An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?
Ask the AP to discuss the issue in a private area
A nurse is supervising an assistive personnel (AP) 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 charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene?
Tells a client he will lose his phone privileges if he does not take his medication
A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include in the meal tray?
Roasted Salmon
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?
“Advance directives include a living will”
A nurse is collecting data from the caregiver of a client who has Alzheimer’s 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?
Encourage the client to take frequent walks during the day
A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply)
Assist the client to empty her bladder
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?
“Gently stroke her abdomen during contractions”
A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?
Use a moisture barrier on the client’s skin
A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client’s autonomy?
Allow the client to choose treatment times
A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?
Appears greenish-brown in color
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?
Inform the adolescent that he might experience a headache
A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by the client indicates an understanding of the teaching?
“I should discuss this document with my family after I sign it”
A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?
Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride
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?
Instruct the client to remain as still as possible during the recording
A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching?
“You should increase fluid intake to relieve dysuria”
A nurse is preparing to empty a postoperative client’s closed-wound drainage system. Which of the following actions should the nurse plan to take?
Compress the container before replacing the drainage plug
A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?
Administer the medication to the toddler each evening
A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship?
Defining responsibilities
A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate?
Lower left
A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
Suction for 30 seconds
A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client?
Hypotension
A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client’s identity?
Verify the client’s identity using a photograph
A nurse in a provider’s office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider?
“I try not to look at the scales on my body”
A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls?
Medication record
A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
Complete post mortem care for a client who has died
A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?
Skin rash with fever
A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching?
“I will instruct the client to sit when putting on a pair of pants”
A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge?
A client who has a sodium level of 140 mEq/L after one episode of diarrhea
A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Administer liquid supplements
A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
“I will document in the medical record the support nurse who assists with planning care for my clients”
A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider?
Urine output 12 mL/hr
A nurse is preparing the administer NPH (Novolin N) insulin to a client who has diabetes mellitus before breakfast at 0700. At which of the ff. times should the nurse plan to check the client for hypoglycemia?
1100
A nurse in a clinic is obtaining a health history from a client scheduled to un- dergo a cardiac catheterization in 2 days. Which of the ff. questions is the most im- portant for the nurse to ask?
“Do you know if you’re allergic to iodine?”
A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possi- ble latex allergy?
Rhinorrhea
A nurse in a provider’s office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the ff. statements by the client demonstrates understanding of the teaching?
“I will rinse my mouth after taking this medication”
A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client who is at risk for a deep thrombosis. Which of the following actions the AP is applying the stockings correctly?
The AP applies the stockings before getting the client out of bed
A nurse working in a provider’s office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is cor- rect?
“When all the blisters are scabbed over”
A nurse is caring for a client who just had blood drawn for an arterial blood gas analysis. Which of the ff. values should the nurse expect if the client is in respi- ratory acidosis?
PaCO2 51 mm Hg
A nurse is reinforcing teaching with a client who has a new prosthesis for an above the knee amputation of the right leg. Which of the ff. instructions should the nurse reinforce to the client?
Apply the prosthesis immediately upon waking each day
A nurse is preparing a client for the insertion of an NG tube. Which of the ff. actions should the nurse take?
Determine if the client has a deviated septum
A nurse is caring for a client who has a fractured radius and has a short arm cast applied yesterday. Which of the ff. findings should the nurse report to the provider?
Client report of decreased sensation in the finger
A nurse is contributing to the plan of care for a client who is on suicide pre- cautions. Which of the ff. interventions is appropriate for the nurse to recommend?
Encourage the client to sign a no-harm contract
A nurse is preparing to administer haloperidol (Haldol) 4 mg IM start to a client. Available is haloperidol for injection mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
0.8 mL
A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting, and fever with chills. Which of the following diagnostics tests should the nurse expect to be prescribed?
Cerebrospinal fluid analysis
A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements is appropriate for the nurse to make?
If you’d like to wear a wig, you should select it before hair loss occurs
A charge nurse in a long-term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first?
Confront the AP about suspected impairment
A nurse is caring a client who has asthma and has a prescription for theophylline (theochron) 200mg PO BID. Which of the following should the nurse include in the teaching?
Discontinue drinking caffeinated beverages
While a nurse is assisting a client to ambulate, the client reports lightheadedness and begins to fall. Which of the following nursing actions demonstrates a correct understanding by the nurse about ergonomic principles?
Spread feet apart and extend one leg for the client to slide down while lowering the client to the floor
A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client’s medications prior to contacting the provider. Which of the following medication is the likely cause of the increased sedation?
Lorazepam (Ativan)
A nurse is caring for a client who had a bronchoscopy and just arrived to the medical surgical unit. Which of the following actions should the nurse perform first?
Check for a gag reflex
A client is requesting information from a nurse regarding the appointment of a health care proxy. Which of the following responses by the nurse is appropriate?
The person you appoint will make health care decision for you if you cannot do so yourself
A nurse enters client’s room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse first?
Assist the client to a nearby waiting room
A nurse is interviewing clients as part of a skin cancer screening program. Which of the following statement made by a client indicates that he may have a premalignant lesion?
I have this flat, scaly area with red edge on neck
A nurse is caring for a client who reports 12 liquid stools in the past 8hr. Which of the following findings indicates that the client is experience dehydration?
Potassium level 2.5 mg/L
A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck. Which of the following should the nurse include?
Avoid exposing the neck to the cold
A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child?
“I will encourage my child to wear a bicycle helmet whenever bike riding”
A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit?
Orthostatic hypotension
A nurse is caring for a client who is recieving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client’s INR is 3.8.Which of the following actions should the nurse take?
Withhold the ordered dose of the medication
A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant’s room indicates a need for further teaching?
The infant is lying in the crib with a stuffed animal
A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B?
Performing oral hygiene
A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse evaluates that the client understands the teaching when she states she will gain
A..?
A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the following?
From onset of symptoms until 24 hours of antibiotic therapy
A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that the “felt something pop” when he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nurse take first?
Cover the wound with sterile saline-soaked gauze
A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan?
Increase counter traction every 24 hours.
Inspect the ropes, knots, and pulleys every 8 hours.
A nurse is using contact precautions while caring for a toddler. Which of the following actions should the nurse take?
Use a designated stethoscope for the toddler
A client’s daughter calls the nurse requesting information about her mother’s condition. The client’s chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse?
“You will need to contact your mother directly about her condition”
A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam. Which of the following should indicate to the nurse the child is not current with the minimum required immunization?
One MMR vaccine
A nurse is reinforcing teaching with a new mother on facility security measure. Which of the following statements by the mother indicates that the teaching was effective?
“I will have an identification band that matches the one my baby wears”
A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she
Develops edema of the ankles
A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate?
Monitor the client’s skin integrity on a regular schedule
A nurse is working on a mental health unit is reviewing policies for client seclusion. For which
of the following is seclusion appropriate?
Aggressive behavior
A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first?
A client who has COPD and dementia and was agitated during the night shift
A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use?
Leave space between the tip of the penis and the end of the condom catheter
A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?
Ask the client to flex the hips and knees
A nurse is supervising an assitive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take?
Reinforce safe meal setup techniques
A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client’s understanding of the teaching when the client states, “I will
Install gates at the top and bottom of the stairs
A nurse is preparing a sterile field to peform a dressing change. Which of the following actions should the nurse take?
Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field
A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states,
“I guess I have to take some of the blame because of the way my friends and I dress”
A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client?
4 tablets
A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching?
“I will walk barefoot to prevent slipping”
“I will check my smoke alarms once a month”
A Client with emphysema asks the nurse why he has difficulty exhaling. Which of the following statements by the nurse is appropriate?
“Your windpipe is inflamed and constricted”
A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client?
Irritability
A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparartion classes. Which of the following responses by the nurse supports the partner’s involvement during labor?
“Breathing with your partner will help her to relax during contractions”
A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first?
Remove the tracheostomy inner cannula
A nurse in a provider’s office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching?
Wash the bed linens in hot water.
Clean the child’s toys with 1:10 bleach solution.
A nurse caring for the mother of a newborn finds the client crying in her room. The client tells th nurse, “I don’t think I can handle caring for a baby.” Which of the following nursing interventions is appropriate?
Encourage the client to share her feelings
A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identity
Chromosomal abnormalities
A nurse is caring for client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching?
Nicotinic acid (niacin)
A nurse is caring for a client who is 12hr postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first?
Massage the fundus.
Obtain the client’s vital signs.
A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer?
1.5 mL
A nurse is caring for a child who has terminated cancer. Which of the following responses by the child’s school-age brother should the nurse expect?
Believes his bad behavior is causing his brother’s death
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal?
Lorazepam
A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy?
16 lb
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure?
Disorientation
A nurse is caring for an adolescent client who has bulimia nervosa. Which of the following actions should the nurse take first?
Observe the client during and after meals
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 preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroplasty. Which of the following information about the client should the nurse include in the report?
Time of last pain medication
An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict?
I will plan to avoid grapefruit juice while taking this medication
A nurse is reinforcing teaching with a client who has arthritis. Which of the following instructions should the nurse include in the teaching?
Engage in low-impact aerobic exercises
A nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
Secure the tubing with adhesive tape to the lower abdomen
A nurse is assisting with a support group for clients who have experienced intimate partner violence. The nurse should identify which of the following client statements as indicating the greatest risk for violence?
I have decided to tell my husband I am leaving him
A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse expect?
Hypotension
A charge nurse working in a long-term care facility overhears two AP’s in the nurses’ stations discussing a client who was just admitted. Which of the following actions should the charge nurse take?
Tell the APs to stop the conversation
A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements made by the client indicates an understanding of the teaching?
I will feel a warming sensation after injection of the dye
A nurse is assisting with the plan of care for a client who has end-stage amyotrophic lateral sclerosis and has developed pneumonia. Which of the following actions should the nurse take?
Verify the status of the client’s advance directive
A nurse is reinforcing teaching with a new mother on facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
I will have an identification band that matches the one my baby wears
A nurse working at an inpatient mental health facility is contributing to the plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care?
Record the amount of food the client consumes
A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following statements indicates any understand of the teaching?
I will dispose of my needles in a plastic laundry detergent container
A nurse is visiting the home of a client who recently had a total hip arthroplasty. During Observation of the clients’ home, which of the following findings places the client at risk for falls? (select all that apply.)
Medication stored on the top shelf of the cupboard.
Client walks barefoot in the house.
A nurse is reinforcing teaching with a client who has a new prescription for nitro- glycerin (nitrostat) sublingual tablets for treatment of angina. Which of the following instructions should the nurse include?
Take up to three tablets during a single angina episode
A nurse is caring for a client who has right-sided heart failure. The client’s partner expresses concern that the client will die. Which of the following is an appropriate re- sponse by the nurse?
“It is difficult to see someone so sick. What have you been told about your partner’s prognosis?”
A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increase fatigue. Listen to the audio clip. Which of the following lung sounds should the nurse report to the provider?
Fine crackles
A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa (Epogen). Which of the following instructions should the nurse include?
Administer the medication subcutaneously
A nurse is caring for a client who has a Salem Sump tube connected to intermittent wall suction. Which of the following nursing interventions should the nurse perform?
Reposition the client every 2 hours
A nurse is provider’s office is reviewing pediculosis capitis management and pre- vention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (select all that apply)
Store the child’s clothing in a separate cubicle when at school.
Boil brushes and combs in water for 10 min.
Dry bed linens and clothing for at least 20 mins.
A nurse is contributing to the plan of care for an adolescent who has cystic fibrosis. Which of the following diets should the nurse recommend?
High-calorie
A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the medical record to the locate information about the clients personal health insurance?
Admission sheet
A nurse is reinforcing teaching with a client who has a new prescription for pred- nisone for the treatment of Addison’s disease. Which of the ff. instructions should the nurse include?
“You will need to schedule a bone density test”
A nurse is assisting in the admission of a client who has diabetic ketoacidosis to a medical unit. Which of the ff. IV solutions the nurse anticipates administering first upon admission?
0.9% sodium chloride
A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings is the priority?
Tingling around the mouth
A client who has asthma and is started on montelukast (Singular) returns to the clinic 1 month later. Which of the ff. indicates that the client is complying with this medication regimen?
The client takes the medication once daily at bedtime
A nurse is collecting data from an older adult client who is receiving a unit of packed RBCs. Which of the ff. findings should the nurse report to the provider as an indication of circulatory overload?
Crackles heard on auscultation
A nurse is preparing a client for surgery. The client states, “I’m sure this surgery will not help me get better.” Which of the ff. responses by the nurse is appropriate?
“You’re saying that you are doubtful that this procedure will benefit you”
A nurse is preparing to provide suctioning for a toddler who has a tracheostomy. Which of ff. actions should be included in the plan of care?
Allow the child to rest for 45 seconds between aspirations
A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suction. Which of the ff. supplies does the nurse need to perform this task?
Yankauer catheter
A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions by the nurse is appropriate?
Wear a surgical mask within 3 feet of the client
A nurse is collecting data from a client who has cholecystitis. In which of the ff. lo- cations should the nurse expect the client to report pain?
Right upper quadrant
The parents of a 12-month-old voice their concern that their child is crawling but not pulling herself up to stand like the other children at the day care center. The nurse should recommend to the parents that they
Have the child evaluated by a pediatrician
A nurse recognizes that nurse-client communication is effective when the client.
Asks the nurses to listen to potential solutions
A nurse is caring for a client who is receiving IV fluids. As the nurse enters the room, the IV pump’s alarm begins beeping. The client tells the nurse, “That happens all the time. Just turn off the alarm.” Which of the ff. actions should the nurse take first?
Observe the IV site
A nurse is caring for a client who is scheduled for colonoscopy with polyp removal. Which of the following client statements should alert the nurse that the client may be at risk for complications from the procedure?
“I needed three ibuprofens for my arthritis pain last night”
A nurse is reinforcing teaching with the parents of a newborn about physical assessments. Which of the ff. statements by the parent demonstrates understanding of the newborn hearing screening test?
“If my baby fails the hearing test, he will need to be tested in 3 months”
A nurse is reviewing instructions with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the client should take after washing his hands. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must used.)
A. Expose the glans of the penis
B. Cleanse the penis using aseptic swab
C. Begin urination
D. Pass the cup into the urine stream
E. Move the cup out of the urine stream
F. Move the cup out of the urine stream
G. Replace the foreskin
(IDK if in right order??)
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the ff. actions should the nurse take?
Provide step-by-step instructions for performing ADLs
A nurse is reinforcing teaching about breastfeeding with a pregnant client. Which of the ff. statements by the nurse is appropriate?
“Breastfeeding reduces the infant’s risk of infection”
A nurse is reviewing client positioning for a thoracentesis with a newly licensed nurse. The nurse validates that newly licensed nurse’s understanding when he indicates that the client should be placed in which of the ff. positions for the procedure?
Leaning forward over pillows
A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of car seat. Which of the following statements by a parent indicates an understanding of the teaching?
“I can place a rolled towel on each side of my newborn’s head until he can hold his head up”
A nurse is preparing to apply a pulse oximeter to a client’s finger. Which of the following actions should the nurse take before applying the sensor?
Check the client’s capillary refill
A nurse is caring for a client who is asking about the technique of eTheurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique?
“It is a light stroking of the skin during a uterine contraction”
A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing postoperative pain. Which of the following is an adverse effect of this medication?
Urinary Retention
A nurse is administering medication. A client states, “I know that the Inderal helps my blood pressure, but I don’t like the way it makes me feel. I don’t think I’ll take it today.” Which of the following actions should the nurse take?
Asks the client to describe what he is experiencing
A nurse is reinforcing teaching with a client regarding the use of guided imagery to relieve back pain. Which of the following statements made by the nurse is appropriate?
“Think about a pleasant memory as you visualize your pain floating away”
A nurse is caring for an older adult client who is postoperative following a total hip replacement.
The client is incontinent of stool and urine.
To prevent skin breakdown, the nurse should apply moisture-absorbing undergarments.
A client comes to the clinic with reports to nasal congestion. Which of the following medications should the nurse anticipate that the primary care provider will prescribe?
Pseudoephedrine (Sufaded)
A nurse is provider’s office is reinforcing teaching to the parents of a school-age child who has an ankle sprain. The nurse should include which of the following statements in the teaching?
“Offer aspirin every 4 hours for discomfort”
“Elevate the affected extremity to a level higher than the heart”
A nurse is caring for a client with a closed head injury. Which of the following findings should indicate to the nurse a need for futher data collection?
Inappropriate words when speaking.
Sharp sensation when touched with safety pin point.
A nurse is reinforcing teaching regarding management of penetrating eye injuries with a parent of a school-age child during a sports physical. Which of the following statements by the child’s parent indicates an understanding of the teaching?
A or C?
A nurse is reinforcing teaching to the parents of an infant who has pavlik harness. Which of the following statements should the nurse include in the teaching?
“The harness promotes hip joint development”
A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the client is most in need of intervention?
States he is being told to hit his roommate
A nurse is reinforcing teaching for a client who has just started taking amitriptyline (Elavil). Which of the following should the nurse include as an adverse effect of this medication?
Orthostatic hypotension
A nurse in a long-term care facility is caring for a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime sleepiness. Which of the following actions should the nurse take first?
Check for proper fit of the mask on the CPAP machine.
Provide activities during the day to stimulate the client.
A nurse is caring for a client in the provider’s office who has is experiencing an episode of acute asthma. The nurse should aminister which of the following medications?
Traimcinolone (Azmacort)
A nurse is assisting with the care of a client who is recieving IV therapy of 0.9% sodium chloride. The client recieved 200mL more than prescribed in 1 hr because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because
The client was not harmed as a result of the incident
A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat laryngeal cancer and has developed mucositis. Which of the following client statements indicates an understanding of the teaching?
“I will rinse my mouth with room-temperature saline solution”
A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hr postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage?
Frequent swallowing
A nurse is caring for an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?
Absence of menses.
Elevated blood pressure.
A nurse has administered cephalexin (Keflex) to a client. Which of the following is the earliest indicator of an anaphylatic reaction?
Wheezes.
Hypotension.
A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention?
Place the client in a room that is ventilated to the outside
A nurse is providing change-of-shift report on four clients. Which of the following is most important for the nurse to include in the report?
A client had a blood glucose of 140 mg/dL
A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and regulat insulin (humulin R) 15 units SQ. Which of the following actions should the nurse perform first?
Inject 10 unites of air into the NPH insulin vial
A nurse discovers a fire in the trash can of a client’s room. Which of the following actions should the nurse take first?
Escort the client to a secure area
A client has a large, deep ulcer on her right hip. The primary care provider has prescribed a woman vacuum to be applied. Which of the following is an appropriate nursing action?
Maintain hydrophillic material deep into the ulcer
A nurse is reinforcing teaching to a client who has been taking dig 0.25 mg PO daily for 6 months, which of the following indicates a need for further teaching?
I will call my provider if I experience a yellow tinge to my vision
A nurse receives a verbal order for a client to receive a stat dose of meperidine (demerol) 100 mg PO. She administers the medication, charts the administration, and then realizes she has administered Phenytoin (dilantin) 100 mg PO. After obtaining the client’s vital signs, which of the following actions should the nurse take?
Notify the provider
A nurse is administering medication to a client. Which of the following actions is appropriate for the nurse to take?
Verify with another nurse when calculating a new dose of medication
A nurse is reinforcing discharge teaching to a client who is prescribed propylthiuracil. For which of the following should the nurse instruct the client to monitor and report to the provider immediately?
Sore throat
A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following clients’ statements indicate to the nurse a need for further teaching?
“I will soak my feet in warm water every night”
A nurse is caring for a client who has heart failure and is taking furosemide (lasix). Which of the following statements made by the client indicates a need for the nurse to intervene?
“I have to sleep sitting up”
A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching?
“I will leave the patch on for 12 to 14 hours each day”
A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error?
Incident report
A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement?
Take the client for a walk to the recreation room
A nurse is caring for a client who is in bed and experiencing a toni-clonic seizure. Which of the following actions should the nurse take?
Place the bed in the lowest position
A nurse is preparing to irrigate a wound of a client who has methicillin-resistant Staphylococcus aureus (MRSA).The nurse should use which of the following personal protective equipment?
A face shield
A nurse is collecting data for a client who has been recieving medroxyprogesterone acetate (Depo- Provera) for the past 6 months. Which of the following statements made by the client should be reported to the provider?
“I’m experiencing calf pain”
A nurse is reinforcing teaching with a new mother regarding the use of breast milk. Which of the following statements by the mother indicates an understanding of the teaching?
“I can store my breast milk in the freezer for up to 6 months”
A nurse in a long-term care facility is caring for a client who has spinal cord injury. The client is demonstrating manifestations of autonomic dysreflexia. Which of the following actions should the nurse take first?
Check the client for bladder distention.
Loosen the client’s clothing.
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 teaching?
Skim milk
A nurse is caring for a client who has a new mastectomy. Which of the following statements by the client should indicate to the nurse that the client is beginning to cope with the changes in her body image?
I am afraid to discuss my concerns with my husband
A nurse is caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?
Establish a daily exercise routine
pn comprehensive predictor 2023 quizlet
ati pn comprehensive predictor ngn
ati pn comprehensive predictor quizlet
ati pn comprehensive predictor study guide
vati pn comprehensive predictor assessment
ati pn comprehensive predictor practice test
pn comprehensive online practice 2023 a with ngn quizlet
ati comprehensive predictor ngn quizlet