practice 3 50-100
A woman has just delivered a stillborn baby. Which of the following is the appropriate response by the nurse?
"I'll stay with you just in case you want to talk."
A nurse is preparing a discharge teaching plan regarding dressing changes for a client who had reconstructive surgery for facial scars. The nurse knows that the client is ready for teaching when the client states which of the following?
"I need a mirror to view my face after the dressing is removed."
A nurse is providing teaching to a client who has rheumatoid arthritis and is prescribed methotrexate. Which of the following statements by the client indicates an understanding of the teaching?
"I should call my doctor if I develop sores in my mouth."
A nurse manager is providing orientation to a nurse who is new to hospice care. Which of the following statements indicates that the new nurse needs additional orientation?
"I will provide care and education to clients in order to promote recovery."
A nurse is working with a group of older adult clients at an independent living facility who are discussing their plans for family reunions. Which of the following statements by a group member warrants further assessment by the nurse?
"I'm not going to the reunion because no one asked me to help plan it."
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
"The pain is like a dull ache in my stomach."
A nurse receives report on four clients. Which of the following clients should the nurse assess first?
A client admitted for a fractured hip who has developed slurred speech
There has been a massive community disaster and stable clients must be discharged from the hospital to prepare for the influx of new casualties. Which of the following clients is safe to discharge?
A client with multiple sclerosis who reports ataxia
A nurse is caring for a client who is receiving total parenteral nutrition. A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?
Administer 10% dextrose in water until the new bag arrives.
A nurse is providing teaching for a client who is perimenopausal and has been prescribed hormone therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.)
Calf pain Numbness in the arms Intense headache
A nurse is educating a client who is at 30 weeks of gestation regarding a 3-hr oral glucose tolerance test. Which of the following should the nurse include in her teaching?
Consume 150 g of carbohydrates daily for 3 days prior to the test.
A nurse is caring for a client who is receiving radiation treatment for colon cancer. The client states, "I have had three episodes of diarrhea since treatment." Which of the following should the nurse suggest to the client?
Limit caffeine.
A nurse is caring for a school-age child prescribed methylphenidate for ADHD. The nurse has initiated interventions to minimize adverse effects. Which of the following findings indicates a successful intervention?
Maintains age-appropriate weight
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the following should the nurse document as a therapeutic outcome?
Decrease in flexor and extensor spasticity
When planning care for a child who has increased intracranial pressure (ICP), which of the following should the nurse include in the child's plan of care?
Maintain head in midline.
Which of the following nursing interventions is helpful in establishing trust in the initial phase of a nurse-client relationship?
Discussing the boundaries of the relationship with the client
A community health nurse identifies an increase in the occurrence of osteoporosis-related fractures in women experiencing menopause. Which of the following primary prevention strategies should the nurse implement?
Encourage the women to participate in weight-bearing activities.
A nurse is providing teaching to a female client who has been newly diagnosed with a seizure disorder and has begun phenytoin. The nurse should tell the client that phenytoin can decrease the effectiveness of which of the following?
Ethinyl estradiol/desogestrel
A nurse is caring for a client who has just delivered a newborn. The nurse is preparing to administer oxytocin. Which of the following findings is an indication for the use of oxytocin? (Select all that apply.)
Flaccid uterus Excess vaginal bleeding
A client who has systemic lupus erythematosus (SLE) presents to the clinic. Which of the following findings should be reported to the primary care provider?
Increase in heart rate 25/min above baseline
A nurse is caring for a client who has been diagnosed with placenta previa. The nurse should expect which of the following findings?
Painless vaginal bleeding
A nurse is providing postoperative instructions about complete proteins to a client following a below-the-knee amputation. Which of the following food choices indicates a need for additional instruction?
Pinto beans
A client walks into the emergency department with reports of numbness and tingling of the lower extremities following a fall from a ladder. Which of the following actions should the nurse take first when admitting the client?
Place the client on a backboard.
A community health nurse is asked to give a health education program to a group of African-American men age 40 to 75. Considering the health concerns of this group, which of the following topics is most important to include in the program?
Prostate cancer screening
Which of the following activities is an example of a nurse's role as a case manager?
Providing referral information to clients
A student at a local high school is diagnosed with syphilis. Which of the following actions should the nurse take?
Report the case to the state health department.
A nurse is caring for a client who is at 18 weeks of gestation and whose maternal serum alpha-fetoprotein (MSAFP) results are high. Which of the following actions by the nurse is appropriate?
Request a prescription for an ultrasound.
A client who is taking fluoxetine for depression presents to the clinic for follow-up treatment. Which of the following adverse effects reported by the client should the nurse recognize as being attributable to this medication?
Sexual dysfunction
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.)
Sleepiness Widening pulse pressure Decerebrate posturing
A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has jugular vein distention. Which of the following actions should the nurse anticipate taking?
Slow the infusion rate.
A nurse is caring for an older adult client who has kidney failure. The client tells the nurse that she has decided to stop hemodialysis treatment. Which of the following actions by the nurse is appropriate in regard to serving as the client's advocate?
Supporting the client's decision regarding treatment
A nurse is working at a community health center. Which of the following nursing activities demonstrates a tertiary level of prevention?
Teaching a client who has rheumatoid arthritis measures to prevent joint deformities
A hospice nurse is visiting a parent on the 1-year anniversary of the death of his child from leukemia. Which of the following reactions by the parent would indicate to the nurse the need for a bereavement counseling referral?
The parent has not returned to work.
A charge nurse assigns an RN to administer IV medications and infusions, another RN to manage admission assessments, a licensed practical nurse to give treatments, and an assistive personnel to handle hygiene needs for a caseload of clients. Which of the following is a rationale for this functional nursing approach?
To optimize efficiency of staff
A nurse observes a client in the hallway who is having a generalized tonic-clonic seizure. The client has become cyanotic. Which of the following nursing interventions is appropriate for this client?
Turn the client onto her side.
The nurse is assisting a group of clients to identify skin cancer-related risk factors that can be reduced. Which of the following is an appropriate health behavior change?
Wearing a wide-brim hat while gardening
A nurse in a community health clinic is conducting focused assessments of the skin of four clients. Which of the following skin conditions should be reported to the provider immediately?
brain looking like one
A nurse walks into the nurses' station and sees several staff members looking at the electronic chart for a celebrity client on another unit. The nurse should first
remind the staff members that this is a breach of confidentiality.
A nurse is moving into the role of a hospice nurse. She recognizes that when she is working with clients in the community, the collaborative process for hospice care begins in the hospital with
the discharge planner.
A client who is pregnant arrives at the labor and delivery unit reporting leakage of fluid from the vagina. The nurse determines that the client has probable rupture of membranes when assessment reveals that
the ferning test is positive.
