the following client should the nurse recommend for discharge to make room for the new admissions? a. A client who had a cerebrovascular accident 8hrs ago and received thrombolytic therapy b. A client who had a lobectomy and has a chest tube drainage system c. A client who has cervical cancer and an internal radioactive implant d. A client who had a radial mastectomy 36 hr ago and has a surgical drain.
c
1. 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 to include in the plan? a. Initiate NPO status 1hr prior to ECT b. Provide frequent reorientation after ECT c. Instruct the client to notify the provider if discomfort is felt during ECT. d. Schedule follow up ECT treatment 1 month apart
c
1. A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take? a. Use a 12 point font size b. Write the information at an 8 grade reading level c. Present information from complex to simple d. Explain medical terminology using basic, one syllable words.
d
1. A nurse at a long term care facility is reviewing the plan of care for a client who has a prescription for mitten restrains. Which of the following tasks should the nurse assign to an assistive personnel? a. Evaluate the need for the client to remain in mitten restrain b. Instruct the client family about the purpose of mitten restrain c. Determine the circulation status of the affected extremities every 2hrs d. Assist the client with range of motion exercise of the hands.
d
1. A nurse health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client? a. Place area rugs on slick floor surface b. Keep lighting in the home dim c. Place the bedside tablet 2 feet away from the bed d. Move the clients bed to the main floor of the house
d
1. A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client? a. Room number of the client b. Client full medical diagnosis c. Name of the client provider d. Clients telephone number
d
1. A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? A. Improve absorption of vitamin B and C B. decrease sodium excretion c. improved respiratory function d. reduced fat in the stool
d
1. A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following finding indicates the information likely contains credible medical information? a. The author cites references to statement made b. The website URL Is listed as .com c. The authors name is listed without credentials d. The website was last updated 3 year ago.
d
1. A nurse is assisting with a community health program for caregivers of client who have alzheimer's disease. Which of the following should the nurse include? a. Provide a stimulating environment for the client b. Use written signs to assist the client with location the bathroom c. Use confrontation to manage the client behavior d. limit the number of choices for the client
d
1. A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN) which of the following actions should the nurse take? a. Verify the amount of TPN solution the client is receiving every 4hrs b. Use a clean technique when changing the catheter dressing c. Place the client in sims position for catheter insertion d. Prepare the client for a chest d-ray to verify catheter placement
d
1. A nurse is assisting with the care of a client who is in the latent state of labor and has pelvic pain with contractions. Which of the following actions should the nurse take? a. Tell the client to push during contraction b. Apply fundal pressure during contractions c. Encourage the client to soak in a hot bath d. Instruct the client to change position frequently
d
1. A nurse is caring for a child who has terminal cancer. which of the following responses by the child school age brother should the nurse expect? a. Regresses to an earlier developmental level b. Believes his bad behavior is causing his borther death c. Believes that his brother death will be reversible
d
1. A nurse is caring for a client who has been given methylergonovine intramuscularly for a postpartum hemorrhage. The nurse should monitor for which of the following adverse effects? a. Diarrhea b. Uterine relaxation c. Hematuria d. Elevated blood pressure
d
1. A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure? a. Administer an oral contrast solution b. Ensure that the client bladder is full c. Inform the client the procedure will take 60min' d. Ensure that the client gave informed consent
d
1. A nurse is caring for a client who is 2 days postoperative following an above the knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility? a. Maintain abduction of the client residual limb with a pillow b. Caution the client to avoid a prone position while in bed c. Keep a loose , absorbent dressing over the client surgical site d. Encourage the client to use the overbed trapeze.
d
1. A nurse is caring for a preschool who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group? a. Expresses curiosity about the funeral service b. Believes the death is punishment for bad behavior c. Understands that everyone dies eventually d. Recognizes the parent will never wake up
d
1. A nurse is caring for an older adult client who report dry, itchy skin. Which of the following actions should the nurse take? a. Place a humidifier in the clients room b. Apply powder to the client skin c. Encourage the client to bathe frequency d. Add moisturizing oil to the client bath water.
d
1. A nurse is collecting data form a client who has alcohol use disorder and is experiencing withdrawl. Which of the following manifestation should the nurse expect? a. Constipation b. Polyuria c. Bradycardia d. Hypertension
d
1. A nurse is collecting data form a client who is at 12 weeks of gestation. The client states, "we been trying to get pregnant for several months, but now I m not sure im ready. " which of the following responsses should the nurse make? a. Why do you feel that way if you've been trying to get pregnant? b. You need to talk to a therapist about how you are feeling c. I would not worry about it if I were you. You'll be a good mother d. Many women experience feeling of ambivalence during pregnancy
d
1. A nurse is collecting data from a client who has acute cholecystitis. Which of the following finding should the nurse expect? a. Pain radiating to the jaw b. Discomfort with urination, c. Increased abdominal discomfort prior to meals d. Pain in the right upper abdomen
d
1. A nurse is contributing to an in- service for newly licensed nurses about situation requiring an incident report. Which of the following examples should the nurse include? a. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm b. A nurse discovers that a client family member has administered a PCA dose c. A nurse observes a client vomiting after receiving an oral pain medication d. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client.
d
1. 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? a. Keep the client daily protein intake below 0.8 g/kg b. Restrict the client sodium intake to 3g per day c. Position the client supine with legs elevated d. Measure the client abdominal girth daily
d
1. A nurse is contributing to the plan of care for a client who has herpes simplex, the nurse should plan to initiate which of the following isolation procedure when caring for this client? a. Airborne precaution b. Droplet precaution c. Protective environment d. Contact precaution
d
1. A nurse is monitoring a client who has received external radiation for throat cancer. which of the following findings should the nurse expect : a. Increase appetite b. Loose stool c. Bladder infection d. Loss of taste
d
1. 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? a. Review the facility policy and procedure manual b. Identify data collection methods c. Define the problem d. Perform chart audits
d
1. A nurse is planning to obtain a 12 lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? a. Assist the client to the orthopneic position b. Tell the client to expect a mild stinging sensantion during the test c. Attach blood pressure cuff to the client upper arm d. Instruct the client to remain as still as possible during the recording
d
1. A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother question the purpose of the medication. Which of the following responses should the nurse make? a. This medication will decrease the possibility of your newborn developing jaundice b. This medication will increase absorption of nutrients in the intestine c. This medication will increase the immunity of your newborn d. This medication will decrease the risk of hemorrhage in your newborn
d
1. A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take? a. Call the provider about admitting the client to the facility overnight b. Give the client a list of home care assistants to contact c. Contact the next of kin to assist the client at home d. Assist with a referral to a home health care agency
d
1. A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching? a. I should use the cap during my menstrual cycle to prevent pregnancy b. I should avoid using spermicide with the cervical cap c. I need to have my provider check the size of the cap every 6months d. I need to keep the cap in place for at least 6 hours after intercourse
d
1. A nurse overhears two assistive personnel in the nurse station discussing a client who was recently admitted. Which of the following actions should the nurse take? a. Document the event in the client progress notes b. Inform the client of the AP's actions c. Submit an incident report tot the risk manager d. Tell the AP's to stop the conversation
d
a. 1. A nurse is receiving change of shift report on four client. Which of the following clients should the nurse plan to see first? a. A client who had a renal biopsy 3hrs ago and has pink tinged urine b. A client who had a laparoscopic appendectomy 8hrs ago and is awaiting discharge c. A client who has a femur fracture and reports numbness of the toes d. A client who has cirrhosis and severe pruritus
d
1. A nurse is preparing to administer a nasal drop medication to a client . identify the sequence of action the nurse take. Position the client head as indicated for the affected sinus cavity Have the client flow their nose gently Position the client on her back Place the dropper above the naris Instill the medication Have client blow nose before administration. Assist client to seated position with head tilted back, if not contraindicated. Be sure client inhales gently through nose during medication administration. While inserting tip of nasal medication in one nostril, gently press other nostril closed. Activate medication as the client inhales through nose. While still compressed, remove medication from nostril, and then release. Instruct client to exhale through the mouth after a few seconds. Repeat on other side if prescribed. When fnished, clean applicator tip with tissue and recap while offering one to client for any drainage Instruct client to avoid blowing nose for 5 to 10 minutes after medication administration completed. *Ensure that the client is in a safe position prior to leaving the room and has the call light within reach. Evaluate the outcome at the pt. Eye drop: If necessary, gently clean eyelids and/or eyelashes prior to administration. Always wipe from inner to outer ends of eye. Have client tilt head backward and slightly turned toward affected side. Remove cap from bottle, ensuring not to contaminate end. Have the client look up while gently applying downward pressure on the lower eyelid. Rest the side of your hand on the forehead for stability and hold the medication near the eye. Squeeze prescribed number of drops or amount of ointment into the conjunctival sac and release lower lid. Instruct client to close eyes. If using drops, gently press inner canthus to prevent flow in to tear duct. Instruct client to not rub the eye. Repeat if necessary, in other eye. After complete, recap bottle without contaminating tip. *Ensure that the client is in a safe position prior to leaving the room and has the call light within reach. Evaluate the outcome at the appropriate time frame.
Position the client head as indicated for the affected sinus cavity Have the client flow their nose gently Position the client on her back Place the dropper above the naris Instill the medication
1. A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states. "I guess I will be locked in my room again for wetting the bed. which of the following action should the nurse take? a. Review the medical record to see if the client has reported abuse in the past b. Contact the clients' caregiver to discuss the client comment c. Restrict family member from visiting with the client d. Report the suspected abuse to the nurse manager
a
1. A nurse enters a client 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. Measure the client vital signs b. Notify the clients provider c. Complete an incident report d. Document the fall in the clients medical record.
a
1. A nurse in a mental facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first? a. Explore behaviors that have helped to reduce the client anxiety in the past b. Administer an anti-anxiety medication c. Explain to the client that anxiety causes physical manifestations d. Minimize environmental stimuli in the clients surrounding
a
1. A nurse in an acute care setting is assisting in collecting client information to include in referral for a physical therapist. Which of the following information should the nurse plan to include? a. Physical assessment finding b. Medications taken prior to admission c. Medical health insurance claims d. Family medical history
a
1. A nurse is administering hydromorphone to a client who is experiencing post-operative pain. Which of the following finding is an adverse effect of this medication? a. Urinary retention b. Dilated pupil c. Hypertension d. Tachypnea.
a
1. A nurse is assigned to care for an older adult female client. The client tells the nurse that she wants a female nurse to care for her. Which of the following statements should the nurse make? a. I will ask to have you assigned to a female nurse b. You will need to speak with the nurse manager about this c. I will get a female assistive personnel to provide your bath d. I care for other female client and they do not mind having a male nurse
a
1. 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. Assist the client to a negative pressure airflow room b. Initiate contact precautions for the client c. Administer aspirin if the client develops a fever d. Have visitors remain at least 0.91 ( 3ft) away form the client.
a
1. A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect? a. Nuchal rigidity b. Jaundice c. 2+ pedal edema d. Hematuria
a
1. A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take? a. Choose a room that is well lit b. Exaggerate lip movement while speaking c. Sit on the client right side d. Ask a few questions at a time
a
1. A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced breast cancer. the client states, I am thinking about stopping the treatment. Which of the following responses should the nurse make? a. Tell me more about what you are thinking b. I would feel the same way if I were you c. You'll be cancer free after you complete you treatment d. Why do you think that would be good choice?
a
1. 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. Roasted salmon b. Shrimp salad c. Pulled pork sandwich d. Clam chowder
a
