a nurse is caring for a client who is taking alprazolam. Which of the following prescriptions should the nurse clarify with the provider?
ceftriaxone
a nurse is assessing a client who is postoperative following abdominal surgery. The client states “I feel like my incision ripped open” the nurse notes dehiscence of the incision. which of the following actions should the nurse take?
place the client in a low-fowlers position
a nurse is caring for a client who is receiving radiation therapy through a sealed implant. Which of the following actions should the nurse take?
wear a lead apron when providing care for the client.
a nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take?
apply the tourniquet 15 cm above the insertion site
a nurse is administering medications to a client who has dysphagia and a new prescription for divalproex sodium extended release tablets. which of the following actions should the nurse take?
administer the medication with applesauce
a nurse is completing a dietary assessment for a client who is jewish and observes kosher dietary practices. which of the following behaviors would the nurse expect to fine?
meat and dairy products are eaten separately
a nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears agitated and apprehensive. The nurse identifies that the client is in the arm stage of general adaptation syndrome and should expect which of the following findings.
tachycardia
a nurse is caring for a client who has a femur fracture and is on bedrest with bucks extension traction. which of the following actions should the nurse take?
inspect the clients skin under the device every 8 hours
a charge nurse is creating assignments for the next shift for several nurses and one of them is pregnant. which of the following clients should the charge nurse assign to a nurse who is not pregnant?
60 year old client who is recovering from shingles
a nurse is caring for a client who has a partial laryngectomy and is receiving continuous internal feeding at 65 ml/hr through a gastrostomy tube. which of the following findings requires immediate intervention by the nurse?
the client is lying in a supine position
a nurse is teaching a client about smoking cessation. Which of the following client statements should the nurse identify as an understanding of the teaching?
I will set a specific date to stop smoking
a nurse has been caring for a female client who has bruises on her arms that are a result of physical abuse by her partner. The client states “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave” Which of the following is an appropriate nursing intervention?
help the client to recognize the signs of escalation of abusive behavior
a client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravid 2, para 2, and her blood type is AB negative. The newborn’s blood type is B Positive. which of the following statements is appropriate?
you should receive Rh immune globulin within 72 hours of delivery
a client hospitalized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. the clients sibling comes to visit but has obvious manifestations of an upper respiratory infection. which of the following nursing actions is appropriate at this time?
allow the sibling to visit after donning a sterile gown, mask, gloves, but prohibit physical contact
a nurse is planning care for a client who takes haloperidol for the treatment of schizophrenia. which of the following should the nurse include in the plan of care?
screen the client for tardive dyskinesia
a nurse is performing a vision screening for a client. which of the following findings should the nurse identify as an indication that the client has cataracts?
increased opacity of the lens of the eye
a nurse is caring for a client who reports difficulty falling asleep at night. which of the following actions should the nurse take?
schedule routine care tasks during the hours when the client is awake
a nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. which of the following should the nurse recommend the client increases in their diet during lactation?
calcium
a nurse is providing nutritional counseling to the parents of a toddler. which of the following instructions should the nurse include in the teaching?
offer snacks throughout the day
a nurse is assessing a clients cardiovascular system. identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic valve.
option A
A nurse is planning to perform wound irrigation for a client who has an open secondary wound. when creating a sterile field. which of the following actions should the nurse take?
place the lid of a bottle sterile solution with the sterile field
a nurse is planning an education session for a client who has type 1 diabetes mellitus. which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?
diaphoresis
a nurse is instructing a group of newly hired nurses about medication to promote fetal lung maturation. which of the following medications should the nurse include in the instructions?
betamethasone
a nurse is caring for a client who has atypical depression and is taking phenelzine. which of the following is appropriate for the nurses to offer as an evening snack?
low fat yogurt
a nurse is planning care for a newborn who is receiving phototherapy. which of the following actions should the nurse include the plan of care?
assess the infants eyes for corneal irritation every 4 hrs
a nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops a hemolytic reaction. which of the following actions should the nurse perform?
infuse 0.9% sodium chloride IV
a nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. which of the following referrals should the nurse make?
social worker
a nurse from the state health department is instructing a group of nurses regarding infections. which of the following infections should the nurse report to the centers for disease control and prevention?
Lyme disease
a nurse is preparing to provide education about electroconvulsive for a client who has major depressive disorder. which of the following should the nurse include in the teaching?
a general anesthetic is administered prior to ECT treatment
a nurse is teaching a client and their family about home hospice care. which of the following information should the nurse include in the teaching?
hospice care improves quality of life through palliative care
a nurse is preparing to administer an enteral feeding via NG tube for a client the day after verifying placement of the tube using a chest x-ray. which of the following methods should the nurse use to confirm placement prior to initiating the feeding?
test the pH level of the clients gastric aspirate
a nurse is assessing a client who has non-hodgkins lymphoma. which of the following findings should indicate to the nurse that the clients might be experiencing syndrome of inappropriate antidiuretic hormone?
diminished deep tendon reflexes
a nurse received change of shift report on four clients. based on the shift report information. which of the following clients would the nurse plan to assess first?
a client who had a hip arthroplasty reports pain and erythema in their calf
a nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. when reviewing the clients medical history, the nurse should recognize which of the following diagnosis as a contraindication to the administration of methylergonovine?
hypertension
a nurse is caring for a client who is undergoing peritoneal dialysis and notes that the dialysate outflow has become cloudy. which of the following complications of this procedure should the nurse suspect?
peritonitis
a home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. which of the following information should the nurse include in the teaching?
allow the infant to suck on the pacifier during feedings?
a nurse in an inpatient psychiatric unit is setting short-term goals for an adolescent client who was admitted for treatment of anorexia nerves. which of the following is an appropriate short-term goal the nurse should set?
the client will develop a personalized meal plan
a nurse is preparing to witness a clients signature on an informed consent for a total knee arthroplasty. which of the following client statements indicates the nurse should contact the surgeon?
“I am thankful there are no serious complications from this type of surgery”
a nurse is caring for a client who reports chest pain. which of the following laboratory findings indicates myocardial damage?
troponin 1.8ng/ml
a nurse is caring for a school-age child who has a blood pressure of 88/50 mmhm and develops septic shock. which fo the following medications should the nurse expect the provider to prescribe?
dopamine
a nurse is caring for a client who is receiving a controlled epidural analgesia infusion. which of the following nursing actions is appropriate?
covering the insertion site with a transparent dressing
a nurse discovers that the wrong dosage was given to a client. when determining what action to take, the nurse should recognize that which of the following ethical principals should be applied?
veracity
a nurse notices smoke coming from a clients room and discovers a fire in the wastebasket. after moving the client to safety. which of the following is the priority action?
notify the facility operator
a home health nurse is teaching the parents of a school-age child who has legs-calve perches disease. which of the following information should the nurse include?
your child should continue to attend school
a nurse in the post anesthesia care unit is caring for four postoperative clients. the nurse realizes that coughing poses a risk to which of the following clients?
a client who had a thyroidectomy
a nurse in a mental health facility is interviewing a newly admitted client. which of the following actions should the nurse take when conducting the interview?
insist the client use direct eye contact during the interview
a nurse on a medical unit has just received change-of-shift report. which of the following clients should the nurse assess first?
a 68-year old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10
a nurse is caring for a client who has just returned to the unit following a bronchoscopy. which of the following actions by the assistive personal requires the nurse to intervene?
offer oral fluids to the client
a nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. after establishing trust and rapport. which of the following should the nurse say?
“lets talk about what happened to you”
a client at 38 weeks of gestations enters the emergency department. the nurse should recognize that which of the following indications that the client is in the latent phase of labor?
the cervix is dilated 2cm
a nurse is caring for a client who is 2hr postoperative following an ideal conduit procedures for bladder cancer. for which of the following findings should the nurse notify the provider?
a dusky-colored stoma
a nurse is teaching a client who has a low-literacy level about home management of diabetes mellitus. which of the following actions is appropriate?
show the client an educational video
a nurse is caring for a group of clients. the nurse should request a referral for a speech language pathologist for which of the following clients?
a client who has difficulty swallowing
a nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate by continuous IV infusion. which of the following client findings medication toxicity?
urine output 20 ml/hr
a nurse is assessing a client who has pneumonia. which of the following findings is priority for the nurse to report to the provider?
a change in vocal tone after drinking liquids
a nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. which of the following instructions should the nurse include?
try to have your baby empty your breasts with each feeding
a nurse is caring for a client who will be receiving a transfusion of platelets. the nurse recognizes that the expected outcome of this treatment will be which of the following?
decreases in bleeding from puncture sites
a nurse is caring for a client who has just given birth to a stillborn newborn. which of the following is the priority task for the nurse to facilitate in the clients grief process?
acknowledging the reality of the newborns death
a nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. which of the following interventions should the nurse include?
place the newborn 45cm (18in) from the light source
a nurse is precasting a nursing student who brings the following client observations to the nurses attention. which of the following clients should the nurse assess first?
a client who is coughing up pink tinged sputum following a bronchoscopy and lung biopsy 1 hr ago
a nurse in a pediatric unit is caring for a group of clients. for which of the following disease should the nurse implement droplet precautions?
pertussis
a nurse is planning to delegate a client assignments to an assist personnel. which of the following tasks is appropriate for the nurses to delegate?
collecting a urine specimen
a nurse is caring for a toddler who has respiratory syncytial virus. which of the following actions should the nurse plan to take?
use a designated stethoscope when Caring for the toddler
a nurse is assessing a client who has 2, para 1. the client is at 41 weeks of gestations and is receiving oxytocin for the augmentation of labor. the nurse should decrease the infusion rate for which of the following findings?
contractions occur every 90 seconds
a nurse is caring for a client who has fractures ribs, has developed thrombophlebitis, and is being treated with a heparin drip. the client develops hematuria and has an activated partial thromboplastin time of 100 seconds. which of the following actions should the nurse take first?
turn off the heparin drip
a nurse is providing teaching to the parent of a 6-month old infant who is teething and having difficulty sleeping. which of the following instructions should the nurse include?
“administer acetaminophen drops to your child before bedtime”
a nurse is admitting a client who has antisocial personality disorder. which of the following clients behaviors should the nurse identify as consistent with this disorder?
uses other for personal gain
a nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. which of the following information should be included?
-newborn swallowing sounds are audible while breastfeeding
-newborns stools are yellow and seedy after 7 days of breastfeeding
-maternal breasts become soft following feedings
a nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. which of the following is the highest priority for the client to report to the provider?
fever
a nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. which of the following statements by the client indicates that the teaching has been effective?
“I will use my cell phone on the ear opposite of my pacemaker”
The nurse is caring for a client who is receiving lactated ringers to treat fluid volume deficit. the nurse should identify that which of the following findings indicates a therapeutic response to the treatment?
increased hemoglobin and hematocrit levels
a nurse is caring for a client who is receiving systematic desensitization therapy to treat agoraphobia. which of the following client statements should indicate to the nurse that the treatment has been effective?
“I was able to sit on a park bench for 30 minutes”
a nurse is assessing a client who has pericarditis. which of the following findings is the priority?
paradoxical pulse
a nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1hr ago. which of the following is an appropriate intervention?
support the affected leg on a pillow
a nurse is caring for a client who is taking allopurinol. the nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication?
uric acid level
a nurse is assessing a client prior to performing a blood draw. the nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex?
avocados
a nurse is delegating tasks to an assistive personnel. for which of the following clients should the nurse have the AP measure vital signs?
a client who is requesting pain medication 2 days after surgery
a nurse is caring for a client following an open colectomy. which of the following findings places the client at risk for delayed wound healing?
hyperemesis
a nurse is caring for a client who has cirrhosis of the liver. which of the following actions should the nurse take?
monitor fort abdominal ascites
a nurse is preparing to discharge a client who is to be transferred to a long-term care facility. the nurse should recognize that which of the following actions is a breach of client confidentiality?
discussing the clients reaction to the transfer with another staff nurse
a nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion.
occlude the IV tubing above the injection port
a nurse is caring for a client who has a new prescription for lithium carbonate. prior to administering the first dose, which of the following laboratory values should the nurse evaluate?
thyroid hormones
a nurse is caring for four clients. which of the following tasks can the nurse delegate to an assistive personnel?
perform chest compressions during cardiac resuscitation
a client asks the nurse if it is safe to take a glucosamine supplement. the nurse should assess for which of the following potential contraindications?
shellfish allergy
a nurse is caring for a client who has a chest tube and notes continuous bubbling in the water-seal chamber. which of the following actions should the nurse take?
observe the system for an air leak
a nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. which of the following instructions is appropriate for the nurse to include in the plan of care?
initiate droplet precautions for this client
a nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. which of the following is an appropriate nursing action?
check ortho BP 1hr after administration
a nurse is planning care for a child who is unresponsive and has increased intracranial pressure. which of the following actions should the nurse take?
pad the side rails of the bed
a nurse is providing dietary teaching to a client who has an increased cholesterol level. which of the following foods should the nurse recommend?
egg whites
a nurse is caring for a client who has meningitis. which of the following assessments should the nurse perform?
brudzinzkis sign
a nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. which of the following findings should the nurse report to the provider?
magnesium 9 meq
a nurse is teaching a client who has a new prescription for digoxin. which of the following statements should the nurse include in the teaching?
“report a weight gain of one-half pound per day”
an infection control nurse is reviewing the medical records of several clients. which of the following infections should the nurse report to the centers for disease control and prevention?
syphillis
a nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. which of the following actions should the nurse take?
apply pressure to the lacrimal punctual for 1 min following administration
a nurse is caring for a client who has schizophrenia. the clients states “run cats soon the rain throwing procedure mechanical paper lake.” the nurse should document that the client is demonstrating which of the following speech alterations?
word salad
a nurse is discussing a living will with a client. which of the following statements by the client indicates an understanding of this document?
“it will communicate my wishes for end of life care”
a nurse is planning care for a client who has anew diagnosis of dysphagia. which of the following foods should the nurse recommend?
oatmeal
a nurse is assessing a client who is 8 hr postoperative following a right modified radical mastectomy. which of the following should the nurse recognize as the priority finding?
coughing frothy, pink secretions
a nurse is caring for a client who has s diagnosis of antisocial personality disorder. the nurse should expect the client to demonstrate which of the following?
poor impulse control
a nurse is assessing a client who has delirium due to a febrile illness. which of the following findings should the nurse expect.
hallucinations
a nurse is providing care for a newly admitted client. which of the following interventions should the nurse plan to take?
Intiate iv access for the client
a home health nurse is admitting a client who has prescribed peritoneal dialysis. which fo the following actions should the nurse take first?
clarify the clients actual and perceived health needs
a nurse is assessing a client for pitting edema. when pressing into the dorsal side of the clients foot, the nurses fingers leaves a depression in the skin that is 8mm (0.3 in) deep. with which of the following clarifications should the nurse document this finding?
4+ edema
a nurse is caring for a client following a possible exposure to anthrax. which of the following actions should the nurse take?
begin prophylactic treatment with cirpofloxacin
a nurse is creating a plan of care for a client who has anorexia n nervosa. which of the following interventions should the nurse include in the plan?
monitor the client for 1 hour after meals
a nurse is caring for a client who is receiving gentamicin. which of the following findings indicates the client is developing toxicity?
tinnitus
a nurse is preparing to discharge a newborn who has an atrial septal defect. the nurse should expect the provider to refer the client to which of the following Interprofessional team members?
case manager
a nurse is assessing an adolescent who has anorexia nervosa. which of the following findings should the nurse expect?
hyokalemia
a nurse is admitting a client to the medical surgical unit. which of the following actions should the nurse take first?
observe the clients level of mobility
a nurse is teaching a group of farmworkers who works with pesticides about minimizing exposure. which of the following information should the nurse include in the teaching?
change clothes after working in the field
a nurse is caring for a client who is manic. which of the following activities is appropriate for the nurse to suggest?
taking a daily walk on the hospital grounds
a nurse is performing triage following a natural disaster. which of the following clients should the nurse identify as the highest priority to receive care?
a client who has a traumatic arm amputation
a nurse in the clinic is providing information to a client who has mastitis of the left breast. the client asks the nurse, “does this mean that I must stop nursing my baby?” which of the following is an appropriate statement by the nurse?
“no, you can continue to nurse from both your breasts”
a community health nurse us caring for a client who requests a referral for family therapy. the nurse should initiate a referral to which of the following members of the interdisciplinary team?
social worker
A nurse on an orthopedic floor is completing the morning assessments on several clients. which of the following clients has the greatest risk for fat embolism syndrome (FES)?
a 24-year old make who has a casted femur fracture
a nurse is assessing a full-term newborn who is 24 hr old. which of the following findings should the nurse report to the provider?
the newborn scleras have a yellowish tint
a nurse on mental health unit receives report on four clients. which of the following clients should the nurse attend to first?
a client who has begun to demonstrate catatonic behavior
a nurse is setting up a sterile field for a dressing change on a postoperative client. which of the following actions should the nurse plan to take to maintain the sterile field?
open the first flap of the sterile package away from the nurses body
a nurse is teaching the parent of an infant about the manifestations of food allergies. the nurse identify which of the following findings as a common manifestations of a food allergy?
vomitting
a nurse is assessing a client who has systemic lupus erythematous (SLE). which of the following is an expected finding?
dry raised facial rash
a nurse is preparing to administer enoxaparin to a client. which of the following actions should the nurse plan to take?
inject the medication in the lateral abdominal wall
at the beginning of the day shift, a team leader delegates the following tasks to the assist personal (AP): bathe four clients, distribute fresh water, and obtain morning vital signs. at noon, the nurse asks the AP to transport one client to physical therapy. the AP reports too clients still need bed baths. which of the following is an appropriate strategy for the nurse to delegate more effectively in the future?
set a clear time frame for the completion of each tasks
a nurse manager at a public health clinic is concerned about the rising n umber of sexually transmitted infections in the community. the purpose of which of the following id to generate new ideas to address the public health concern?
a brainstorming session with nurses
a home health nurse is reviewing treatment goals with a client who has diabetes mellitus. the nurse should evaluate which of the following laboratory test to determine effective long-term management of blood glucose levels?
HbA1c
a nurse is teaching a client who is to start taking phenelzine for major depressive disorder. which of the following foods should the nurse teach the client to avoid consuming while taking this medication?
cheddar cheese
a nurse is about to administer an injection to a client when the client states, “I don’t want that injection. the last time I got that I was sore for a week.” the nurse goes ahead and administers the injection against the clients wishes. The nurse committed which of the following?
battery
a nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. which of the following findings should the nurse expect?
hyperreflexia
a community health nurse is performing a vision screening on a 4-month-old infant. when shining a light source into the infants visual field. which of the following is an expected finding?
the infant closes their eyes
a nurse is assessing a client who has pneumococcal pneumonia. which of the following findings should the nurse expect?
tachypnea
a nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. the Nurse should include which of the following as a potential adverse effect of the medication?
burning
aerobis culture from a client who has a draining pressure injury. identify the sequence of actions in order of performance.
-assess the appearance of the wound
-cleanse the wound with 0.9% sodium chloride irrigation
-obtain the specimen from granulation tissue of the wound
-place the swab in the culture tube
-cover the wound with a sterile dressing
a nurse is caring for a group of clients in an inpatient mental health facility. which of the following tasks should the nurse delegate to an assistive personnel?
sit with the client who has anorexia nervosa during meals
a nurse is assessing an infant who has water intoxication. which of the following findings should the nurse expect?
generalized edema
at the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. which of the following client reports should the nurse assess first?
indigestion
a nurse is caring for a group of clients. which of the following clients should the nurse identify as being at risk for metabolic alkalosis?
a client who has kidney failure
a nurse is assessing a client who has COPD and experienced recent weight loss. which of the following findings should the nurse report to the provider immediately?
coughing and wheezing after eating
A nurse is providing teaching about car seat safety to the parent of a term newborn. which of the following statements by the parent indicates an understanding of the teaching?
“I should place a rolled blanket along each side of my babies head in the car seat”
a nurse is caring for a postoperative client. which of the following interventions will reduce the risk of deep-vein thrombosis?
apply venous plexus foot pumps
a community health nurse is preparing to collect data to study the health of a local community. the nurse should plan to obtain information about which of the following factors during a windshield survey?
the leading cause of death for the prior year
a nurse is assessing the vitals of a newborn who was born 8hrs ago. which of the following findings requires interventions by the nurse?
blood pressure 72/45
a nurse administers a does of metaclopramide to a client prior to a chemotherapy treatment. the client develops uncontrolled contractions of the head and neck muscles. which of the following medications should the nurse administer?
diphenhydramine
a nurse in the emergency department is caring for a client following a motor-vehicle crash. which of the following actions should the nurse take first?
stabilize the cervical spine
a nurse is admitting an unidentified female infant who was brought into the emergency department. based on the assessment findings, the nurse should estimate the infants age to be which of the following
3 month old
a nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. which of the following information should the nurse include in the teaching?
estrogen increases the risk for thrombus formation
a nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. the nurse should identify that these findings are potential manifestations of which of the following?
opioid intoxication
a nurse is providing teaching to the guardian of a 5-month old infant about introducing new foods. which of the following instructions should the nurse include in the teaching?
“introduce a new food every 5 to 7 days”
a nurse is teaching a group of newly hired nurses about placenta previa. which of the following client findings should the nurse include?
bright red vaginal bleeding
four clients present to the emergency department. the nurse should plan to see which of the following clients first?
a 50-year old client who has slurred speech, is disoriented and reports a headache
a nurse is performing an admission assessment for a client who is to undergo a colonoscopy. the client informs the nurse that he took prescribed medications before coming to the clinic. which of the following medications is the priority to report to the provider?
clopidogrel
a charge nurse is evaluating the time management skills of a newly licensed nurse. which of the following actions should the charge n nurse identify as an effective time management skill?
completes activities for one client before moving to the next client
a nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. which of the following is an appropriate action for the nurse to take?
IDK
a nurse in a providers office is teaching to a client who is at 16 weeks of gestations and has a new prescription for ferrous sulfate. which of the following instructions should the nurse include?
“take your iron medication with fluids other than coffee or tea”
a nurse is caring for a client who has heart failure and has started taking loop diuretic. which of the following findings indicates the clients is experiencing an adverse effect of the medication?
decreased reflexes
a nurse is performing a skin assessment for a client who is on bedrest. which of the following actions should the nurse take to prevent a pressure injury?
encourage client fluid intake of 2,500 mL daily
a nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. which of the following statements indicates the newly licensed nurse understands the purpose of the teaching?
“this technique decreases the risk of subcutaneous infiltration”
a nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. which of the following findings indicates the treatment has been effective?
the child has increased sputum production
a nurse is planning care for a client who is at 10 weeks of gestations and has a history of urinary tract infections (UTI’s). which of the following information should the nurse plan to include in the teaching about UTI prevention?
empty the bladder before and after intercourse
a nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. the client is scheduled to have the morning dose at 0700. the should schedule the trough level at which of the following times?
1800
a nurse is caring for a client who has breast cancer and has been receiving chemotherapy. which of the following laboratory values should the nurse report to the provider?
WBC 3,000
a nurse is reviewing the laboratory report of a client who has a magnesium level of 1.0 men/ml. which os the following assessment findings should the nurse expect?
confusion
a charge nurse is teaching a group of unit nurses about the policy for clients who have a history of MRSA. which of the following information should the nurse include?
a client who has a history of MRSA can still transmit the infection
A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?
bounding pulse
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique
a. This technique decreases the risk of subcutaneous infiltration
- A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
a. Monitor the client for 1 hr after meals
A nurse notices smoke coming from a client’s room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action?
a. Close the fire door on the unit
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
a. Hallucinations
- A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?
hyperemesis - A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?
A1C - A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?
a. Use a dedicated stethoscope - A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?
Tell the client to avoid drinking fluids 1 hr before bedtime - A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?
a. Place the newborn 45 cm from the light source - A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make?
social worker - A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication
decreased reflexes - At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
indigestion - A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene?
offer oral fluids to the client - A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first?
a. A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10 - A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex?
avocados - A nurse is preparing to witness a client’s signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?
a. I am thankful there are no serious complications from this type of surgery - A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder?
a. Uses others for personal gain - A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication?
burning - A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching?
muscle weakness - A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention?
a. Empty the bladder before and after intercourse - A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation?
a. Calcium - A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include?
a. Try to have your baby empty your breasts with each feeding.” - A nurse is caring for a client who reports chest pain. Which of the following findings indicates myocardial damage?
a. Troponin I 1.8 ng/mL - A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?
a. “I should place my baby’s car seat rear-facing until 6 months of age.” - A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective?
a. The child has increased sputum production - A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take?
antitoxin - A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take?
a. Keep a 3 foot distance from the radiation implant
A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?
a. Observe the client’s level of mobility
- A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC?
hep A - A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill?
a. Completes activities for one client before moving to the next client - A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
a. Hyperreflexia - A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?
a. Hold the bottle of sterile solution with the palm over the label while pouring - A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?
a. Wear a dosimeter film badge while in the client’s room - A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?
a. Report the incident to Adult Protective Services - A nurse is assessing a client who is postoperative following abdominal surgery. The client states, “I feel like my incision ripped open.” The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?
a. Extend the client’s legs above heart level - A nurse is providing teaching to the parent of a 6 month old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include?
a. Administer acetaminophen drops to your child before bedtime - A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?
egg whites - A home health nurse is teaching a guardian about administering tube feedings to their 3 month old infant. Which of the following information should the nurse include in the teaching?
a. Allow the infant to suck on a pacifier during feedings - A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant?
a. A 60 year old client who is recovering from shingles - A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect?
a. Hypotension - A nurse is reviewing the medical record of a client who has a new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client’s risk for ototoxicity?
a. Furosemide - A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?
a. A client who has a traumatic arm amputation - A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?
a. Contractions occur every 90 seocnds - A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following?
a. Opioid intoxication - A nurse is precepting a nursing student who brings the following client observations to the nurse’s attention. Which of the following clients should the nurse assess first?
a. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching?
a. Include the complete name of the medication morphine sulfate - A community health nurse is performing a vision screening on a 4 month old infant. When shining a light source into the infant’s visual field, which of the following is an expected finding?
the infant closes their eyes - A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?
a. Hospice care improves quality of life through palliative care - A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate?
a. Use aseptic technique and drop the medication into the conjunctival sac - A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern?
a. A brainstorming session with nurses - A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching?
a. Change clothes after working in the field - A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?
a. Monitor for abdominal ascites - A nurse is caring for a client who is receiving systematic desensitization therapy to treat agoraphobia. Which of the following client statements should indicate to the nurse that the treatment has been effective?
a. I was able to sit on a park bench for 30 minutes - A nurse is caring for a client who is receiving a blood transfusion at 125mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform?
a. Infuse 0.9% sodium chloride IV - A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?
a. The gastric residual volume is 250 mL following 2 hr of infusion - A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective?
a. I will go to my cardiologist’s office when the battery needs to be changed - A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints?
a. The client apologizes for their aggressive behavior - A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions should the nurse take?
a. Occlude the IV tubing above the injection port - A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client’s medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine?
hypertensio - A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?
1800 - A nurse is performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take to prevent a pressure injury?
a. Apply a donut ring pillow under the client’s sacral area - A nurse from the State Health Development is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention?
lyme disease - A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first?
a. Demonstrate how to perform the procedure - A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?
a. Metformin - A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications?
shellfish allergy - A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority for the client to report to the provider?
fever - 2 hr postoperative following an ileal conduit procedure bladder cancer
dusky colored stoma - Administer an injection to a client when the client states, “I dont want that injection. The last time I got that was sore for a week
battery - Assessing client who systemic lupus erythematous SLE which of the following is an expected findings
dry rasied fasical rash - Caring for a client who has a new prescription for chlorpromazine by IM injection
a. check ortho bp 1 hr after administration - Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first?
a. a 10-year old who has pneumonia and is receiving respiratory treatments. - Child who is unresponsive has increased intracrainal pressure
pad rails - A client hopitialized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious manifestations of an upper respiratory infection.
a. Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits physical contact - Client who has given birth to a stillborn
a. Acknowledging the reality of the nb death - Client who is receving a controlled epidural analgesia infusion
a. Covering the insertion site with a transparent dressing - delegates the following tasks to the assistive personnel bathe four clients distribute fresh water obtain morning vital signs
a. set a clear time frame for the completion of each task - Diagnosis of antisocial personality disorder
a. poor impulse control - Haloperidol for the treatment of schizophrenia
a. screen the client for tardive dyskinesia - In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for treatment of anorexi nervosa
a. The client will develop personalized meal plan - A nurse in a pediatric unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions?
a. Pertussis - A nurse in the emergency department is caring for a client following a motor vehicle crash. priority?
c spine - A nurse is admitting a client who has chronic gout what med should the nurse admin?
allopurinol - nurse is admitting an unidentified female who was brought to the emergency department
3 month old - A nurse is caring for a client who has a typical depression and is taking phenelzine. what can you eat?
low fat yogurt - A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest?
taking walks - a nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity
a. tinnitus - nurse is caring for a client who will be, receiving a transfusion of platelets
a. Decrease in bleeding from puncture sites - nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time aPTT of 100 seconds
turn off heparin drip - A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of deep-vein thrombosis
boots - nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1 hr ago.
pillow - a nurse is interviewing a client who presents with multiple injuries that are consistent with intimate partner abuse. After establishing trust and rapport, which of the following should the nurse say?
lets talk about what happened to you - a nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parent
swallowing sounds are audible
stool are yellow and seedy after 7 days
maternal breasts become soft following feeds - Windshield survey
religous
A nurse is reviewing the lab report of a client who has a mag level of 1.0mEq/L. Which of the following should the nurse expect?
Cardiac dysrrhythmia
A nurse is caring for a client who has breast cancer and has been receiving chemotherapy.
which of the lab values will you report to the provider?
WBC 3,000
A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention?
Empty the bladder before and after intercourse
A nurse is teaching a client about nutritional intake. include in the teaching
Carbs should be atleast 45%-65% of you caloric intake
A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective?
The child has increased sputum production
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?
This technique decreases the risk of subcutaneous infiltration
A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication
Decreased reflexes
client who had a CVA. perform to prevent foot dropping
Place positing boots on the client’s feet
A nurse in a provider’s office is teaching a client 16 weeks of gestation and has a new prescription for ferrous sulfate. What should the nurse include in the teaching
Take you iron with fluids other than coffee and tea
A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take?
Keep a 3 foot distance from the radiation implant
A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill?
Completes activities for one client before moving to the next client
A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client states he took all his meds before coming. which of the following medication is priority to report to the provider
Clopidegrel
Four clients to an emergency department. The nurse should plan to see which of the following first?
50-year old client who has slurred speech, disoriented and reports a headache
placenta previa. Which of the following client findings should the nurse include?
Bring red vaginal bleeding
A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following?
Opioid intoxication
A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. What should the nurse include in the teaching
estrogen therapy increase the risk for thrombus formation
A nurse administers a dose of metoclopramide to a client prior to a chemotherapy treatment. The client develops uncontrolled contraction of the head and neck muscles. Which of the following medications should the nurse administer
diphenhydramine
A nurse on a med-surg unit is caring for a group of clients. Which of the following clients would benefit from a three-way indwelling catheter
female who is prone to development of blood clots in the urine
A nurse is assessing the vital signs of a newborn who was born 8hrs ago. Which of the following findings require interventions by the nurse?
blood pressure
windshield survey
The availability of religious facilities.
A nurse is caring for a postoperative client. Which of the following interventions will reduce the risk of DVT
apply venous plexus foot pumps
A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?
“I should place a rolled blanket along each side of my baby’s head in the car seat.”
A nurse is providing teaching about nutrition to the parents of a preschooler who has chronic renal failure. Which of the following indicates understanding teaching
I should limit my child’s intake of protein
A nurse is assessing a client who has COPD and experienced recent weight loss. Which of the following findings should the nurse report to the provider?
Coughing and wheezing after eating
Risk for metabolic alkalosis
A client who has severe hyperemesis
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
Indigestion
A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?
elevated urine specific gravity
A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following task should the nurse delegate to the AP
Sit with the client who has anorexia nervosa during meals
obtaining a culuture
- Assess the appearance of the wound
- Obtain the specimen from granulation tissue of the wound
- Place the swab in the culture tube.
- Cleanse the would with 0.9%
- Cover the wound with a sterile dressing
A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication?
burning
A community health nurse is performing a vision screening on a 4 month old infant. When shining a light source into the infant’s visual field, which of the following is an expected finding?
the infant closes their eyes
A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
hyperreflexia
The patient states they do not want the injection but the nurse gives it anyways
battery
Client taking phenelzine
cheddar cheese
A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?
HbA1C
A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern?
A brainstorming session with nurses
hip arthroplasty and notes the dressing is saturated with sanguineous drainage. Which of the following actions should the nurse take?
Reinforce the dressing with sterile gauze
bathe four clients, distribute fresh water, and obtain the morning vital signs. At noon the nurse ask the AP to transport one client to physical therapy. The nurse delegate more effectively in the future?
Plan a more reasonable job assignment
A nurse is preparing to administer enoxaprin to a client. Which of the following actions should the nurse plan to take?
Inject the medication in the lateral abdominal wall
systemic lupus
dry raised facial rash
common manifestation of food allergies
vomiting
sterile field
open the first flap away from the body
A nurse on a mental health unit receives report on four client. Which of the following clients should the nurse attend to first
A client who is having auditory hallucination and is becoming agitated
A nurse is assessing a full-term newborn who is 24hr old. What should be reported to the provider
newborn neck is short and surrounded by skin folds
A nurse on an orthopedic floor is completeing the morning assessments on several clients. Which client is more at risk for a fat embolism
24 yr old male who has a casted femur fracture
A community health nurse is caring for a client who request a referral for family therapy. The nurse should include who from interdisciplinary team?
Social worker
A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching?
Include the complete name of the medication morphine sulfate
A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?
A client who has a traumatic arm amputation
A nurse is caring for a client who is manic. Which of the following activities is appropriate for the nurse to suggest?
take a daily walk on the hospital grounds
A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching?
Change clothes after working in the field
A nurse is admitting a client to a med-surg unit. What action should the nurse take first
Assess the clients level of mobility
A nurse is reviewing the medical records of four clients. Which of the following prescriptions correct documentation?
Enoxaparin 30 mg SC every 12 hr
Adolescent who has anorexia nervosa
hypokalemia
a nurse is preparing to discharge a newborn who has atrial septal defect. Who should the nurse expect the provider to recommend
occupational manager
gentamicin toxicity
tinnitus
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Monitor the client for 1 hr after meals
A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take?
Begin prophylactic treatment with ciprofloxacin
Report to the CDC
Hepatitis A
levels a depression in the skin 8mm deep
4+edema
A nurse is teaching a client who is at 35 week of gestation about amniocentesis. Which of the following statements should the nurse include in the teaching?
you should monitor for the onset of contractions after the test
A nurse is caring for a client who has heart failure and a potassium level of 3 mEq/L. The nurse should obtain verification of which of the following prescriptions from the provider
digoxin 0.125mg po daily
A home health nurse is admitting a clinet who is prescribed peritoneal dialysis. Which of the following actions should the nurse take first
Clarify the client’s actual and perceived health needs.
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect?
Hallucinations
diagnosis of antisocial personality disorder
poor impulse control
A nurse is caring for a client who is post right-modified radial mastectomy. Which of the following should the nurse recognize as a priority finding.
emesis of 110ml of thick yellow fluid
dysphagia, what should the client recommend
oatmeal
A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?
Report the incident to Adult Protective Services
Run cats spin the rain throwing procedures mechanical paper lake
word salad
eye drops
maintain the child in a sitting position 3 mins after
report to the CDC
syphilis
A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching?
notify your provider if you experience muscle weakness
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV fusion. Which of the following should be reported to the provider
Mag levels 9mEq/L
meningitis. What assessment to perform?
Brudzinski sign
A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend?
egg whites
A nurse is planning care for a child who is unresponsive and has increased ICP. Which of the the following actions should the nurse take?
place the child in trenedelenburg position
A nurse is caring for a child who has a new prescription for chlorpromazine by IM injection. Which of the following is an appropriate action?
Check orthostatic blood pressure 1hr after administration
mononucleosis . What findings
splenomegaly
malaise
sore throat
meningitis
initiate droplet precaution
continuous bubbling in the water-seal chamber
check for an air leak
A client asks the nurse if it is safe for him to take a glucosamine supplement
shellfish allergy
A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate?
Thyroid hormones
A nurse is preparing to administer an IV bolus of albumin 5% to a client receiving a continuous IV infusion. What action should the nurse take
use the injection site farthest away from the IV insertion site
breech of client confidentiality
Discussing the clients reaction to the transfer with another staff nurse
A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?
Monitor for abdominal ascites
A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?
Hyperemesis
A nurse is delegating task to an AP. For which of the following can the nurse assign to the AP to measure vital signs
A client who is requisition pain medication 2 days after surgery
A circulating nurse is implementing a “time-out” before moving a client who is having total hip arthroplasty to the surgical site. Which of the following actions should the nurse take.
confirm the provider has market the surgical site
A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex?
avocados
allopurinol. Which of the following lab findings to determine the effectiveness
uric acid level
haloperidol for the treatment of schizophrenia
screen the client for tardive dyskinesia
A nurse is caring for a preschool-age child who has a short-leg plaster cast applied 1 hr ago. Which of the following is an appropriate intervention
support the affected leg on a pillow
A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
substernal chest pain
bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemo.
Allow the silbling to wave at the client through the window of the door
A client who is 8hr postpartum asks the nurse id she will nee to receive Rh immune globulin. The client is gravid 2, para 2, and her blood type is AB negative. The newborn’s blood type is B positive. Which of the following statement is appropriate ?
should be given 72 hrs after delivery
receiving lasted Ringer’s to treat fluid volume deficit. Indicates a therapeutic response to the treatment
Increased blood pressure
neutropenia about food safety to prevent food borne illness
Refrigerate leftover with 2 hrs
A nurse is caring for a female client who has bruises on her arms that she explains are result of physical abuse by her partner.
Insit that the client report the abusive behavior to the proper authority
providing postoperative teaching to a client who has a newly inserted pacemaker
I will use my cellphone on the ear opposite of my pacemaker
a nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is priority to report to the provider
blurred vision/ fever
A nurse is performing a vision screening for a client. Which of the following finding should the nurse identify as an indication that the client has cataract
increased opacity of the lens of the eye
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take?
Tell the client to avoid drinking fluids 1 hr before bedtime
A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation?
calcium
A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take?
Hold the bottle of sterile solution with the palm over the label while pouring
A nurse is assessing a client who is postoperative following abdominal surgery. The client states, “I feel like my incision ripped open.” The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?
place the client in low fowler’s
A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take?
Wear a lead apron
A nurse is planning an educational session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia
diaphoresis
A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the following actions should the nurse take
Apply the tourniquet 15cm(6in) about the insertion site
fetal lung maturation
betamethsone
A nurse is planning care for a newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care
Assess the infants eyes for corneal irritation every 4hrs
A nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops a hemolytic reaction. which of the following action should the nurse perform
infuse 0.9% sodium chloride IV
A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make?
art therapist
report to the cdc
lyme disease
a client who has dysphasia and a new prescription for divalproex sodium extended release
administer with applesauce
education about electroconvulsive therapy ECT major depressive disorder
general anesthetic administered prior to ECT treatments
A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?
Hospice care improves quality of life through palliative care
A nurse is caring for a client who is taking alprozolam. Which prescription needs clarifying with the provider
lorazepam
Jewish
meat and dairy are eaten separate
A nurse is assessing a client who has non-Hodgkin’s lymphoma. Which of the following findings should indicate to the nurse that the client might be experiencing syndrome of inappropriate antidiuretic hormone
diminished deep tendon reflexes
Which of the following methods should the nurse use to confirm placement prior to initatiaing feeding
Test pH level from client gastric aspirate
a home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?
Allow the infant to suck on a pacifier during feedings.
A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescence client who was admitted for treatment of anorexia nervosa. Which of the following is an appropriate short-term goal the nurse should set?
The client will gain 2 to 3lbs weekly
A nurse is preparing to witness a client’s signature on an informed consent for a total knee arthroplasty. Which of the following indicates the nurse should contact the surgeon
I am thankful there are no serious complications from this type of surgery
A nurse is caring for a client who reports chest pain. Which of the following findings indicates myocardial damage?
Troponin I 1.8 ng/mL
A nurse is caring for a client who has a femur fracture and is on bedrest with Buck’s extension traction. Which of the following actions should the nurse take?
Inspect the clients skin under the device every 8 hrs
A nurse receives change-of-shift report on four clients. Based on the shift report information, which of the following clients should the nurse place to assess first?
A client who had a hip arthroplasty reports pain and erythema in their calf
A nurse in the post anesthesia care unit is caring for four postop clients. The nurse realizes that coughing poses a risk to which of the following clients?
A client who had a thyroidectomy
A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first?
A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene?
Offers oral fluids to the client
2 hr postoperative following an ileal conduit procedure bladder cancer
dusky color stoma
A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following action should the nurse take?
Occlude the IV tubing about the injection port
A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder
use other for personal gain
A nurse is providing teaching to the parent of a 6 month old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include?
Administer acetaminophen drops to your child before bedtime
droplet precautions
pertussis
A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include?
Place the newborn 45 cm from the light source
nurse is caring for a client who will be receiving a transfusion of platelets
Decrease in bleeding from puncture sites
A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the following is the priority task for the nurse to facilities in the client grief process
Acknowledging the reality of the newborn’s death
A nurse is teaching a client about smoking cessation. Which of the following client statements should the nurse identify as an understanding of teaching?
Will use high carbohydrate snacks as a substitute for cigarette.
A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include?
Try to have your baby empty your breasts with each feeding
A nurse is caring for a client who is who is receiving continuous feeding via NG tube. Which of the following actions would the nurse take?
Check the clients gastric residual every 4hrs
A nurse is teaching a client who has low-literacy level about home managements of diabetes mellitus. Which of the following action sis appropriate?
Show the client as educational video
A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?
A client who has difficulty swallowing
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings indicate medication toxicity?
Urine output 20 ml/hr
A charge nurse is creating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant?
A 60 year old client who is recovering from shingles
A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor
Cervix dilated 2cm
A home health nurse is teaching the parents of a school age child who has legg-calve-perthes disease. Which of the following information should the nurse include
Your child should continue to attend school
A nurse notices smoke coming from a client’s room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action?
notify the facility operator
wrong dosage of medication was given
fidelity
A nurse is caring for a client who is racing a controlled epidural analgesia infusion. Which of the following nursing action is appropriate?
Replacing the infusion tubing every 72 hrs
A nurse is caring for a school age child who has a blood pressure of 68/50 mm Hg and develop sepsis shock. Which of the following medication should the nurse expect to be prescribed?
Dopamine
A nurse is caring for a toddler who has RSV. Which of the following actions should the nurse plan to take?
use a designated stethoscope when caring for the toddler
A nurse is precepting a nursing student who brings the following client observations to the nurse’s attention. Which of the following client should the nurse assess first?
a client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago
A nurse is assessing a client who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?
Weight loss of 4lbs in 1 month
A nurse manager is making staffing assignments for the medical-surgical unit. Which of the following clients is appropriate to assign to a float nurse from the postpartum unit?
A client who is 2 days post following a colon resection.
A nurse is assessing a client who is gravida 2, para 1. This client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?
Contractions are strong to palpatation
A nurse is caring for a client who has fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated ptt of 100 seconds. Which of the following actions should the nurse take first ?
Turn of the heparin drip
A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview?
Seat the client at least 12 feet from the nurse
atrial fibrillation
C
A nurse is assessing a client who has minor injuries following a motor-vehicle crash and appears agitated and apprehensive. The nurse identifies that the client is in the alarm stage of general adaption syndrome and should expect which of the following findings?
tachycardia
A nurse is caring for a client who is postpartum and has a new prescription for methylergovine for vaginal bleeding refectory to fundal massage and oxytocin.
hypertension
A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65ml/hr through gastrostomy tube. Which of the following findings requires immediate interventions by the nurse?
The infusion pump for administering continuous feeding is turned off
A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of parents. Which of the following information should be included
Newborn swelling sound are audible while breastfeeding
Newborn stools are yellow and seedy after 7 days of breastfeeding
Maternal breast become soft following feedings.
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