RN Comprehensive Online Practice 2019 A

A clinic nurse is caring for a client who is in the first trimester of pregnancy. The client reports using acupressure bands on both wrists. Client statement indicates this therapy is giving the desired effect?

"I haven't vomited as much recently"

A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which client statement indicates the client understands the teaching?

"I should report a change in the color of my stools"

A nurse is providing discharge instructions to a client who has a new prescription for amitriptyline to treat depression. Which client statements shows understanding of teaching?

"I should watch for dry mouth and constipation"

A nurse is teaching about TPN and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include?

"You will receive fingersticks for blood glucose testing"

A nurse is providing discharge teaching to a client following a cataract extraction. Client statement understands teaching?

"bend at my knees when picking up objects from the floor"

A nurse is teaching a newly admitted client who has heart failure about advance directives. Nurse statement?

"complete advance directives in the case you can't express your own wishes"

A nurse is providing discharge teaching to a new parent about car seat safety. Which statement should the nurse include in the teaching?

"secure the retainer clip at the level of baby's armpits"

A nurse is teaching the parents of a preschooler about sleep promotion. Parents report child reluctance in going to bed "I'm not tired". Statement shows parental understanding?

"we should read a story together before bed every night"

A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eye glasses. Which of the following instructions should the nurse give to the child?

"you should keep both eyes open during the test"

A nurse is providing teaching to an adolescent following insertion of a tunneled central venous catheter. Which of the following information should the nurse include in the teaching?

"you should keep the catheter clamped when not in use"

Intermittent Urinary Catheterization

'straight cath'

A nurse is providing teaching about improving nutrition for a client who has MS. Which instructions should the nurse include?

-a speech pathologist -rest before eating -thicken beverages before eating

A nurse is assessing a client who is experiencing autonomic dysreflexia. Expected nursing findings?

-facial flushing -nasal congestion -headache

A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. "I'm worried about being discharged because I live alone. My insurance doesn't cover ostomy supplies." Nursing action?

-refer to community based social worker -initiate home health consult -give info about local support groups

A nurse is providing teaching to the parent of a child who has a permanent trach. Steps of trach care:

1. remove inner cannula 2. remove soiled dressing 3. clean w/ saline 4. change the trach collar

A client is receiving lorazepam IV for panic attacks and develops a RR of 6/min and a BP of 90/44mm Hg. What med should the nurse anticipate administering?

Flumazenil

A nurse is initiating discharge planning for a client who has a stroke and is experiencing R side weakness. Nurses first action?

Request PT referral

A nurse is administering enoxaparin. Where?

SubQ

A nurse in a mental health facility is planning care for a client who has anorexia nervosa. Which intervention should the nurse include in the plan of care?

Supervise the client during and after eating

A nurse is reviewing lab findings of a client experiencing chest pain. The nurse should identify that an elevation in which lab indicates myocardial cell tissue injury?

Troponin T

A nurse is preparing to administer a long-acting insulin to a client who has DM. Which of the following actions should the nurse plan to take first?

check the dose with another nurse

A nurse is assessing a client who has schizophrenia. The nurse should identify the following alteration in speech as which of the following?

clang association

A nurse is planning care for a client who has a deficit with cranial nerve II. Which of the following actions should the nurse plan to take?

clear objects from the client walking area

A nurse is caring for a group of clients. Which event requires an incident report?

client's IV pump administers inadequate dose of medication

A nurse is caring for four clients at the beginning of a shift. After report, which client should the nurse attend to first?

confused client getting out of bed

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Assessment finding priority?

confusion

A nurse is caring for a client with MRSA. Implement which precautions?

contact

A nurse is caring for a newborn with herpes simplex virus (HSV). Which isolation precautions?

contact

A nurse is caring for a client that is in labor at 39 weeks gestation. During the second stage of labor, the nurse observes early decelerations on the monitor. What action should the nurse take?

continue observing the fetal heart rate

A nurse is caring for a client with a potassium level of 3. What manifestation should the nurse monitor for?

decreased DTR

A nurse is assessing a client who has macular degeneration. Which of the following findings should the nurse expect?

decreased central vision

A nurse is caring for an older adult client. Physiological change associated with aging?

decreased lung expansion

A nurse in an ER is planning discharge for a client who has experienced intimate partner violence. Which action should the nurse take first?

develop a safety plan

A nurse is caring for a client receiving TPN by IV at 60mL/hr. The nurse discovers the infusion pump isn't working. Which action should the nurse take while waiting for a new pump?

dextrose 10% in water using manual drip tubing at 60mL/hr

A nurse in an ER is assessing a client that took MDMA. What should the nurse expect?

diaphoresis

A nurse is teaching the parents of a toddler about snacks. Which of the following foods should the nurse recommend?

diced steamed carrots

A nurse on a mental health unit has a patient refusing IM lorazepam. What is the nursing action?

document the refusal

A nurse is teaching home wound care to the family of a child who has a large wound. Which intervention should the nurse recommend?

double bag soiled dressings in plastic bags for disposal

A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first?

dry the newborn

A nurse is planning care for a client who is receiving heparin to treat a L leg DVT. Nursing intervention?

elevate the leg

A nurse is caring for a toddler who is admitted to the pediatric unit for surgery. What should the nurse include in the plan of care?

encourage the parents to bring toys from home

A nurse is caring for a client at 28 weeks gestation. The client asks what's causing her constipation. Which response should the nurse make?

enlarged uterus compresses the intestines

A nurse is preparing to administer 2U FFP to a client. Which action should the nurse plan to take?

enter the plasma product number into the client's medical record

A mental health nurse is conducting the first of many meetings with a client whose partner recently died. The nurse should perform which action to establish trust in the orientation phase of the nurse-client relationship?

establish the termination date

A nurse is caring for a client who has a STI that must be reported to the state health department. Which of the following actions should the nurse take?

explain to the client why this information will be shared

A nurse is performing an admission assessment on a preschooler who is in the acute phase of Kawasaki disease. Which finding should the nurse expect?

fever unresponsive to antipyretics

A nurse is administering meds to a client who has a percutaneous gastrostomy tube for enteral feedings. Which of the following actions should the nurse take to prevent the tube from clogging?

flush the tube before meds

A charge nurse observes a staff nurse document a dressing change in a client's chart that wasn't performed. First charge nurse action?

gather more information about the staff nurse's actions

A nurse is caring for a client in the manic phase of bipolar. Expected manifestations?

grandiose delusions

A nurse in an outpatient clinic is working with a client that has PTSD and asks for recommended nonpharm therapy. What should the nurse recommend to help alleviate distress?

guided imagery

A nurse is teaching a client about a new prescription for estradiol. For which of the following adverse effects should the nurse tell the client to monitor and contact the provider?

headaches

A nurse is assessing a client w/ sickle cell anemia. Manifestation of vaso-occlusive crisis?

hematuria

A nurse is assessing a child with CF. Which finding is priority to report to the provider?

hemoptysis 275mL in 24 hours

A nurse is providing teaching for a client about newborn safety. Which statement should the nurse include in the teaching?

hot water heater temp 120F or less

A nurse is assessing a client who has obstructive sleep apnea. Which complication should the nurse monitor?

hypertension

A nurse is providing client education to a postpartum client who has decided to bottle feed their newborn. Instructions to prevent the discomfort of engorgement?

ice packs on the breasts for 15 minutes several times per day

A charge nurse is preparing to administer 0900 meds and is told by pharmacy the meds are not available. First charge nurse action?

inform the nurse manager

A nurse is caring for a client who has generalized anxiety disorder and is going to start alprazolam. Which action should the nurse take?

initiate fall precautions

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?

initiate oral rehydration therapy for the toddler

A nurse is preparing to administer 15U regular insulin along with 20U NPH. Which action plan should the nurse take?

inject 20U air into NPH insulin vial

An RN is planning care for a group of clients and is working with an LPN and an AP. What tasks should the RN delegate to the LPN?

insert a NG tube

A nurse is providing discharge instructions to a client following a total hip arthroplasty. Which instruction should the nurse include?

install a raised toilet seat at home

A nurse is providing dietary teaching to the parents of a 6 month old. What instructions should the nurse give?

introduce new foods over 5-7 days

A nurse manager reviews falls occur most often between 0530 and 0730. Which action should the nurse take in root cause analysis?

investigate environmental factors

A nurse is caring for a client that requires PT after discharge. First nursing action?

involve the client in selecting their PT provider

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates understanding of the procedure?

keeps the HOB elevated to 45 degrees for 1hr after feedings

A nurse is assessing a client who has antisocial personality disorder. Expected manifestations?

lack of remorse

A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which condition prior to starting the procedure?

latex allergy

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should indicate to the nurse that the client is having a hemolytic transfusion reaction?

low back pain

A nurse is administering cyclophosphamide to a school age child with neuroblastoma. Nursing action to administer medication?

maintain hydration with liberal fluid intake

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which method should the manager use to evaluate time management skills?

maintain regular notes about the nurses time management skills

A nurse is caring for a client who has a closed-head injury and is receiving mechanical ventilation. The nurse should expect to administer which med to reduce intracranial pressure?

mannitol

A home health nurse is planning care for an older adult client who has impaired vision. Which intervention in the plan of care to prevent injury at home?

mark the edges of stairs for contrast

a nurse is caring for a client who is 4hrs postpartum with a boggy uterus and heavy lochia. First nursing action?

massage the uterus to expel clots

A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanity and sexual references. Which of the following actions should the nurse take first?

move the client to a private place away from others

A nurse is teaching a client that has a new prescription for digoxin about manifestations of toxicity. Which finding should the nurse include in the teaching?

nausea

A nurse is assessing a client who is 2hrs post op following a cardiac cath. Report to MD?

neuro status

A nurse manager is on a planning committee to develop an emergency preparedness plan. Which action takes place first when implementing an emergency preparedness plan?

notify the incident commander

A nurse is assessing a client who has MS. Which manifestation should the nurse expect?

nystagmus

A nurse is caring for a client who has hypertension and is taking captopril. Delegatetask to AP?

obtain vital signs

A nurse is planning teaching about allowable foods for a client with uric acid-based urinary calculi formation. What foods should the nurse recommend?

oranges

A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The nurse should identify which of the following findings as fluid volume deficit?

orthostatic hypotension

A nurse is assessing a client who has a stage II pressure injury. Expected would characteristics?

partial thickness skin loss

A community health nurse is assisting with the development of a disaster management plan. What nursing responsibility should be included in the disaster response stage?

perform a rapid needs assessment

A nurse is caring for a client at 37 weeks gestation and is experiencing abruptio placentae. Which finding should the nurse expect?

persistent uterine contractions

An AP and a nurse are turning a patient on their R side. Which AP action requires the nurse to intervene?

place a pillow

A nurse is caring for a client that vomits on a reusable BP cuff. Nurses action?

place the BP cuff in a labeled bag for decontamination

A nurse is caring for a child who is experiencing a tonic-clonic seizure. What action should the nurse take?

place the child in a side-lying position

A nurse is providing colostomy care for a client using a two-piece pouch system. Which action should the nurse take?

place the skin barrier over the stoma and hold it for 30 seconds

A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Expected finding?

protein

A charge nurse is planning care for a client in mechanical restraints. What interventions?

provide a staff member to stay with the client continuously

A nurse manager is planning to make changes to the current scheduling system on the unit. To facilitate staff acceptance, what should the nurse manager do first?

provide information about scheduling issues to staff

A nurse is teaching the parent of a school-age child about administering ear drops. Parent response indicating understanding?

pull the top of the ear up and back

A nurse in an emergency department is admitting a client who has cardiac tamponade. Which assessment finding should the nurse expect?

pulsus paradoxus

A nurse is assessing a client who has delirium. Which manifestation should the nurse expect?

rapid speech

Foods high in vitamin A

raw carrots

A nurse working in a long term care facility is assessing an adult client. Which of the following findings places the client at risk for developing a pressure injury?

recent weight loss

A nurse is teaching a client who has opioid use disorder about methadone. Information to include in teaching?

sedation is a common adverse effect of this medication

A nurse is teaching a client who is to start taking misoprostol and is currently on long-term NSAIDs for arthritis. The nurse should provide what information?

serum pregnancy test

A nurse is preparing a sterile field in order to insert an indwelling urinary catheter on a male client. Which technique should the nurse use to maintain aseptic technique?

set the tray on the table at waist height

A community health nurse is performing triage tagging following a mass casualty incident. Black tag?

significant head trauma w/ agonal respirations

A nurse is assessing a 2 month old infant during a well-baby exam. Which of the following actions should the nurse take to assess the infant's rooting reflex?

stroke the cheek

"My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out". The client demonstrates which defense mechanism?

sublimation

A nurse is assessing a preschooler who has CF and has been receiving oxygen therapy for the past 36 hours. Which finding shows oxygen toxicity?

substernal pain

A charge nurse overhears 2 staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which action should the charge nurse take?

tell the nurses to stop the discussion

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following requires manager intervention?

tells the hospital chaplain a client's diagnosis

A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which finding is the priority for the nurse to provide to the provider?

temp 102.9f

A charge nurse is teaching a newly licensed nurse how to identify true labor. What should the nurse include in the teaching?

the cervix transitions to an anterior position

A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client can sign the informed consent?

the client an accurately describe the procedure

A night shift nurse is giving change-of-shift-report to the day shift nurse on a client ready for discharge. Priority information to oncoming nurse?

the client needs assistance transferring from bed to w/c

A nurse is caring for a client with a closed femur fracture and has had a fiberglass leg cylinder cast for 24 hours. Which of the following assessment findings should the nurse identify as the priority?

the client's heel is red and tender

A charge nurse is planning an educational session for staff nurses about working with parents whose terminally ill children are candidates for organ donation. Which information should the nurse plan to include?

the family can have the child in an open casket

A nurse is reviewing the ABG results of a client with COPD. The results include pH 7.3, PaO2 56 mm Hg, PaCO2 54 mm Hg, HCOs 26 mEq/L, SaO2 87%. Correct interpretation?

uncompensated respiratory acidosis

A nurse is assessing a client who has skeletal traction for a femur fracture. Which should the nurse identify as the priority?

upper chest petechiae

A nurse is performing gastric lavage for a client who has GI bleeding and a NG in place. Nursing action?

use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube

A home health nurse is providing teaching to a client that has hep A.Which of the following instructions should the nurse include?

use hydrogen peroxide to clean kitchen surfaces

A nurse is caring for an immediately post op total vaginal hysterectomy. Which action should the nurse take first?

vital signs

A nurse in a clinic receives a call from a guardian whose child has varicella. The guardian asks when the child returns to school. Which of the following responses should the nurse make?

when crusts have formed on every lesion

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm3. What intervention should the nurse include in the plan?

withhold the varicella vaccine

A charge nurse is watching a newly licensed nurse perform a physical assessment. Which action should the charge nurse intervene?

writes detailed notes

A nurse is caring for a client who has a terminal illness and requests no life saving measures if a cardiac arrest occurs. Nurse should make what statement?

"I will provide you with information about medical treatment to include in your living will"

A home health nurse is teaching about infection prevention to a cancer pt on chemo. Which statement indicates understanding?

"I'll walk short distances throughout the day"

A nurse is caring for a client who has end stage Alzheimer's Disease. The adult child of the client says 'I don't know why I bother to visit my mother anymore". Nurse response?

"It seems like you feel your visits are a waste of time"

A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?

"Maybe this is better for our child because we don't want any suffering through chemotherapy treatments"

A nurse is talking with the partner of a client who attempted suicide. Which of the following statements by the client's partner is priority?

"My husband doesn't know I;ve already moved out and filed for divorce"

A nurse receives a request from a client to review the information in his medical record. Which response should the nurse give?

"There's a protocol for reviewing your medical record, and I can initiate the process"

5,000U SubQ heparin, available 10,000U/mL. How much to administer?

0.5mL

A nurse is preparing to administer diazepam 0.3mg/kg IV bolus to a 22lb toddler who is experiencing a grand mal seizure. Available is 5mg/mL. How many mls should the nurse administer?

0.6mL

A home health nurse is assessing a 2 week old newborn who had a birth weight of 3.64kg (8lbs) and is being breastfed. Effective breastfeeding?

6-8 wet diapers per day

A nurse is interviewing a client who is now without a home d/t natural disaster. After ensuring the clients safety, what's the nurses first action?

Determine the client's perception of the personal impact of the crisis

A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse take first?

Identify health-related issues within the community

A nurse is assessing a client who has Raynaud's disease. Which finding should the nurse expect?

blanching of the fingers and toes

A nurse is caring for a newborn whose parents ask why their baby is receiving vitamin K. The nurse explains vitamin K prevents:

bleeding

When caring for a child a nurse plans to use nonpharm interventions to enhance pain med effectiveness. Which of the following strategies incorporates visualization techniques to help decrease the child's discomfort?

blowing bubbles to "blow the hurt away"

A nurse is reviewing the medical record of a client who has schizophrenia and is to start taking clozapine. Which finding is a contraindication for the client to receive clozapine?

WBC count 2800/mm3

A nurse is assessing a client during the immediate postpartum period. Which finding requires immediate intervention?

boggy uterus

A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference?

a client who has DM and repeat admissions for DKA

A nurse has 4 patients. What should the nurse delegate to the AP for meals?

alzheimers w/ aphasia

A nurse is caring for a 12 hour post op on a PCA for pain control and requires a blood pressure check in 10 min. Which of the following staff members should the nurse assign to collect this information.

an Ap who is assisting a client to bed

A community health nurse is reviewing the medical records of four newly diagnosed clients. The nurse should identify which of the following clients as having a nationally notifiable infectious condition?

an adolescent with foodborne botulism

A nurse is performing trach care for a client post op following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

apply suction for 10 seconds

A nurse working on a med-surg unit receives a telephone call requesting the status of a client from an individual who identifies themselves as the client's parents. Nursing action?

ask the caller for verification of their identity

A client who is 24 hours post op following abdominal surgery refuses to ambulate. First nursing action?

ask the client to rate their pain level

A charge nurse assigns a new nurse to a client with a chest tube. The new nurse expresses concern d/t limited experience with monitoring drainage. What should the charge do to teach about chest tubes?

ask the nurse about their knowledge of the procedure

A nurse is caring for a client who had a recent stroke. Prior to transferring the client to the bedside commode, which action should the nurse take first?

assess for functional limitations

A nurse is caring for an older adult client in the PACU following general anesthesia. What finding should the nurse report to the provider

audible stridor

A nurse is planning care for a client receiving HD from an AV fistula in the R arm. Which intervention should the nurse include in the plan of care?

auscultate for bruit

A nurse is teaching about child safety measures. What statement indicates understanding?

avoid sun exposure 10am-2pm

A nurse is planning care for a client who has thrombocytopenia. Which of the following instructions should the nurse include in the client's plan of care?

avoid venipunctures when possible

A nurse is assessing a 2hr old newborn. Report to MD?

axillary temp 36.2C (97.2F)