*Study Guide
A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?
Wash hands with soap and water for 20 seconds
A nurse is reinforcing teaching with a client who has a UTI. Which of the following instructions should the nurse include in the teaching?
Wear cotton underwear.
A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?
Write information at an 8th-grade level.
A nurse is reviewing the laboratory results for a client who has respiratory acidosis. Which of the following arterial blood gas values should the nurse expect?
pH 7.30, PaCO2 50 mmHg
A nurse is reinforcing teaching about preventing dental caries with the parents of a 12-month-old toddler. Which of the following instructions should the nurse provide?
"Clean the teeth with a small, soft-bristled toothbrush"
A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?
"Discontinue the medication. I will ask your provider for another antibiotic."
A nurse is collecting data from a client who reports difficult sleeping at night. Which of the following client comments indicates an understanding of sleep promotion?
"I am going to bed at the same time every night"
A nurse is verifying informed consent for a client who is postoperative for a vaginal hysterectomy. Which of the following comments should the nurse identify that the client has given informed consent?
"I am thankful I am done having children"
A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?
"I try not to look at the scales on my body"
A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?
"I will mix the medication with a full glass of water"
A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following indicates an understanding of the teaching?
"I will place the patch on a hairless area of skin."
A nurse is discussing hand hygiene with an assistive personnel (AP), which of the following statements by the AP indicates an understanding of the teaching?
"I will rub my hands together until they are dry when using an alcohol-based hand rub"
A nurse is reinforcing teaching with a parent of a 4-month-old infant during a home visit. Which of the following statements indicates an understanding of the teaching?
"I will use a cool-mist vaporizer in my baby's room."
A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?
"It enhances quality of life by promoting comfort"
A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should the nurse make?
"Let me give you some information about respite care for your mother"
A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?
"Perform sponge baths until the baby's umbilical cord falls off"
A nurse is assisting in the care of an older adult who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?
"Prednisone can cause blood glucose levels to increase."
A nurse is reinforcing teaching with a client who has asthma and a new prescription for a beclomethasone inhaler. Which of the following instructions should the nurse include in the teaching?
"Rinse your mouth after each use of the inhaler"
A nurse is talking with the partner of a client who has recently died. Which of the following statements should the nurse make?
"Tell me what I can do for you at this time"
A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?
"Tell me what you know about depression"
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.
"What makes you think the staff is following you?'
A nurse is reinforcing teaching with a client who has active pulmonary tuberculosis. Which of the responses should the nurse take?
"You are no longer contagious when you have negative sputum culture."
A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching?
"You can sign the informed consent form after the provider explains the pros and cons of the procedure"
A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following actions should the nurse include in the teaching?
"You will have a leg bag to collect the urine."
A nurse is reinforcing teaching with a client who is scheduled to undergo a hysterectomy. Which of the following statements should the nurse make?
"You will need to report any temperature above 98 degrees Fahrenheit after discharge"
XANTHELASMA PICTURE SELECTION
2nd option (old lady with eyes closed and yellow deposits on eyelids)
Erythema toxic baby picture selection
3rd option (baby showing belly with red patches)
A nurse in a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first?
A client who has schizophrenia and is having command hallucinations
A nurse is assisting with the planning of an-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best EVIDENCE-BASED information?
A peer-reviewed journal article
A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make? A. "Sit back down for a few minutes when this occurs" B. "Restrict your daily fluid intake" C. "Discontinue this medication if this occurs again" D. "Take a daily potassium supplement"
A. "Sit back down for a few minutes when this occurs"
A nurse is reinforcing teaching with a client who had a total right hip arthroplasty. Which of the following instructions should the nurse include? A. "You should avoid sleeping on your right side" B. "You should avoid exercising for the next 6 weeks" C. "You should avoid putting a pillow between your legs in bed" D. "You should avoid crossing your legs for 3 months"
A. "You should avoid sleeping on your right side"
A nurse is providing site care for a child who has a skin-level gastrostomy enteral tube. Which of the following actions should the nurse take? A. Apply a skin barrier protectant to the skin B. Cleanse the site with warm soap and water C. Apply water soluble lubricant to the site D. Tape the tube to the child's check
A. Apply a skin barrier protectant to the skin
A nurse is performing a heelstick on a newborn to obtain glucose monitoring. Which of the following actions should the nurse take? A. Apply a warm cloth to the heel 10 minutes prior to the procedure B. Use a 25-gauge butterfly needle C. Place the newborn in the prone position D. Puncture the inner lateral part of the newborn's heel
A. Apply a warm cloth to the heel 10 minutes prior to the procedure
Digoxin toxicity adverse effect? A. Blurry vision B. Joint pain C. Constipation D. Tinnitus
A. Blurry vision
A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take? A. Check the client's status every hour B. Document the client's behavior leading to the initiation of restraints C. Obtain written consent by the client for the placement of the restraints D. Release the client's restrains every 4 hr
A. Check the client's status every hour
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take? A. Clean the stoma using an inward to outward circular motion B. Ensure at least three finger widths of space under the tracheostomy ties C. Prepare sterile supplies after removing the inner cannula D. Cleanse the inner cannula with isopropyl alcohol
A. Clean the stoma using an inward to outward circular motion
A nurse on a medical-surgical unit is planning care at the beginning of a shift. Which of the following tasks should the nurse assign to an assistive personnel? A. Collect a random stool specimen from a newly admitted client B. Administer a vaginal suppository to a client C. Provide client instruction on collecting a urine specimen D. Remove a client's nasogastric tube
A. Collect a random stool specimen from a newly admitted client
A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect? A. Deep tendon reflexes 2+ B. Positive clonus C. Urinary output 20 mL/hr D. Respiratory rate 10/min
A. Deep tendon reflexes 2+
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. Discontinue use and tag the IV pump B. Plug the IV pump's cord into a different outlet C. Clear the setting and reset the IV pump D. Replace the IV pump's tubing
A. Discontinue use and tag the IV pump
Improvement plan for assistive personnel SATA A. Include the performance standard that the AP should meet B. Base performance goals on peer comments C. Request clients complete an evaluation about the AP's quality of care D. Ask the nurse supervisor to review the plan E. Set a specific time frame for meeting performance goals
A. Include the performance standard that the AP should meet D. Ask the nurse supervisor to review the plan E. Set a specific time frame for meeting performance goals
A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take? A. Inform the adolescent that he might experience a headache. B. Position the adolescent with his neck hyperextended. C. Keep the adolescent NPO. D. Administer opioids to the adolescent on a schedule.
A. Inform the adolescent that he might experience a headache.
A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change? A. Moisten the dressing before removal B. Wear sterile gloves to remove the dressing C. Clean the wound from the center to the outer edges D. Remove the tape by pulling from the center of the dressing
A. Moisten the dressing before removal
A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? SATA. A. Record the date and time of the telephone prescription B. Request that the provider confirm the read-back of the prescription C. Ask the provider to spell out the name of the prescription D. Withhold the medication until the provider signs the prescription E. Instruct another nurse to record the prescription in the medical record
A. Record the date and time of the telephone prescription B. Request that the provider confirm the read-back of the prescription C. Ask the provider to spell out the name of the medication
Which of the following findings should the nurse identify as a risk factor for child maltreatment? A. The infant is younger than 1 year of age B. The infant has otitis media C. The infant was born large for gestational age D. The infant's guardians are both over the age of 30
A. The infant is younger than 1 year of age
A nurse determines that clients who receive zolpidem postoperatively have an increased fall rate compared to other postoperative clients. Which of the following members of the health care team should the nurse report these findings? A. The risk manager B. The pharmacist C. The case manager D. The surgeon
A. The risk manager
A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following intervention should the nurse include in the plan? A. Use a no rinse perineal cleanser after incontinence B. Avoid the use of draw sheets for repositioning C. Limit period of sitting in a chair to 4 hr D. Keep the head of the client bed elevated to 45 degree
A. Use a no rinse perineal cleanser after incontinence
Albuterol can help treat which of the following manifestations? A. Wheezing B. Hand tremors C. Hyperglycemia D. Swelling of the lips
A. Wheezing
A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?
Administer oxygen to the client.
A nurse is caring for a client who recently died and practiced Jewish faith. Which of the following actions should the nurse take?
Allow a family member to stay with the body
A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?
Allow the client to have 1 hr of time alone in their room
A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
Anterior fontanel closed
A nurse is assisting with a group therapy session and notes a client who remains silent. Which of the following actions should the nurse take?
Ask the other group members to limit the number of times they speak.
A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching? A. ""I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water." B. "I will put soiled dressings in a tied plastic bag before placing them in the trash" C. 'I will place used sharp items in an empty cereal box for disposal" D. "I will use animal skin condoms when having sex"
B. "I will put soiled dressings in a tied plastic bag before placing them in the trash"
A nurse is collecting data from a client following a myocardial infarction. Which of the following statements by the client should the nurse address first? A. "I will be ready to leave the cardiac rehabilitation program after 1 week" B. "I'm worried my body will never be the same as it was before" C. "I might need some help learning about sodium food options" D. "I keep my nitroglycerin tablets on the windowsill in my kitchen"
B. "I'm worried my body will never be the same as it was before'
A nurse is recommending a client for discharge to allow for admission of a client following a tornado disaster. Which of the following clients should the nurse recommend for discharge? A. A client who has atrial fibrillation and an INR of 4 B. A client who has a sodium level of 140 med/L after one episode of diarrhea C. A client who is 3 days postoperative following hip arthroplasty and has a warm red are on his left calf D. A client who reports chest pain after ambulation
B. A client who has a sodium level of 140 med/L after one episode of diarrhea
A nurse in a clinic is caring for a client who is at 40 weeks gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? A. Has a pH of 7 B. Appears greenish-brown in color C. Preceded by bloody mucus D. Turns a nitrazine strip blue
B. Appears greenish-brown in color
A nurse is collecting data from a client who is at 35 weeks gestation. Which of the following findings should the nurse report to the provider? A. Leg cramps B. Blurred vision C. Urinary frequency D. Gingivitis
B. Blurred vision
The nurse is caring for an older adult who wears hearing aids with detachable ear molds. Which of the following actions should the nurse take when caring for the hearing aids? A. Change the battery once per month B. Clean the hearing aids with a soft club C. Disinfect the hearing aids with isopropyl alcohol D. Replace the ear molds once per year
B. Clean the hearing aids with a soft club
A nurse is caring for a client who has a peanut allergy. The client states, "I feel like my throat is closing." Which of the following actions should the nurse take? A. Administer diazepam PO B. Give epinephrine intramuscularly (Epi-pen) C. Deliver 2 L of oxygen via partial non-rebreather mask D. Notify the radiology department
B. Give epinephrine intramuscularly (Api-pen)
A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include? A. Oranges B. Grapes C. Potatoes D. Corn
B. Grapes
A nurse is reviewing the medication record of a client who takes atenolol PO and applies a nitroglycerin transdermal patch daily. For which of the following interactions should the nurse monitor this client? A. Thrombocytopenia B. Hypotension C. Dry cough D. Hypoglycemia
B. Hypotension
A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure? (DOUBLE-CHECK THIS ANSWER WITH SJ8 CHAT) A. Pin-point pupils B. Irritability C. Pallor D. Decreased blood pressure
B. Irritability
A nurse is collecting data from a client who is 12 weeks of gestation. The client states, we have been trying to get pregnant for several months, but now I am not sure I am ready. Which of the following statements should the nurse make????? A. Why do you feel that way if you have been trying to get pregnant? B. Many women experience feelings of ambivalence during pregnancy C. I would not worry about it if I were you, you will be a good mother D. You need to talk to a therapist about how you are feeling
B. Many women experience feelings of ambivalence during pregnancy
A nurse is caring for a client who receives cyclosporine instead of cycloserine. The nurse should monitor the client for which of the following adverse effects? A. Respiratory depression B. Nephrotoxicity C. Hypoglycemia D. Hypotension
B. Nephrotoxicity
A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment? A. Slurred speech B. New onset of hearing loss C. Constipation D. Hyperthermia
B. New onset of hearing loss
A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client reports a pain level of 6 on a scale from 0 to 10. Which of the following medications should the nurse administer? A. Celecoxib B. Oxycodone C. Ibuprofen D. Acetaminophen
B. Oxycodone
A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make? A. Raise chairs to keep knees lower than hips B. Perform pelvic rocking exercises several times per day C. Use the arm to pick up heavy items D. Sit in a hot tub for 30 min every morning
B. Perform pelvic rocking exercises several times per day
A nurse is collecting data from a client who has heart failure and edema of the lower extremities. Which of the following actions should the nurse take to monitor for pitting edema? A. Observe the skin color of the edematous areas B. Press firmly with the fingertips on edematous areas C. Lightly pinch the skin over the client's calf D. Compress the nail beds of the client's toes
B. Press firmly with the fingertips on edematous areas
A nurse is reinforcing teaching with a client who will collect stool specimens at home for fecal occult blood testing. Which of the following foods should the nurse instruct the client to avoid for 3 days before the test? A. Milk B. Red meat C. Almond D. Whole wheat bread
B. Red meat
A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a transfusion reaction? A. Straw-colored urine B. Temperature 38.8*C (101.8*F) C. Blood pressure 158/92 mmHg D. Apical pulse rate 58/min
B. Temperature 38.8*C (101.8*F)
A nurse in a pediatric clinic is collecting data from a school-age child and their parent. Which of the following findings should the nurse report as an indication of potential maltreatment? A. The child has bruises on the right shin. B. The child has symmetric burns on the feet. C. The child expresses a fear of failing in school. D. The child missed a dental cleaning the previous week
B. The child has symmetric burns on the feet.
A nurse is collecting data from a client who is 8 hr postoperative following an appendectomy. Which of the following manifestations is the best indication that the client needs a PRN analgesic? A. The client demonstrates a decreased attention span B. The client reports 7 on a scale of 0 to 10 C. The client's heart rate has increased to 110/min D. The client grimaces when changing positions
B. The client reports pain as 7 on a scale of 0 to 10
A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take? ***I guessed on this answer A. Position the knot of the rope at the top of the pulley B. Remove the weights for 20 minutes for the client's reports of severe pain C. Compare bilateral pedal pulses D. Apply 6.8 kg (15 lb) of weight for use in traction
C or D?
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 should expect to have diarrhea while taking this medication." B. "I can take antacids at the same time as this medication." C. "I will need to remain upright for 1 hour after taking the medication." D. "I have to take this medication on an empty stomach"
C. "I will need to remain upright for 1 hour after taking the medication."
A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take? A. Wipe from outer to the inner canthus after administering drops. B. Flush the eye with normal saline solution before administering drops. C. Apply pressure to the lacrimal punctum after administering the drops D. Position the child side-lying on the bed before administering the drops.
C. Apply pressure to the lacrimal punctum after administering the drops
A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium? A. Sweet potato B. Orange juice C. Baked chicken breast D. Cantaloupe
C. Baked chicken breast
A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics describe hyperactive bowel sounds? A. Sounds are soft and at a rate of 1/min B. Can be a result of paralytic ileus C. Can be the result of an early bowel obstruction D. Indicates decreased motility
C. Can be the result of an early bowel obstruction
A nurse is assisting with the admission of a client who has Vancomycin-resistant enterococcus of the urine. What isolation should the nurse implement for this client? A. Airborne B. Droplet C. Contact D. Protective
C. Contact
A 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. Ensure that an attorney has reviewed the client's advance directives B. Tell the client that a family member should serve as a healthcare surrogate C. Contact the facility's risk manager to verify if the client has a living will D. Document the client's decisions about end-of-life care in the medical record
C. Contact the facility's risk manager to verify if the client has a living will
A nurse is contributing to the plan of care for an older adult client. Which of the following physiological changes should the nurse consider when administering medication? A. Increased liver function B. Increased metabolism C. Decreased kidney function D. Decreased pulmonary function
C. Decreased kidney function
A nurse is collecting data from a client who is at risk for pulmonary embolism following surgery. For which of the following findings should the nurse monitor? A. Bradycardia B. Headache C. Dyspnea D. Hypertension
C. Dyspnea
Which of the following beverages contains the least amount of caffeine? A. Cola soft drink B. Instant coffee C. Hot cocoa D. Brewed green tea
C. Hot cocoa
Contraindication for oral contraceptive? A. Irregular menses B. Vaginal yeast infection C. Hypertension D. History of ectopic pregnancy
C. Hypertension
A nurse is caring for a client who states i feel we have a good relationship and you will keep my information confidential. I want you to know i am planning to commit suicide today. Which of the following responses should the nurse make?????not sure about this answer A. I won't tell anyone if you promise not to harm yourself B. Why do you think suicide is the answer to your problem? C. I can't keep a conversation like this to myself D. You should think about how your family will be affected
C. I can't keep a conversation like this to myself
A nurse is assisting with the plan of care for a child who has neutropenia. Which of the following interventions should the nurse include? A. Place the child in a room with negative pressure airflow B. Monitor the child's platelet count C. Inspect the child's skin daily for abrasions (risk of serious infection) D. Administer the varicella vaccine
C. Inspect the child's skin daily for abrasions (risk of serious infection)
A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase" of maternal adjustment. Which of the following manifestations should the nurse expect? A. Performs self-care independently B. Begins reconnecting with their partner C. Is eager to review the birth experience D. Tolerates physical discomforts
C. Is eager to review the birth experience
A nurse is completing post mortem documentation for a client. Which of the following information should the nurse include in the documentation? A. Location of the identification tag on the client's body B. Cause of the client's death C. Last set of the client's vital signs D. Copy of the client's advance directives
C. Last set of the client's vital signs
A nurse is caring for a client who has rheumatoid arthritis and is having difficulty with ADLs, such as cooking and eating. The nurse should ensure that the client has a referral to which of the following members of the interprofessional team? A. Dentist B. Nutritionist C. Occupational therapist D. Alternative care provider
C. Occupational therapist
A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse first take? A. Debrief staff members about the conflict B. Place the client in seclusion C. State expectations for the client's behavior D. Request security personnel restrain the client
C. State expectations for the client's behavior
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain which of the following adverse reactions can occur following the procedure? A. Tingling of the scalp B. Voice alteration C. Temporary memory loss D. Neck pain
C. Temporary memory loss
A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include? A. Encourage socialization during meal times. B. Elevate the head of the client's bed to 30 degrees. C. Tilt the client's head forward during meals. D. Provide three large meals per day
C. Tilt the client's head forward during meals
A nurse is assisting with a prenatal examination of a client who is at 8 weeks 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?
Chadwick's sign
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?
Choose a room that is well lit
A client is contributing to the plan of care for a client who has a new ileostomy. Which of the following actions should the nurse include?
Cleanse around the client's stomach with hydrogen peroxide
A nurse is reinforcing teaching with the parents of a newborn about bathing. Which of the following instructions should the nurse include in the teaching?
Cleanse the eyes from the inner canthus outward
DORSALIS PEDIS PULSE HOTSPOT SELECTION
D
A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following instructions should the nurse include in the teaching? A. "Carry your newborn back to the nursery in your arms when you need to rest" B. "Request that the nurses show their nursing license prior to removing your newborn from the room" C. 'Leave your newborn in the bassinet in your room while you use the bathroom" D. "Alert the staff if any of your newborns identification bands are missing"
D. "Alert the staff if any of your newborns identification bands are missing"
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 breathe in deeply at the beginning of each contraction." B. 'Help her focus on an object in the room." C. "Gently stroke her abdomen during contractions." D. "Apply steady pressure with this tennis ball to her sacral area"
D. "Apply steady pressure with this tennis ball to her sacral area"
A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching? A. "I should expect my stool to be formed" B. "I will irrigate the colostomy every day" C. "I will empty the pouch every 2 to 3 hours" D. "I will notify my doctor if the stoma starts to look purple"
D. "I will notify my doctor if the stoma starts to look purple"
A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "My partner and I will both use a condom during intercourse" B. "I will be able to remove my contraceptive sponge immediately after intercourse" C. "My partner and I will use petroleum jelly with latex condoms" D. "My partner will use condoms with spermicides"
D. "My partner will use condoms with spermicides"
A nurse is collecting data from a group of clients who have major depressive disorder. The nurse should identify that which of the following clients is at greater risk for suicide? A. A client who has psychomotor retardation B. A client who reports an inability to concentrate C. A client who experiences persistent insomnia D. A client who exhibits an increase in energy
D. A client who exhibits an increase in energy
A nurse is assisting with the plan of care for an older adult client who has dementia and is experiencing nocturnal confusion. Which of the following actions should the nurse take to decrease the client's risk of injury? A. Encourage napping during the daytime B. Keep overhead lights on through the night C. Minimize contact with the client D. Activate a bed alarm
D. Activate a bed alarm
A nurse is caring for a client who has been given methylergonovine intramuscularly for postpartum hemorrhage. The nurse should monitor for which of the following adverse effects? A. Uterine relaxation B. Elevated blood pressure C. Diarrhea D. Hematuria
D. Hematuria
A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include? A. Use confrontation to manage the client's behavior B. Use written signs to assist the client with locating the bathroom C. Provide a stimulating environment for the client D. Limit the number of choices for the client
D. Limit the number of choices for the client
A nurse is contributing to the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? A. Administer a client's nighttime dose of milk of magnesia. B. Educate a client about the use of an incentive spirometer. C. Obtain the diet history from a client who has heart failure D. Perform basic life support (CPR) for a client who has become unresponsive
D. Perform basic life support (CPR) for a client who has become unresponsive
A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings should the nurse identify as an indication that the client has HYPOglycemia? A. Extreme thirst B. Fruity breath odor C. Abdominal pain D. Rapid pulse
D. Rapid pulse
A nurse is reinforcing dietary teaching with a client who has cholecystitis. Which of the following food choices should indicate that the client understands the nurse's instructions? A. Cream of potato soup B. Peanut butter C. Dark chocolate D. Skim milk
D. Skim milk
A nurse is caring for a client who is receiving continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take? A. Elevate the arm B. Apply a warm compress C. Document the infiltration D. Stop the infusion
D. Stop the infusion
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 keeps a framed picture of his partner on the wall. B. The client reports no interest in dating C. The client attends a grief support group twice a month D. The client develops chest pain each time he talks about his partner
D. The client develops chest pain each time he talks about his partner
A nurse is providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family? A. To bury the client's body within 24 hr of their death B. To prohibit medical personnel from touching the client's body C. To stay with the client's body for 8 hr following their death D. To cremate the client's body
D. To cremate the client's body
A nurse at a long-term care facility is preparing to irritate a client's ear. Which of the following actions should the nurse take?
Direct the solution toward the wall of ear canal
A nurse is collecting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?
Draw a horizontal line through the space and sign at the end of the line.
A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?
Empty the client's ostomy pouch before removing the skin barrier.
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?
Encourage the client to be assertive
Pertusis manifestation...
Fever
A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the....
Frequent swallowing
Diabetic ketoacidosis expected finding?
Fruity breath odor
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has manifestations of meningitis. Into which of the following positions should the nurse assist the client?
Head flexed to the chest and her knees pulled up to her abdomen
A nurse is preparing to administer an antibiotic to a client who has pneumonia. After confirming that the client's assigned identification number matches the medication administration record, the nurse should use which of the following as a second identifier?
Home telephone number
A nurse is administering a pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?
Improved respiratory function
A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?
Increased urinary output
A nurse is reinforcing teaching with a newly licensed nurse about client privacy. Which of the following information should the nurse include in the teaching?
Information regarding client health can be emailed if encrypted
ABDOMINAL EXAMINATION TECHNIQUES (PLACE IN ORDER OF PERFORMANCE) A. Inspection B. Auscultation C. Light Palpation D. Deep palpation
Inspection, Auscultation, Light Palpation, Deep Palpation ... ?
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?
Measure the circumference of the client's upper leg
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
Memory loss that disrupts ADLs
A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?
Observe the movements of the client's chest wall
A nurse is supervising an assistive personnel (AP) to obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?
Oral suction equipment
A nurse 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?
Place a pillow under the child's head
A nurse is reviewing the medical record of a client who has COPD. Which of the following laboratory values indicates a need to request a dietary referral for the client?
Prealbumin 13 mg/dL
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
Remind the client of the day and time often.
A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who is on isolation precautions. Which of the following instructions should the nurse include in the teaching?
Roll used gowns inside out for disposal
A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Supplement spoken language with pictures
A nurse overhears assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take FIRST?
Tell the staff members to stop their discussion.
A nurse is collecting data from a client who uses a CPAP machine at night. Identify which of the following findings as an indication of proper CPAP use?
There is one finger width between the strap on the mask and the client's face. *Double-check answer*
